Burn Injury Management Considerations for Rehabilitation Professionals

Original Editor - Carin Hunter
Top Contributors - Jess Bell, Carin Hunter, Kim Jackson, Stacy Schiurring and Robin Tacchetti

Introduction

Burn injuries are a major cause of pain and disability. 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.

Pain Management for Individuals with Burn Injuries

There are many factors to consider when treating pain associated with burn injuries, and the clinician must understand the cause of the current pain. There is no standardised treatment for patients with burn injuries. Pain assessments should be performed throughout the day and during each phase of care. 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

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

The general consensus is that "opioid therapy is an essential tool for pain management in thermal injuries", 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.

Romanowski et al. 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)
• while the reasonable use of opioids is supported to manage severe pain, attempts should be made to use "as few opiate equivalents as needed"
• opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments

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

Initial Acute Pain

"The energy from the burn source causes cell damage and release of inflammatory mediators [...] Descending pathways from the thalamus and release of endorphins and other neurotransmitters in the spinal cord may result in there being little or no pain for the first few hours after injury".

First aid strategies:

• cool the burn with tepid or cold water (do not use ice water, as this causes further damage to the affected area)
• prevent general heat loss: hypothermia can be caused by cooling the burn and evaporation of oedema fluid, so provide the patient with a blanket or alternative source of warmth

Pain Management in Individuals with Burn Injuries Admitted to Hospital

"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."

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 pruritus (itching). The management for each type of pain can differ.

Background Pain

This type of pain is defined as "pain at rest that is almost always present and not caused by specific medical procedures" Thus, it is persistent but usually low-grade. 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).

Breakthrough Pain

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

Pain Associated with Procedures

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.

Important considerations:

• 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
• analgesia should be used in a preventive way, especially as some of these procedures can be predicted
• general anaesthetic may be used for prolonged procedures

Pain Associated with Surgery

Early post-operative pain tends to be managed with opioids and other non-opioid medications. Opioids may be given transdermally, orally, intramuscularly or intravenously:

• intramuscular administration can be difficult because of the extent of dressings, surgical site, pain at the site of injection, unpredictable absorption
• patient-controlled analgesia (PCA) can be used (particularly for breakthrough pain after a procedure), but the patient must be conscious and alert and be able to use the device - this can prevent its use in individuals with hand burns
• 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
  • they "should be used with extreme caution especially in patients with bigger burns and those on intensive care in whom the risk of gastrointestinal haemorrhage and acute kidney injury is greater than that in the normal population"
• 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

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

• a general anaesthetic or deep intravenous sedation may be required while dressing large, deep burns, as they can take up to two hours to dress and may need to be debrided, or staples may need to be removed
• smaller dressings can be managed by administering analgesia (e.g. opioids, local anaesthetics) before starting the procedure
• nitrous oxide (e.g. Entonox) can be used for short procedures in addition to opioids to help reduce breakthrough pain and avoid long periods of sedation
• using appropriate dressings (e.g., a synthetic temporary skin substitute) can help reduce the requirement for procedures, which is particularly beneficial for paediatric patients

Pain Associated with Rehabilitation (Physiotherapy, Occupational Therapy, Speech Language Therapy, Movement Therapy)

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:

• 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

Pruritus

Pruritus or itching is a common issue after burn injury, affecting up to 93% of individuals by the day of their discharge. 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.

Current treatments for pruritus have not been found to have clinically significant benefits, and Andrade et al. note that further research on the management of pruritus is required. Treatments can include:

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

Persistent / Chronic Pain

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%. It develops as a result of partial or complete peripheral nerve injuries. 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.

Treatments for persistent pain following a burn injury might include:

• analgesics
• antidepressants
• anticonvulsants
• regional nerve block
• cognitive behavioural therapy (CBT)

Alternative Pain Management Techniques for Burn Injuries

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".

There are four broad categories of nonpharmacological techniques:

• cognitive-behavioral therapy (CBT)
  • "most effective when decatastrophizing and reinterpreting pain signals were targeted"
• hypnosis
  • can be used in the management of procedural pain and anxiety
  • "was most effective when the affective component of pain was targeted in posthypnotic suggestions and for patients who had high pain"
• distraction (e.g. virtual reality)
  • 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
    • it has been found that for patients who "feel more “present” in the virtual world have lower pain scores during wound care and physiotherapy"
    • patients using virtual reality can have lower pain scores during dressing changes
• relaxation (breathing, music, stress inoculation, aromatherapy, massage)

Physiotherapy strategies to help with pain, pruritus and altered sensation include:

• education, reassurance, distraction
• splinting
• exercise
• massage (discussed below)
• 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

Oedema Management for Individuals with Burn Injuries

When oedema occurs in the acute phase after a burn wound, two commonly used management options are elevation and compression.

Elevation

In order to decrease oedema, a limb should be elevated above the level of the heart, so that gravity can assist in the removal of oedema. Sometimes, this may not be possible due to pain and discomfort. In these cases, it is important to raise the limb as high as possible. A sling can be used to facilitate elevation. Slings also protect the burn site while allowing a degree of movement. This means blood flow can be actively increased.

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:

• 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

Compression (e.g. wraps, pressure garment therapy) is commonly used to help manage oedema in burn injuries:

• pressure garment therapy (discussed below) has been shown to help manage oedema
• 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

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

Scar Management for Individuals with Burn Injuries

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

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

Hypertrophic scars require specialised treatment, from the acute phase of injury to many years post-injury.

Scar Outcome Measures

Vancouver Burn Scar Scale (VBSS/VSS):

• assesses four characteristics of the scar: vascularity, height, pliability, and pigmentation
• does not measure a patient's subjective assessment of the scar, such as pain, itching, functional impact or psychological impact
• 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
• assesses the scar from the patient's and the observer's perspective
• for more information, please see: About POSAS

Management Options for Hypertrophic Scars

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

• intralesional injection
• laser and light therapies
• topical steroids
• moisturisers

Silicone

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, a Cochrane review from 2020 has found that "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" and further research is required. Nischwitz et al. note that silicone gel appears to be mainly beneficial for pruritus and pain. 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
• silicone gel sheets can be washed and reused, which reduces the financial burden on the patient

Pressure Garment Therapy (PGT)

Pressure garment therapy is widely used in the management of hypertrophic scars and for oedema management. Recent research suggests:

• there is "sufficient evidence to support the prophylactic and curative use of pressure therapy for scar management"
• it can help improve the colour and thickness of the scar, scar quality and pain
• it 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 pressure garment therapy; a wait of 10-14 days is recommended post-grafting, depending on the surgeon's instructions
• it should continue for at least 12 months, preferably for up to 18-24 months
• minimal pressures of 20-25 mmHg are recommended - please note that pressures exceeding 40 mmHg have been found to result in complications
• DeBruler et al. recommend that pressure garments should be worn 23-24 hours per day, but note that even wearing pressure garments for 8 hours per day can significantly improve scar outcomes versus no treatment
• 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

How does pressure garment therapy work?

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." It potentially creates localised hypoxia to the scar, thus reducing blood flow to hyper-vascular scars, which reduces the influx of collagen and decreases scar formation.

Pressure garment therapy is believed to help:

• reduce scar thickness
• reduce redness
• decrease swelling
• reduce pruritus
• improve the protection of the new skin / grafts
• maintain contours and prevent contractures

Scar Massage

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

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

Recent research suggests:

• "there is preliminary evidence to suggest that scar massage may be effective in improving scar height, vascularity, pliability, pain, pruritus and depression in patients with hypertrophic scarring as a result of burn injury in the short term"
• the "meta-effects" of scar massage include improved scar formation and decreased pruritus and anxiety, suggesting that scar massage can be effective and feasible for individuals with burn injuries
• 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

Scar massage techniques and proposed effects:

• retrograde massage
  • aids venous return
  • increases lymphatic drainage
  • mobilises fluid 
• effleurage
  • increases circulation
• kneading, skin rolling and wringing
  • mobilise the scar and surrounding tissue
  • restore mobility to tissue interfaces
  • stretch and promote collagenous remodelling
• frictions
  • loosen adhesions

Table 1. Guidelines for massage during the three stages of healing
Inflammatory phase	Gentle massage to decrease oedema and increase blood supply - please note there is no high-level evidence to support this
Proliferative phase	Massage should be used to apply gentle stress to the healing scar
Remodelling phase	Progress massage to include prolonged stretching to minimise adhesions

Treatment considerations:

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

Contraindications:

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

Surgical Management for Individuals with Burn Injuries

“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.” These burns require surgical intervention to remove devitalised tissue and to promote regeneration by providing the injured skin with a new source of epidermis.

Since the 1970s, the acute management of burn injuries has included early excision and grafting. This approach has led to improved survival rates and decreased length of hospital stay.

Early Excision

Early excision is considered the gold-standard treatment:

• there is debate over the optimal timing for early excision
• surgery aims to ensure there is no full-thickness burned tissue left behind and to debride down to viable tissue

Skin Grafts

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 / cadaver) is used to temporarily cover debrided tissue when:

• 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. Autologous skin grafts can be split-thickness skin grafts (STSGs) or full-thickness skin grafts (FTSGs).

Split-thickness skin grafts (STSG):

• most commonly used for wound coverage
• include the epidermis and the upper layer of the dermis
• are beneficial when patients have extensive total body surface area burns (TBSA) as the same donor sites can be re-harvested after one to two weeks (this can, however, lead to hypopigmentation)
• meshing the graft can increase the total surface area of the mesh, but this can result in significant scarring
  • 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: this results in rapid closure, but can affect functional / aesthetic outcomes
  • 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

For more information on STSGs, especially for larger burns (i.e. more than 60%TBSA), please see: Burn injury.

Full-thickness skin grafts (FTSG):

• 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

A graft should take within five days. It should be placed over bleeding, healthy tissue to ensure adequate vascularity.

Post-operatively, the graft site will be dressed with sufficient pressure to limit haematoma formation. This 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.

Skin grafts are more likely to fail if:

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

Other causes of graft failure include:

• 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)

Grafting for large burns is performed in stages because complete coverage following a large burn “rapidly exhausts available donor skin”.

Skin Substitutes

If the excised area requires more skin than is available, temporary skin cover is required. There are many types of skin substitutes. Allografts (cadaver skin) are most commonly used, but porcine skin (xenografts) is another option. These can provide coverage for up to 14 days before rejection. There are also a number of biologic and synthetic skin substitutes.

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

• Burn injury
• The role of skin substitutes in acute burn and reconstructive burn surgery: an updated comprehensive review

Skin Flaps

Skin flaps are also used in patients with burn injuries. The key difference between a skin flap and a skin graft is that a skin flap has its own vasculature (i.e. it brings its own blood supply from the donor site). A skin graft is vascularised by the recipient site.

Skin flaps might be used on areas such as:

• 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.

Reconstruction Surgery

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

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

• 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. Surgical scar revision can involve skin substitutes, laser therapy, flaps, biomaterials, etc.

Many members of the multidisciplinary / interdisciplinary team are involved in addressing specific post-surgical needs, such as splinting, physiotherapy, occupational therapy, laser and scar management.