Burn Rehabilitation: A Multidisciplinary Approach
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Direct answer
Surgery closes the burn wound, but rehabilitation decides whether the survivor can turn a head, lift an arm or earn a living — and it begins on day one, not at discharge. Its pillars are anti-contracture positioning and splinting from the acute phase, daily range-of-motion and stretching exercises, pressure garment therapy worn about 23 hours a day for six to 18 months to flatten hypertrophic scars, silicone gel sheeting and scar massage, and staged reconstructive surgery — contracture release with skin grafting, Z-plasties and flaps — when deformity matures or threatens function. Around this stands the team: physiotherapist, occupational therapist for hand function and activities of daily living, psychologist or psychiatrist for post-traumatic stress, depression and body image, dietitian for the hypermetabolic state, and vocational counsellor for return to work. In Indian practice, kitchen-flame and Diwali firework burns dominate, late presentations with established neck, axillary and hand contractures are common, and structured rehabilitation beyond apex centres is scarce — so families must leave hospital with a written programme.
What you must remember
- Positioning catalogue: neck extended with no pillow under the head (a roll under the shoulders instead), axilla abducted to about 90 degrees in an aeroplane splint, elbow extended, dorsally burnt hand splinted with the metacarpophalangeal joints flexed to prevent hyperextension claw, knee extended, ankle at 90 degrees.
- Why the position opposes the deformity: burns contract in flexion across neck, axilla, elbow, fingers and hip; every position of comfort is a future contracture — comfort is the enemy.
- Pressure garments: approximately 23 of 24 hours daily for six to 18 months once epithelialised, with refitting as the scar responds; adherence is the commonest failure point.
- Exercise: active and passive range of motion daily, ambulation as early as graft stability permits; serial casting for early contractures; mouth-stretching exercises and splints for microstomia in facial burns.
- Scar surgery timing: most releases wait for scar maturity — six to 12 months — but function-threatening contractures of neck or joint, or eyelid exposure, operate earlier.
- Itch: among the most distressing persistent symptoms — antihistamines, gabapentin, moisturisers for xerosis; a favourite long-term symptom question.
- Psychological burden: post-traumatic stress, depression and sleep disruption are common after major burns; screen at every visit, not only when asked.
- Outcome measures: Vancouver Scar Scale for scar severity, goniometry for range, hand function scores — the vocabulary of a multidisciplinary review.
Walking a rehabilitation prescription
Admit a 24-year-old with 25% flame burns across the neck, anterior chest, right axilla and right hand. Day one, before any grafting: positioning as per the catalogue, an aeroplane splint made by the occupational therapist, a hand splint, and gentle explanation that therapy will hurt. From day three, once grafts are stable, active-assisted exercises begin, with the therapist timing sessions after analgesia. At week six, healed areas are measured for pressure garments and silicone sheeting; ambulation and shoulder elevation are pushed. Month three: range of motion documented, garment adherence reviewed with the family, itch and sleep treated. Month nine: a dense axillary adduction contracture is released and grafted, followed by immediate re-splinting in abduction — release without postoperative splinting is surgery wasted. Throughout: psychology review at weeks one, six and 26, and a return-to-work plan negotiated with the employer. Every element above belongs to a different professional; the surgeon who writes the whole prescription is the one who understands the team.
Where students slip
The standard wrong answer is "start physiotherapy once the wound heals" — by then the contracture has been rehearsed for weeks; positioning starts on admission. The second slip is the pillow under a burnt head, a kindness that manufactures a neck flexion contracture. Third, pressure garments prescribed for a few hours a day: the evidence base is about 23 hours, and the exam quotes the number. Fourth, the dogma "no scar surgery before a year" is falsely generalised — eyelid exposure, severe neck contracture and joint ankylosis cannot wait. Finally, candidates forget itch and post-traumatic stress as long-term problems, remembering only contractures.
Frequently asked questions
When does burn rehabilitation begin?
On day one, with anti-contracture positioning and splinting, before wounds are closed. Waiting for healing forfeits the joint range that positioning protects.
How long are pressure garments worn each day?
About 23 of 24 hours, for six to 18 months, once wounds are epithelialised. Non-adherence is the commonest reason for failure.
Why is an aeroplane splint used for axillary burns?
To hold the shoulder near 90 degrees of abduction and prevent an adduction contracture. The comfortable position is precisely the deformity position.
When is contracture release performed?
Usually after scar maturity at six to 12 months, but earlier when function or vision is threatened. Postoperative splinting determines whether the release holds.
How is chronic burn itch treated?
Regular emollients, oral antihistamines, and gabapentin for refractory itch. Itch often outlasts healing and disturbs sleep for months.