277

Rehabilitation of Burn Casualties

Chapter 13

REHABILITATION OF BURN CASUALTIES

TRAVIS L. HEDMAN, PT*; CHARLES D. QUICK, OTR/L†; REGINALD L. RICHARD, MS, PT‡; EVAN M. RENZ, MD§; 

STEVEN V. FISHER, MD¥; ELIZABETH A. RIVERS, OTR, RN¶; JAMES C. CASEY, MOT, OTR/L**; KEVIN K. CHUNG, 

MD††; PETER A. DESOCIO, DO‡‡; WILLIAM S. DEWEY, PT, CHT, OCS§§; JAIME L. DROOK, OTR/L¥¥; NICOLE J. 

LEHNERZ, OTR/L¶¶; CHRISTOPHER V. MAANI, MD***; ALFREDO E. MONTALVO, MSN, BSN, APN†††; BETH A. 

SHIELDS, RD, LD, CNSD, MS‡‡‡; MELISSA Z. SMITH, MOT, OTR/L§§§; CHARLES K. THOMPSON, PA-C¥¥¥; ALICIA F. 

WHITE, PT, DPT¶¶¶; JAMES F. WILLIAMS, PA-C, MPAS****; and ALAN W. YOUNG, DO††††

INTRODUCTION

PATHOPHYSIOLOGY OF BURNS

CLASSIFYING AND ASSESSING BURNS

SEVERITY OF BURNS

CRITICAL CARE OF BURN CASUALTIES

PAIN MANAGEMENT

REHABILITATION OF THE BURN CASUALTY

COMPLICATIONS ASSOCIATED WITH REHABILITATION

SCAR MANAGEMENT

PLASTIC AND RECONSTRUCTIVE SURGERY

SPECIAL CONSIDERATIONS

SUMMARY
278

Care of the Combat Amputee

*

Captain, US Army, Medical Corps; Chief, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 

Rawley E. Chambers Avenue, Fort Sam Houston, Texas 78234

†

Major, US Army, Medical Corps; Chief, Occupational Therapy Service, Burn Rehabilitation Department, US Army Burn Center, US Army Institute 

of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas 78234

‡

Clinical Research Coordinator, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. 

Chambers Avenue, Fort Sam Houston, Texas 78234

§

Lieutenant Colonel, US Army, Medical Corps; Director, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

¥

Chief, Department of Physical Medicine and Rehabilitation, Hennepin County Medical Center, Minneapolis, MN 55415; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Minnesota Medical School

¶

Burn Rehabilitation Specialist (Retired), Burn Center, Regions Hospital, formerly known as St. Paul Ramsey Medical Center, 640 Jackson Street, St. 

Paul, Minnesota 55101

**Occupational Therapist, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

††Major, US Army, Medical Corps; Medical Intensivist, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

‡‡Captain, US Army, Medical Corps; Anesthesiologist, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

§§Occupational Therapist, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

¥¥Occupational Therapist, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

¶¶Occupational Therapist, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

***Major, US Army, Medical Corps; Chief, Anesthesiology, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

†††Lieutenant Colonel, US Army, Medical Corps; Psychiatric Clinical Nurse Specialist, US Army Burn Center, US Army Institute of Surgical Research, 

3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas 78234

‡‡‡Dietitian, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley East Chambers Avenue, Fort Sam Houston, Texas 78234 §§§Occupational Therapist, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

¥¥¥Physician Assistant, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas 

78234

¶¶¶Physical Therapist, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers 

Avenue, Fort Sam Houston, Texas 78234

****Physician Assistant, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas 

78234

††††Physiatrist, Burn Rehabilitation Department, US Army Burn Center, US Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, 

Fort Sam Houston, Texas 78234
279

Rehabilitation of Burn Casualties

INTRODUCTION

function, is the clinical focus of burn centers.4

The healing process is impeded by battlefield and 

regional conditions (eg, extremes of climate and contaminated environments), dehydration, inadequate 

nutrition, psychological and physiological stressors, 

and burn pain. Managing and recovering from a 

burn is a demanding material and human resource 

endeavor. Casualties with serious burns stress the assets available to deployed combat support hospitals 

in a theater of operations.5

Rehabilitation is critical to the long-term survival 

of the burn casualty.1 For the most favorable outcomes 

to occur, endurance, active range of motion (AROM), 

fine motor dexterity, coordination, and psychosocial 

and community reintegration must be achieved, and 

strength must be integrated into purposeful activity. 

After a major burn injury, casualties depend on a comprehensive, interdisciplinary rehabilitation treatment 

plan designed to expeditiously recover their premorbid 

level of independence, the end goal being return to duty 

and other activities with maximum functional independence.1

 Additional rehabilitative interventions implemented along the continuum of care help minimize 

edema and infection, promoting durable, soft, supple, 

flat, properly colored, and pain-free wound coverage. 

Following stabilization from an acute burn injury, 

battlefield casualties are rapidly evacuated from the 

theater of operations to the burn center at the US 

Army’s Institute of Surgical Research (USAISR) at 

Fort Sam Houston, Texas. The establishment of comprehensive burn centers and advancements in treatment have resulted in a significant decline in burn 

injury mortality.2 The LD50, or total-body surface area 

(TBSA) burned that is lethal to 50% of casualties, has 

improved dramatically, from 65% in 1984 to over 81% 

in the early 1990s (Figure 13-1).3 This improvement in 

survival, combined with efforts to improve long-term 

1943 1984 1995 1996

100

90

80

70

60

50

40

30

20

10

0

Percent Burn

Figure 13-1. Graph of burn patient mortality.

Data source: Saffle JR, Davis B, Williams P. Recent outcomes 

in the treatment of burn injury in the United States: A report 

from the American Burn Association Patient Registry. J Burn 

Care Rehabil. 1995;16(3 pt 1):219–232.

PATHOPHYSIOLOGY OF BURNS

Inflammatory Response and Burn Shock

Thermal insult results in physiological changes 

affecting both injured and noninjured tissue.6 Burn 

shock begins at the cellular level, decreasing cellular 

transmembrane potential.7 Inflammatory and vasoactive mediator release, activated by thermal injury, 

results in increased capillary micropermeability and 

hypovolemia, leading to cellular edema.7,8 Over the 

48 hours following injury, fluid continues to be lost 

through the wound and edema continues to form.

As the burn wound exceeds 20% to 25% TBSA, capillary permeability and intravascular volume deficits 

can exceed the body’s compensatory mechanisms and 

result in circulatory compromise.7 If distance and time 

of transport are lengthy, casualties may suffer burn 

shock by the time they arrive at a treatment facility, 

and self-aid or buddy aid will be ineffective. During 

evacuation, casualties must receive emergency medical 

treatment by providers trained in burn management.

Burn Resuscitation

A fluid resuscitation program is designed to overcome the acute period of massive fluid shifts, electrolyte derangements, acid–base imbalance, edema 

formation (see further discussion below), and fluid 

and protein losses. Replenishing circulatory volume 

using one of several formulas restores and maintains 

organ perfusion and function (Table 13-1). 

A key component in most resuscitation fluids is 

the sodium ion; the fluid (free water) is the vehicle 

that delivers the sodium. Depending on the choice of 

formula, fluid volumes range from 2 to 5 mL/kg/% 

TBSA. Burn resuscitation formulas are similar in the 

milliequivalents of sodium they provide.9 Some formulas use only crystalloid fluids and omit colloid, 

while others vary the amount and timing of colloid 

administration. The role of crystalloid or colloid resuscitation remains an ongoing debate. However, a 

prescribed formula is a guideline to help resuscitate a 
280

Care of the Combat Amputee

burn casualty. The individual response to a prescribed 

formula may be unpredictable and variable, requiring 

continual corrective adjustments. None of these formulas reflects evolving trends that add a sophisticated 

medical resuscitation component to the already existing fluid protocol. Several components are currently 

being used or investigated to improve resuscitation 

and decrease edema and the inflammatory response 

in the early phase, including:

	 •	 low molecular weight dextran,

	 •	 fresh frozen plasma,

	 •	 pentastoid,

	 •	 mannitol,

	 •	 ibuprofen,

	 •	 cimetidine,

	 •	 vitamin C, and

	 •	 vitamin E.9–18

The current approach to fluid therapy has led to 

reduced mortality rates.7 Not long ago, approximately 

50% of deaths occurred within the first 10 days following burn injury because of multiple organ failure 

syndrome and devastating sepsis. A principal cause, 

particularly of multiple organ failure syndrome, is inadequate fluid resuscitation and maintenance. Because 

burn shock is both hypovolemic and cellular in etiology, 

fluid management following successful resuscitation 

is as important as that performed during the initial 

revival process.19 Multiple organ dysfunction resulting 

from inadequate resuscitation has become less common 

with the use of weight- and injury-size based formulas.7

However, increased fluid regimens, known as “fluid 

creep,” are also associated with adverse outcomes, 

including edema formation, increased compartment 

pressures, acute respiratory distress syndrome, and 

multiple organ dysfunction.7 The goal of proper fluid 

resuscitation is to prevent burn shock.7

TABLE 13-1 

FLUID RESUSCITATION FORMULAS

Formula Fluid Composition Calculation

Brooke Ringers lactate; Na 130, 2–4 cc/kg/% TBSA

Cl 130, Lactate 28, K 4, 

Ca 3

Parkland Ringers lactate; 4 cc/kg/% TBSA

D5W + 0.5–2.0 L

Hypertonic Na 200–300 mEq/L, 2 cc/kg/% TBSA

saline Cl 100 mEq/L, 

HCO3 150 mEq/L

D5W: dextrose 5% in water

TBSA: total-body surface area

CLASSIFYING AND ASSESSING BURNS

Burn casualties typically comprise between 5% and 

20% of service members wounded during conventional 

warfare.19–22 Burn injury occurs in a young population, 

with a high incidence of inhalation injury and Injury 

Severity Score (an anatomical trauma severity measure 

that can be used to predict mortality).23 Military burn injuries have a broad impact, affecting everything from the 

individual to the overall status of military operations.24

Burns are classified by mechanism of causation (ie, 

thermal, chemical, electrical, or radiation), as well as 

size, depth, and location of the burn and other associated trauma. Regardless of mechanism or severity, 

rehabilitation goals for burn casualties are the same.

Thermal Injuries

Thermal injury accounts for approximately 95% of 

military burn casualties, with chemical and electrical 

making up the most of the remainder.20,24 Burns resulting from flash fire and flame are the most common in 

wartime.20,24 The detonation of explosive devices, such 

as landmines, artillery munitions, mortar rounds, and 

improvised explosives, has been a significant source 

of combat burns.20,24,25 The most common causes of 

noncombat burns in service members are related to 

burning waste materials, inappropriately handling 

ammunition and pyrotechnics, and misusing fuels.Efforts to prevent noncombat injuries continue to reduce 

their impact on military operations.20,24 Other causes of 

military burn injury include exposure to hot liquids or 

superheated steam, typically from ship or submarine 

boilers, resulting in scald burns. Inhalation injury is 

frequently associated with superheated steam burns.

Chemical Injuries

Chemical burns appear to be uncommon in military 

casualties,26 with reported incidences ranging from 0.9% 

to 6.5% (Figure 13-2).20,27–29 However, the widespread 

use of chemicals and their ready availability creates 

the potential for a large number of this type of casualty. 

Chemical burns are caused by acids, alkalis, or organic 

compounds.26 Except for white phosphorus,26,27 most 

chemical burns should be immediately treated with copious water lavage. Wounds caused by white phosphorus, 

which ignites on contact with air, should be covered 
281

Rehabilitation of Burn Casualties

with water or saline until the wound can be debrided 

of all chemical.26 Powdered chemical should be brushed 

away prior to water lavage to decrease the quantity of 

exposure. The process of neutralization generates heat, 

which can add thermal injury to the chemical insult. The 

duration of irrigation is variable depending on the agent. 

In general, alkalis require a much longer period of irrigation than acids. At a minimum, 30 minutes of continuous 

irrigation are required for all burns, and at least 1 hour of 

irrigation is necessary for alkali burns.28 A period of up 

to 6 hours of irrigation has been recommended for acid 

burns, and one of up to 48 hours has been suggested for 

ocular alkali burns. A good rule of thumb is to irrigate at 

least until there has been a significant decrease in pain.29

Chemical agents produce direct tissue damage by a 

variety of reactions. Acid burns tend to be superficial 

in depth, whereas alkali burns tend to burrow into the 

tissues and cause more significant destruction. Acids 

cause coagulation necrosis, whereas alkaline materials 

cause liquefaction necrosis. Hydrofluoric acid requires 

copious water lavage, followed by topical calcium 

gluconate, which, when injected into the area, may 

decrease the severity of the injury. Using intraarterial 

calcium gluconate on wounds of the hands and feet is 

beneficial. Mustard agent, a chemical previously used 

in warfare, is rapidly absorbed by the skin, conjunctiva, and mucous membranes, and within minutes 

irreversibly combines with tissue proteins, damaging 

the lungs, eyes, and skin.30 Over time, the exposed 

tissues blister and ulcerate.31 Ophthalmic injuries 

are best treated with copious water irrigation. Skin 

should be decontaminated with 0.5% hypochlorite. In 

general, skin burns from mustard are superficial and 

heal without difficulties; injuries to the mucosal linings 

are much more serious and disabling.

Electrical Injuries

Electrical injuries result from the conduction of 

electrical energy through tissue or from heat that is 

released as the current arcs through the air (Figure 

13-3). Current arcs may generate temperatures as high 

as 3,000°C. As they arc, they ignite clothing, which 

results in a combination electrical and thermal injury. 

Injuries caused by low voltage current (< 1,000 V) are 

occasionally fatal because of immediate ventricular 

fibrillation. Survivors rarely have significant tissue 

damage. High voltage (> 1,000 V) current can damage 

tissue anywhere along its route. 

Electrical injuries are heat related. Electrical energy 

is converted to heat energy as expressed by Joule’s 

law: power or heat equals amperage squared times 

resistance (P=I2•R).As voltage or amperage increases,

so does the heat produced. Measurement of tissue 

temperature experimentally reveals that it is highest 

directly underneath and adjacent to the contact site of 

the wounds. Deep tissue destruction is always greatest 

in areas of the body with small volume, such as the 

fingers, toes, wrists, or ankles. The farther away the 

tissue is from the contact point, the lower the current 

density, and the less heat is generated. Various tissues 

have different resistance to current flow; for example, 

nerves and blood vessels have low resistance, while 

cartilage and bone have high resistance. Because bone 

is highly resistant, current tends to flow at its surface, 

making temperature greatest at the periosteum. Thus, 

muscle damage is often extensive adjacent to the bone, 

Figure 13-2. Chemical burn to the lower extremities of a 

burn casualty.

Figure 13-3. Electrical burn to the upper extremity of a burn 

casualty. Note the extent of injury indicated by the presence 

of exposed subcutaneous structures on the dorsum of the 

hand.
282

Care of the Combat Amputee

and many times the periosteum and portions of the 

outer cortex of the bone may not be viable. For these 

reasons, the extent of electrical injury is often not 

well reflected in the cutaneous burn size.20 An electrical injury may be deceiving and not initially appear 

severe, with only small areas visible superficially, but 

the casualty may have severe limb injury that will 

ultimately lead to amputation.32

A sensitive indicator of total muscle damage following electrical injuries is serum creatine kinase (CK). 

Ahrenholz et al33 found that casualties with a total CK 

concentration of under 400 international units (IU) had 

no significant tissue loss; a few casualties with total CK 

concentration ranging between 400 IU and 2,500 IU 

required digit amputations or skin grafts. Casualties 

with a CK total greater than 2,500 IU had a high risk 

of major amputation, and those with a CK total greater 

than 10,000 IU had an 84% risk of major amputation 

or permanent neurologic deficit. More recently, Cancio 

et al reported age, myoglobinuria, and fasciotomy are 

independent predictors of amputation following high 

voltage electrical injuries.20

SEVERITY OF BURNS

The overall severity of a burn is related to the casualty’s age, TBSA affected, burn depth, associated 

injuries, and, to a lesser extent, associated illnesses.34

Age

The very young and the very old do not tolerate illness and trauma (particularly burn trauma) as well as 

those between 10 and 50 years of age. Military burn casualties typically range from 18 to 48 years of age.5, 24,25,35 

Individuals at the extremes of age are generally more 

physiologically fragile and poorly tolerate the massive 

fluid shifts and infectious complications associated 

with burn and its treatment. These factors should be 

considered during triage when the number of casualties exceeds available resources.

Burn Size

Evaluating and treating a burn requires an accurate 

assessment of the injury’s size. The three most commonly used methods of determining burn size include 

using the casualty’s palm as a reference, the rule of 

nines, and the Lund and Browder chart. The area of the 

palm, excluding the digits, represents approximately 

0.5% of the body surface over a wide range of ages.36 

Using a casualty’s palm to determine burn size is particularly useful for spotty burns in multiple areas. The 

rule of nines is a convenient way of estimating adult 

TBSA (Figure 13-4). Developed in the 1940s by Pulaski 

and Tennison, it is easily remembered because it divides the body surface into areas of 9% or multiples of 

9%. The head and neck equal 9%, each upper extremity 

is 9%, the anterior and posterior trunk are 18% each, 

each lower extremity is 18%, and the perineum is 1%. 

The rule of nines is easily applied in field situations, 

but is relatively inaccurate.37 The Lund and Browder 

chart, developed over 50 years ago, more accurately 

defines burn size and is commonly used in most burn 

centers (Figure 13-5). This chart assigns a percent of 

surface area to body segments,38 taking into account 

the disproportionate growth of the trunk, head, and 

lower extremities based on the age of the casualty. 

However, the chart is not always readily available and 

is too complex to commit to memory.

Recent reports show that the average burn size for 

both combat and noncombat injuries is between 7% 

and 15%.20,23–25 Despite the low average burn size for 

military casualties, the use of unconventional incendiary devices has resulted in casualties with large burns 

exceeding 95% TBSA.24

Burn Depth

Historically, burns have been classified into degree 

categories (ie, first, second, third, and fourth).39 More 

recently, however, burns have been classified by depth 

in relation to the tissues involved (epidermal, superficial partial-thickness, deep partial-thickness, full-thickness, or subdermal; Table 13-2). For example, a sunburn 

is a standard epidermal burn, and typically heals in 3 

to 6 days without long-term sequelae (Figure 13-6).40

Superficial partial-thickness burns are deeper than 

epidermal burns (Figure 13-7). They are best treated 

with daily dressing changes and heal without surgical intervention. A superficial partial-thickness burn 

may heal with minor color and texture changes, but it 

does not develop hypertrophic scarring.41 In contrast, 

a deep partial-thickness burn results in fragile skin, 

requires increased time to heal, and may create severe 

scarring (Figure 13-8). This type of burn is best treated 

with early excision and grafting.39 A full-thickness burn 

larger than 3 cm in diameter is best treated with early 

excision and grafting to prevent significant scarring 

(Figure 13-9).39 Subdermal burns should be treated by 

debriding devitalized tissues, ensuring exposed bone 

and tendons are covered by soft tissue, and expeditiously grafting skin to prevent significant scarring 

(Figure 13-10).39 Extensive soft tissue reconstruction 

may be required to cover these wounds.
283

Rehabilitation of Burn Casualties

In the case of a hand burn, knowledge of wound 

depth and location is imperative to determine an appropriate treatment plan. In particular, the presence of 

a deep palmar burn should be noted and taken into 

consideration when designing a splinting program. 

The location of eschar should also be noted prior to 

burn excision. If tendon involvement is suspected with 

a full-thickness burn, precautions should be made as 

if tendon involvement is confirmed.42

The dorsal hand is one of the most common sites for 

tendon exposure, especially over the proximal interphalangeal (PIP) joint. Hunt and Sato found that damage 

to the extensor tissue over the PIP joint resulted in the 

worst functional outcomes.43 Damage to the central slip 

of the extensor mechanism can lead to a boutonnière 

deformity. If tendon exposure is suspected or confirmed, 

care must be taken to protect the integrity of the tendon; 

exposed tendons can desiccate rapidly.44 A moist environment must be maintained with antibiotic ointments 

and petroleum-based gauze to prevent drying.

Reports from current military operations indicate the 

average TBSA full-thickness burn is between 4% and 

8%.23,24 The impact of combat versus noncombat injuries 

on burn depth has been shown to be insignificant.24

4.5

18 18

9

4.5

4.5 4.5 4.5 4.5

9 9 9

1

Figure 13-4. Rule of nines body chart for estimating burn size.

Reproduced from Pulaski EJ, Tennison CW. Exposure (open) treatment of burns. U S Armed Forces Med J. 1951:2;769.
284

Care of the Combat Amputee

Location

The anatomical location of burns is important in 

determining burn severity.45 Burns, even of similar size, 

to various areas of the body have differing and significant impacts on survival, functional outcome, and 

cosmesis, especially when depth of injury is factored 

in (Figure 13-11). Additional considerations for critical care, wound care, and rehabilitation management 

must be made for specialized anatomical areas, such 

as the face, hands, feet, and genitalia.41 Burns that cross 

skin creases require special rehabilitation to prevent 

contracture and minimize hypertrophic scarring.46

For military casualties, the most frequently burned 

anatomical areas include the head, face, and hands.23–

25,47 Injuries to these areas are due to several factors, 

including the need for unimpeded accessibility for 

vision, breathing, and communications, as well as for 

activities requiring maximal hand dexterity. Other anatomical locations frequently burned include the upper 

arm, forearm, thigh, and lower leg.23–25 New advances 

in body armor and flame-resistant protective clothing 

are being examined and fielded to decrease the incidence of burns to these areas.47 There is no noticeable 

difference in burn distribution between combat- and 

noncombat-related burn injuries, except that the face 

is more likely to be burned in combat operations.24

The burn location on the hand is important when 

determining an appropriate treatment plan. Rangeof-motion (ROM) exercises, splinting, or serial casting 

should be implemented in the direction of tissue tension to provide optimal tissue realignment. For example, a dorsal hand burn needs to be placed in the safe 

resting position to put mild tension on the involved 

structures. Exercises should emphasize regaining a 

composite flexion of the digits. A palmar burn will 

contract into thumb flexion, thumb adduction, and 

finger flexion. Splints or casts used for palmar burns 

should hold the hand in the position of thumb radial 

abduction and finger metacarpophalangeal (MCP), 

PIP, and distal interphalangeal (DIP) extension. Caution should be taken to avoid MCP hyperextension 

of the thumb when positioning into radial abduction. 

Exercises should emphasize finger extension and 

radial abduction. Flexion exercises can be performed 

to prevent joint capsule tightness of the MCP and interphalangeal (IP) joints; however, caution should be 

taken to avoid digital extension losses.

Associated Illnesses and Injuries

Most military casualties are healthy adults. However, 37% to 52% of combat burn casualties sustain associated injuries (Table 13-3).23,24,48 Additionally, combat 

burn casualties are significantly more likely to sustain 

associated trauma than noncombat burn casualties.24

Acute injuries, whether due to penetrating or blunt 

trauma, are given first priority. Inhalation injury affects about 16% of combat and 6% of noncombat burn 

casualties.24 An associated injury may complicate care, 

interfere with surgical treatment, and impede normal 

rehabilitation.

2

1

2

A A

1

2 13 2

B B

C C

2

13

B B

C C

LUND AND BROWDER CHARTS

CHART FOR ESTIMATING SEVERITY OF BURN WOUND

NAME WARD NUMBER DATE

AGE ADMISSION WEIGHT

RELATIVE PERCENTAGE OF BODY SURFACE AREA

AFFECTED BY GROWTH

AREA

A = 1/2 OF HEAD

B = 1/2 OF ONE THIGH

C = 1/2 OF ONE LEG

AGE 0 1 5 10 15 ADULT

91/2 81/2 61/2 51/2 41/2 31/2

23/4 41/4 4 41/2 41/2 43/4

21/2 21/2 23/4 3 31/4 31/2

REGION

HEAD

NECK

ANT.TRUNK

POST.TRUNK

RIGHT ARM

LEFT ARM

BUTTOCKS

GENITALIA

RIGHT LEG

LEFT LEG

TOTAL BURN

PTL FTL

%

KINDRE SIMPLE ERYTHEMA

Partial thickness loss

(PTL)

Full thickness loss

(FTL)

11/2 11

/2 11

/2

11/2 11

/2

11/2

21 2 /2 1

/2

11/2 11/2

13 1 /4 3/4

13 1 /4 3/4

Figure 13-5. Lund and Browder chart for estimating burn 

size. 

Adapted from Cioffi WG Jr, Rue LW III, Buescher TM, Pruitt 

BA. A brief history and the pathophysiology of burns. In: 

Bellamy RF, Zajtchuk R, eds. Conventional Warfare: Ballistic, 

Blast, and Burn Injuries. Part 1, Vol 5. In: Textbooks of Military 

Medicine. Washington, DC: Office of The Surgeon General, 

Department of the Army, and Borden Institute; 1991: 341.
285

Rehabilitation of Burn Casualties

Clinical Relevance

The severity of a burn has an impact on casualty 

survival, as well as on nutritional and surgical considerations. Additionally, severity largely influences 

rehabilitation outcomes.49 The physical manifestations 

of burn scar contracture, hypertrophic scarring, and 

overall long-term functioning are often directly attributable to how severely a casualty is burned.

The development and number of burn scar contractures have been directly related to the extent of 

TBSA burned (Figure 13-12).50 If less than 20% TBSA 

TABLE 13-2

BURN TERMINOLOGY

Old Classification New Classification Description

First degree Epidermal burn Involves only the epidermis, is erythematous or deeply tanned in 

appearance, does not blister

Second degree Superficial partial thickness burn Involves both the epidermis and dermis, blisters, is moist and 

erythematous, reepithelializes in less than 3 weeks

Deep partial thickness burn Cream colored or white beneath blisters, takes longer than 3 

weeks to heal

Third degree Full thickness burn Involves the entire depth of the skin, destroys both the epidermis 

and dermis, must heal from the wound margins

Fourth degree Subdermal burn Occurs when damage is deep to the skin and involves muscle, 

bone, and other deeper tissues

Data sources: (1) Richard R. Assessment and diagnosis of burn wounds. Adv Wound Care. 1999;12(9):468–471. (2) Devgan L, Bhat S, Aylward 

S, Spence RJ. Modalities for the assessment of burn wound depth. J Burns Wounds. 2006;5;e2. (3) Peitzman AB. Burns/inhalation injury. 

In: Peitzman AB, ed. The Trauma Manual: Trauma and Acute Care Surgery. 3rd ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams 

& Wilkins; 2008: Chapter 45. (4) Johnson RM, Richard R. Partial-thickness burns: identification and management. Adv Skin Wound Care. 

2003;16(4):178–189.

Figure 13-6. Typical appearance of an epidermal burn.

Figure 13-7. Superficial partial-thickness burn with intact 

blisters.
286

Care of the Combat Amputee

is burned, a casualty is expected to do well, unless the 

hands are heavily involved, in which case the potential 

for impaired functional outcomes is considerable.45 If 

more than 20% TBSA is burned, casualties begin to 

manifest burn scar contractures during the intermediate and long-term phases of burn rehabilitation. 

Recently, the incidence of burn scar contracture has 

been identified to be as high as 50%.51 Additionally, 

burn depth has long been implicated in the appearance of burn scar contractures, based on healing either 

by secondary intent or skin grafting and burn wound 

location relative to anatomic functional sites.50,52,53 In 

recent combat operations, TBSA burned, inhalation 

injury, associated trauma, and length of hospitalization were found to be the most influential parameters 

determining whether or not an injured service member 

would return to duty.54

Figure 13-10. Subdermal burn displaying exposed tendon 

and bone on the dorsum of the hand.

Figure 13-8. Deep partial-thickness burn demonstrating 

mottled appearance. Figure 13-9. Full-thickness burn showing eschar on flank.

CRITICAL CARE OF BURN CASUALTIES

Skin, the largest organ of the body, is vital for 

survival. Aside from protecting the body from losing 

temperature, fluid, electrolytes, and other solutes, skin 

provides the first line of protection from a hostile microbial world. Severely burned casualties experience 

a cascade of metabolic and physiologic consequences, 

including recurrent infections, organ failure, and, in 

the worst cases, death. Until every open wound can be 

closed with functional skin, a burn casualty remains 

at risk for infection and organ failure. Open wounds 

must be closed with autograft and healing conditions 

must be optimized before organ failure and death can 

ensue. Organ support, nutrition, and early rehabilitation should optimize the conditions for successful 

graft take.

Burns involving critical locations must be identified 

immediately to be managed appropriately. The head, 

face, hands, feet, genitalia, perineum, and major joints 

are considered critical areas by the American Burn Association and must be managed at a burn center.

Early Life Support Evaluation and Management

In most cases, especially during military conflict, it 

is crucial to remember that burn injury is a traumatic 

event, often associated with other possibly life-threatening injuries. Isolated burns are rarely immediately 

life threatening; however, burn casualties must be 

viewed within the context of a multisystem injury that 

could reveal varying degrees of life-threatening conditions. Other conditions that may result in immediate 
287

Rehabilitation of Burn Casualties

death include a compromised airway and uncontrolled 

hemorrhage, and should be identified and treated 

first. A thorough and rapid assessment of the casualty 

helps prioritize care during the initial critical phase. 

Primary and secondary surveys are designed to help 

rescuers identify and treat the most life-threatening 

conditions.

Service members often initially manage and treat 

burn casualties. This treatment should follow the 

three basics of first aid: (1) stop the burning process, 

(2) evaluate and secure the airway, and (3) treat other 

life-threatening injuries. If the airway is compromised, 

ventilation should be maintained by mask and oxygen, or intubation if possible (see “Respiratory Considerations” below). When facial or neck edema is 

anticipated from fluid administration and prolonged 

transport times (ie, > 4 hours), intubation is usually 

necessary prior to transfer. The burn wound should be 

covered with a clean sheet or simple dry dressing to 

minimize further contamination and to help conserve 

body heat. The basics of trauma emergency care apply 

to initial burn treatment.

Vascular venous access is established peripherally 

for immediate use, or centrally for when necessary or 

4.5

18 18

9

4.5 4.5 4.5 4.5

9 9 9

1

4.5

18 18

9

4.5

4.5 4.5 4.5 4.5

9 9 9

1

4.5

Anterior Posterior Anterior Posterior

Figure 13-11. Body diagrams of equal size burn depicting the difference that location of burn has on functional areas. Number of Contractures

Total Body Surface Area

60

40

20

20 40

0

60 80

Figure 13-12. Graph displaying the relationship between 

total body surface area burned and the incidence of burn 

scar contractures. 

TABLE 13-3

INCIDENCE OF ASSOCIATED TRAUMA IN 

BURN CASUALTIES

Type of Injury Incidence

Eye injury 8.5%

Skull fracture 7.5%

Neck/Torso fracture 3.5%

Upper limb fracture 10.0%

Lower limb fracture 16.6%

Intracranial injury 2.0%

Internal torso injury 4.2%

Fragment wounds 38.4%

Traumatic amputation 2.3%
288

Care of the Combat Amputee

when multiple ports are required. Obtaining central 

venous access is not without risks; however, central 

venous lines provide a means of monitoring central 

venous pressure and ease serum sampling. Casualties 

with cardiovascular instability or inhalation injuries 

often benefit from arterial lines, which provide hemodynamic values and allow blood to be drawn without 

repeated arterial punctures. 

The secure maintenance of intravascular devices 

warrants special care as well. Loss of these devices 

places a casualty at unnecessary risk of additional 

invasive procedures. Intravascular devices should be 

securely sutured or stapled in place at multiple anchor 

points, with care and attention given to these sites 

during rehabilitation activities. 

Fluid Resuscitation

Severe burn injury results in massive fluid shifts 

from the intravascular space into the interstitium and 

intracellular space of both burned and unburned tissues.55 This fluid shift results in intravascular volume 

depletion and hemoconcentration, with blood hematocrit elevated in the first 24 hours after burn.56 Several 

formulas exist to calculate the required amount and 

rate of volume repletion for burn casualties,57 such as 

the modified Brooke formula,58 in which volume is 

replenished by providing crystalloids (Ringers lactate, 

2 mL/kg/% burn) over the first 24 hours post burn. 

No colloids are given during the first 24 hours. Over 

the next 24 hours, colloids are provided in the amount 

of 0.3 to 0.5 mL/kg/% burn. No crystalloids are given 

during the second 24 hours. Glucose in water is also 

provided over the second 24 hours and titrated to 

maintain good urinary output. 

The Starling equation indicates that two forces, 

capillary hydrostatic pressure and interstitial colloid 

osmotic pressure, push fluid out of the vasculature 

into the interstitium (Exhibit 13-1).6 The remaining two 

forces, capillary colloid osmotic pressure and interstitial hydrostatic pressure, work to counterbalance this 

shift by holding fluid in the vasculature. These forces 

are balanced in a healthy organism.6 Based on this 

principle, fluid resuscitation is managed to maintain 

organ perfusion with minimal physiological cost.7

Delayed or inadequate replacement of intravascular 

volume results in suboptimal tissue perfusion and 

can lead to end-organ failure and death. The goal of 

fluid resuscitation after severe burn is to replace lost 

intravascular volume with intravenous (IV) crystalloid, 

maintaining adequate tissue perfusion throughout the 

48-hour period of increased capillary leak and relative 

hypovolemia at the lowest physiologic cost.59

Casualties with severe burns, extensive soft tissue 

trauma, inhalation injury, or electrical injury require 

increased amounts of fluid to prevent burn shock. In 

certain casualties, burn shock and resuscitation failure 

occur, despite optimal resuscitation by experienced 

personnel, because of factors associated with limits in 

cardiovascular reserve and adverse host responses.60

Under resuscitation, which contributes to shock, 

and acute renal failure must be avoided. On the 

other hand, the consequences of over resuscitation 

have been termed “resuscitation morbidity” and 

have severe, long-ranging effects. Resuscitation 

morbidity includes complications such as extremity 

eschar and compartment syndromes and abdominal 

compartment syndrome (ACS).61 Extremity eschar 

and compartment syndromes resulting from over 

resuscitation have immediate and long-term rehabilitation consequences. Eschar syndrome is characterized by a leathery, noncompressible, circumferential 

burn that prevents skin expansion as tissues become 

edematous. This leads to compromised tissue perfusion. Early mobility may be restricted when edema 

impairs joint motion (Figure 13-13). In addition to 

EXHIBIT 13-1

STARLING EQUATION

Jv = Kf ([Pc - Pi] – σ [πc - πi]) 

Kf: filtration coefficient

πc: capillary oncotic pressure

πi: interstitial oncotic pressure

Pc: capillary hydrostatic pressure

Pi: interstitial hydrostatic pressure 

σ: reflection coefficient Figure 13-13. Example of an escharotomy of the lower 

extremities.
289

Rehabilitation of Burn Casualties

early escharotomy, early extremity elevation and 

range-of-motion exercises are encouraged to decrease 

gravity-dependent edema. 

Extremity compartment syndrome differs from 

eschar syndrome in that it is characterized by tissue expansion occurring specifically within a fascial 

compartment, resulting in decreased tissue perfusion 

and cell death. The mainstay of management is early 

recognition through monitoring of compartment pressures, and release of the involved compartment via 

fasciotomy if compartment pressures are elevated 

(Figure 13-14). 

Delaying escharotomy or fasciotomy can result in 

myonecrosis. Acutely, myonecrosis can lead to acute 

renal failure and lung injury secondary to the systemic 

release of intracellular contents into the circulation. 

The long-term consequences of myonecrosis are linked 

to the muscle groups involved. From a rehabilitation 

standpoint, loss of significant muscle groups can 

severely impact a casualty’s functional outcome in 

various ways, ranging from the loss of independence 

with ambulation or transfers acutely to increased risk 

for overuse and degenerative processes due to muscle 

imbalances over the long term.

ACS results in decreased renal blood flow and subsequent renal failure, intestinal ischemia, respiratory 

failure, and death if not recognized and treated early.62

A resuscitation volume greater than 237 mL/kg over 

12 hours (or 16 liters over a 12-hour period in a 70 kg 

male) appears to be the threshold for the development 

of ACS.63 Treating ACS by placing a drain and performing an abdominal escharotomy (or a decompressive 

laparotomy as a last resort) may improve survival but 

is associated with dramatic increases in morbidity.

The mortality rate after decompressive laparotomy 

for ACS in burn casualties is documented to be 60% 

to 100%.64 For those few survivors, the added catabolic load of an open abdomen (and all the potential 

subsequent complications thereof) can significantly 

increase wound healing times, muscle catabolism, and 

functional recovery time.

Respiratory Considerations

Intubation entails passing an endotracheal tube 

from either the nose or the mouth through the pharynx into the trachea. This tube is then connected 

to a mechanical ventilator to cause inspiration and 

passive exhalation through the lungs. General indications for intubation in burn casualties are to 

improve oxygenation and ventilation, or to maintain 

gas exchange during respiratory distress or clinical 

conditions expected to compromise the airway. Indications include:

	 •	 tachypnea,

	 •	 hypoxia,

	 •	 impending need for airway maintenance,

	 •	 initial management of smoke inhalation injury,

and

	 •	 expected massive edema.

The importance of securing an airway device cannot 

be overemphasized. During rehabilitation activities, 

caution must be exercised and all efforts should be 

made to prevent the loss of the airway. The inadvertent 

displacement or removal of an endotracheal tube is 

often fraught with difficulties and can (rarely) result 

in death. Commercially available, function-specific 

devices are not ideal for burn casualties, especially 

those with burns of the face and neck. Tape does not 

adhere to burned tissue, and the edema associated with 

resuscitation is often marked.

To ensure security of an endotracheal tube, a cotton umbilical tape is tied securely around the tube, 

then around the head. As facial edema increases and 

decreases, adjustments in the ties should be made to 

prevent skin breakdown. Alternatively, stainless steel 

wire may be routed around a molar tooth and the 

wire subsequently attached to the endotracheal tube. 

This technique is sturdy and eliminates the need for 

constricting materials across the face. The challenge of 

this technique is routing the wire. Wire cutters should 

be readily accessible for removing the securing wire 

if necessary.

Endotracheal intubation and respiratory support 

treat burn casualties in two general groups: those 

who need a definitive airway for airway protection, 

and those who need mechanical ventilation. Casualties needing airway protection may include those 

whose airways have been compromised by upper 

airway inhalation injury, airway edema from massive 

Figure 13-14. Example of a fasciotomy (carpal tunnel release) 

of the upper extremity.
290

Care of the Combat Amputee

resuscitation, or loss of consciousness from carbon 

monoxide poisoning. Casualties needing ventilatory 

support include those with severe smoke inhalation 

injury, acute lung injury, acute respiratory distress 

syndrome, or those who require deep sedation for 

extensive burns. 

Endotracheal tubes can be placed either via the 

nasotracheal or orotracheal route. If orotracheal intubation is used, a bite block should be placed between the 

teeth to prevent the casualty from biting the tube and 

obstructing it. The nasotracheal route is preferred because the tube can be better secured, and oral care and 

rehabilitation can be performed that intubation via the 

orotracheal route would not allow. The disadvantages 

of using the nasotracheal route include inability to pass 

the tube, discomfort, and the potential for sinus infection. Occasionally, severe burns involving the face and 

neck preclude traditional nasotracheal or orotracheal 

intubation, and performance of a cricothyroidotomy 

may be required. The cricothyroidotomy is generally 

followed by a formal tracheostomy when appropriate 

surgical support is available.

A tracheostomy may be necessary for some casualties, either acutely due to the inability to access the 

airway via the orotracheal or nasotracheal route, or 

long term because of a prolonged need for mechanical 

ventilation. Tracheostomies often offer the advantage of 

better comfort, improved oral care, and improved ability 

to clear pulmonary secretions. However, the risks and 

benefits of the tracheostomy must be weighed because 

complications, although uncommon, can be fatal.

The tracheotomy tract usually matures in 5 to 10 

days. If the tube is unintentionally pulled out before 

the stoma and if the tract has matured, replacing the 

tube can be difficult. It is therefore crucial that careful attention is given to the tracheotomy site during 

all rehabilitation activities or whenever there is a 

significant position change. It is recommended that a 

respiratory therapist be present at all times during any 

major casualty movement when an endotracheal tube 

or a fresh tracheotomy is present. 

There are various modes of ventilatory support, 

including:

• Controlled mechanical ventilation. The casualty receives a breath from the ventilator 

at predetermined rates, whether or not the 

casualty attempts to breathe. This mode is 

rarely used in the intensive care unit. 

	 •	 Assist control (volume or pressure). The 

casualty receives a ventilator breath, either 

volume- or pressure-targeted, whenever an 

attempt to breathe is made; a minimal rate is 

provided if no attempt to breathe is made.

	 •	 Synchronized intermittent mandatory ventilation. Regular predetermined breaths are delivered and casualties are allowed to breathe 

first at their own tidal volume, later between 

ventilated breaths. This mode is frequently 

used for weaning.

	 •	 Pressure support. The casualty initiates every 

breath, which is supported with a set amount 

of pressure.

	 •	 Continuous positive airway pressure. Continuous positive airway pressure restores the 

glottic mechanism of intrapulmonary pressure 

maintenance, which has been eliminated by 

intubation. This allows the casualty to take 

full spontaneous negative-pressure breaths. It 

is the setting most used during spontaneous 

breathing trials.

	 •	 Other modes. High-frequency oscillatory 

ventilation, high-frequency percussive ventilation, airway pressure release ventilation, 

and bilevel continuous positive airway pressure are alternative modes of ventilation that 

can be used for ventilatory support. 

Ventilation and oxygenation must be monitored in 

casualties on mechanical ventilation. Adequate ventilation is assessed via arterial carbon dioxide tension. 

A casualty’s minute ventilation (the amount of carbon 

dioxide exchanged in 60 sec) is the product of the 

volume of each breath (tidal volume) and respiratory 

rate over a minute. A minute ventilation requirement 

can be affected by a variety of conditions, including 

exercise. Thus, it is possible that simple ROM exercises 

in a severely burned casualty, already pushed to the 

limit in terms of catabolic workload at baseline, can 

result in carbon dioxide accumulation. An acute rise 

in carbon dioxide (hypercapnea) can result in respiratory acidosis, leading to a variety of systemic effects 

(eg, coagulopathy, hemodynamic compromise, and 

mental status changes). A casualty’s ventilatory status 

must be closely monitored during rehabilitative sessions. Arterial carbon dioxide is typically measured via 

blood gas analysis. After assessing the partial pressure 

of carbon dioxide, ventilatory settings can be made to 

adjust minute ventilation.

Oxygenation is determined using the partial pressure of oxygen in arterial blood. In general, 60 mmHg 

of oxygen has been considered sufficient oxygenation. 

Another frequently used monitor is pulse oximetry, 

which is an optical measurement of oxygenated hemoglobin in pulsatile vessels. The percentage of oxygenated hemoglobin in the arteries can be calculated 

using differences in absorption of red and infrared 

light. Because of the shape of the oxyhemoglobin 
291

Rehabilitation of Burn Casualties

dissociation curve, when the saturation of oxygen 

exceeds 90% and the partial pressure of oxygen in 

arterial blood is greater than 60 mmHg, the curve is 

flat, and the latter can change considerably with little 

change in the former. Regardless, it is assumed that an 

oxygen saturation value greater than 90% is indicative 

of adequate oxygenation. Like minute ventilation, the 

impact of exercise on oxygenation can be significant. 

This is particularly important in casualties who have a 

high oxygen requirement (ie, needing > 50% fraction of 

inspired oxygen [FiO2]). It may be necessary to closely 

monitor oxygen saturation to determine the limits of 

an activity. In general, activity should be curtailed or 

stopped when oxygen saturation is less than 90%.

Ventilator-associated pneumonia is a common 

complication in intubated and ventilated casualties 

and is associated with high morbidity and mortality. 

Hospital-acquired pneumonia can occur in nonintubated casualties with an equally morbid impact. In 

burn casualties, especially those with smoke inhalation 

injury, both ventilator-associated pneumonia and hospital-acquired pneumonia occur at a much higher frequency, and all efforts must be made to minimize this 

nosocomial complication. Simple interventions, such 

as frequent handwashing, daily oral care with chlorhexidine oral rinse, and head-of-bed elevation above 

30o can decrease the incidence of hospital-acquired 

pneumonia and ventilator-associated pneumonia.65

Early mobilization out of bed to an upright position, 

either chair or standing frame, can optimize pulmonary function in spontaneously breathing casualties. 

Compared to the supine position, the upright position 

allows for easier diaphragmatic excursion with each 

breath, bibasilar recruitment of atelectatic alveoli, 

and improved aeration. In casualties with abdominal 

distension, a standing position may be preferred over 

a sitting position to allow optimum excursion. In addition to optimal positioning, burn casualties use secretion-clearing devices for aggressive pulmonary toilet.

In general, those casualties who require only airway 

protection may be good candidates for early mobilization out of bed. Casualties who are cooperative, minimally sedated, and have minimal lung pathology, may 

even be able to ambulate, with assistance of frequent 

bagging. Aggressive mobilization out of bed for rehabilitation activities, such as tilting and transfers to sitting 

position, can be safely performed with—and is recommended for—intubated casualties. Respiratory parameters during mobilization of intubated casualties out of 

bed include a peak inspiratory pressure equal to or less 

than 30 cm H2O and a FiO2 equal to or less than 40%.

Once airway edema has subsided and it is determined that casualties are able to protect their own 

airways, extubation may be considered. Typically, 

those who are placed on a ventilator for pulmonary 

problems remain on mechanical ventilation until the 

underlying reason for needing the support has resolved. These casualties are placed on a spontaneous 

breathing trial when the provider feels they no longer 

require as much or any ventilator support. Breathing 

trials can last anywhere from 30 minutes to 2 hours, 

during which it is important that casualties are not 

overly stimulated or anxious. 

A significant amount of interdisciplinary coordination is necessary in order to perform spontaneous 

breathing trials around daily wound care and rehabilitation. In some cases, casualties no longer need a 

ventilator, but may continue to require airway protection. The use of continuous positive airway pressure 

or a minimal spontaneous mode of ventilation may 

be appropriate.

Once the casualty is liberated from a ventilator, aggressive pulmonary hygiene is crucial to maintain the 

airway. Proper casualty care includes frequent deep 

breathing, coughing, position changes, use of incentive spirometer, nebulizer treatment, and provision of 

humidified oxygen. Suctioning may be required if a 

casualty is not able to adequately clear secretions. Continued monitoring of arterial blood gasses or oximetry 

and serial chest radiographs are required.66

Gastrointestinal Considerations

The gastrointestinal response to burn is highlighted 

by mucosal atrophy, changes in digestive absorption, 

and increased intestinal permeability.67 Atrophy of the 

small bowel mucosa occurs within 12 hours of injury 

in proportion to the burn size. Given the changes in 

the gut, it is common to see evidence of gut dysfunction after burn manifested by feeding intolerance and 

mucosal ulceration and bleeding, particularly in the 

stomach and duodenum. Enteral feeding is one of the 

most important means of providing nutrition to burn 

casualties and has led to a decrease in mortality,but at 

times the gut will not cooperate.68 Reduced motility and 

ileus are common, at times requiring parenteral nutrition to meet caloric needs. At the present time, there 

is no specific treatment for burn-induced ileus, but it 

seems that early enteral feeding will prevent some of 

these potential complications. Gastric distention can 

be avoided by nasogastric tube decompression of the 

stomach, accompanied by enteral feeding through a 

tube placed beyond the ligament of Treitz. Failure to 

decompress the stomach can result in respiratory complications that need to be considered when deciding 

optimal positioning of the casualty. Furthermore, the 

risk of aspiration must be considered, and the head of 

the bed elevated to greater than 30o as often as possible.
292

Care of the Combat Amputee

Curling’s ulcer, with erosion of the stomach and 

duodenal mucosa, results in upper gastrointestinal 

bleeding or perforation. However, its incidence has 

been largely eliminated by the use of histamine-2 

blockers, proton-pump inhibitors, early enteral feeding, and antacids. Burn casualties with significant anemia and resultant hemodynamic instability should be 

evaluated for stress-induced gastrointestinal bleed. 

Occasionally, severe burns involving the face and 

neck preclude traditional nasotracheal or orotracheal 

intubation, and performance of a cricothyroidotomy 

may be required. The cricothyroidotomy is generally 

followed by a formal tracheostomy when appropriate 

surgical support is available.

Metabolic Considerations

Over the course of hospitalization, catabolic derangement in burn injury results in a tremendous loss 

of lean body mass. This occurs over the entire first year 

after injury, and the impact on the rehabilitative course 

can be significant, ranging from isolated strength impairments to decreased independence with activities 

of daily living (ADLs). Time to full functional recovery 

may also increase. 

One of the responses to severe burn is a dramatic 

increase in catecholamine production. This has been 

linked to a number of metabolic abnormalities, including increased resting energy expenditure (REE), muscle 

catabolism, and altered thermoregulation.69 The effects 

of this sustained catecholamine surge on the cardiac 

system are to increase heart rate and, therefore, myocardial work. Propranolol, a nonspecific β-blocker, has 

been used to decrease heart rate and myocardial work 

in casualties with severe burns.Propranolol can be given intravenously and orally to equal effect on heart rate 

and myocardial work without detrimental effect on cardiac outputor response to stress. Propranolol administration also decreases peripheral lipolysis and muscle 

catabolism, which are additional beneficial effects.70

Oxandrolone, an anabolic agent that helps decrease 

lean mass catabolism and improves wound healing, 

was recently shown to significantly decrease length of 

hospital stay.71 Oxandrolone should be considered in 

all casualties with a burn size greater than 20% TBSA. 

Liver function tests should be monitored for the potential for hepatotoxicity and stopped if significant 

elevations in enzymes are detected. 

Renal Considerations

Acute renal failure, usually in the form of acute tubular necrosis, is characterized by deterioration of renal 

function over a period of hours to days, resulting in the 

failure of the kidney to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasis.72 In burn casualties, the causes can generally be narrowed to renal hypoperfusion from volume depletion 

or sepsis, or nephrotoxic iatrogenic insults (eg, aminoglycosides or IV contrast agents). Acute renal failure 

may be isolated or may occur in conjunction with other 

organs (ie, multiple organ dysfunction syndrome).

Generally, a conservative approach is applied in 

managing acute renal failure. Supportive care, optimization of hemodynamics, and prevention of further 

insults will result in resolution. In severe cases, renal 

replacement therapy or extracorporeal renal support 

is needed to eliminate toxins. Various modalities can 

be used, including intermittent hemodialysis and continuous renal replacement therapies.73 To date, trials 

have not shown any differences in outcomes between 

continuous modes of renal replacement and traditional 

intermittent dialysis.74

The rehabilitative implications of renal replacement 

therapy depend on the modality. In hemodynamically stable casualties with renal failure, intermittent 

hemodialysis is generally well tolerated and, because 

casualties are off dialysis the majority of the day and 

are allowed to participate in rehabilitation sessions, 

it does not hinder rehabilitation. Casualties who are 

hemodynamically unstable and need vasopressor support are often unable to tolerate intermittent hemodialysis. For these casualties, treatment with continuous 

renal replacement therapy may be effective. While a 

casualty receives treatment, rehabilitation is limited 

to therapeutic bed exercises and positioning because 

working vascular access must be maintained without 

bending or kinking the catheter. Casualties typically 

remain in bed for the duration of treatment. 

Cardiac Considerations

Early rehabilitative care in severely burned casualties requires an understanding of cardiovascular physiology in the acute period. There is a direct link between 

cardiac performance and casualty function. Several factors, including ventricular preload, myocardial contractility, ventricular afterload, and heart rate and rhythm, 

determine cardiac function, and thus tissue perfusion 

of blood, at the whole body level. Understanding the 

effects of each of these components on heart function, 

as well as the effects of added activity, is necessary 

for the optimal rehabilitative care of the casualty.

Ventricular Preload

The force that stretches the cardiac muscle prior 

to contraction is known as “preload.” Severe burns 

reduce preload to the heart through volume loss 

into the burned and nonburned tissues. Therefore, 
293

Rehabilitation of Burn Casualties

volumes predicted by resuscitation formulas must be 

used to maintain blood pressure and hemodynamics. 

The Frank-Starling relationship describes the increase 

in cardiac performance via preload augmentation by 

volume resuscitation.75 Preload is measured clinically 

by either central venous pressure or by pulmonary 

capillary wedge pressure (PCWP) obtained with a 

pulmonary artery catheter. Of these, the PCWP is 

the best estimate because it assesses the left side of 

the heart. 

Myocardial Contractility

The force with which the heart contracts is referred 

to as “cardiac contractility.” Severe burns can induce 

myocardial depression early (characterized by abnormalities in contraction and relaxation),76 reducing 

cardiac output. This is followed by a hyperdynamic 

phase of increased cardiac output that generally persists throughout hospitalization. 

Ventricular Afterload

Afterload is the force that impedes or opposes 

ventricular contraction. Elevated afterload is most 

evident early in the course of injury; however, shortly 

thereafter, it is decreased primarily through vasodilation and an increase in heart rate. 

Heart Rate and Rhythm

For the heart to function properly, the electrical 

conduction system must be intact and provide regular contractions sufficient to propel blood through 

the circulatory system. If heart rate exceeds 160 beats 

per minute, the heart may not have time to fill completely, thus decreasing myocardial fiber stretch and 

heart function. The same effect is seen with frequent 

premature ventricular or irregular beats. Heart rate 

and rhythm are continuously monitored in critically 

ill casualties.

Hemodynamic Therapy: Preload Augmentation and 

Use of Vasopressors

When a patient exhibits hypotension or other signs 

of inadequate cardiac function (eg, decreased urine 

output), the usual response is to augment preload by 

increasing intravascular volume. This sound physiologic approach is based on the Frank-Starling principle, and should be the first therapy for a casualty 

in shock. Intravascular volume can be increased with 

either crystalloid or colloid to increase the central venous pressure and PCWP to a value between 10 and 

20 mmHg. The effects of this therapy can be monitored 

by the restoration of arterial blood pressure, a decrease 

in tachycardia, and a urine output greater than 0.5 

mL/kg/h.

If volume replacement is insufficient to improve 

hemodynamics in burn casualties in shock, vasopressor support may be required. Agents with primary 

effects on the α-adrenergic receptor can be used to 

induce vasoconstriction and increase blood pressure. 

These agents consist of norepinephrine and phenylephrine, and can be used effectively during septic 

shock or neurogenic shock to increase vascular tone. 

In burn casualties, it is believed that these agents 

cause vasoconstriction of the skin and splanchnic circulation to preserve blood flow to major organs, such 

as the heart and brain. This redistribution in blood 

flow can convert partial-thickness skin injuries to 

full-thickness injuries and result in ischemic injury to 

the gut. The benefits of specific vasoconstrictors must 

be weighed against these effects. Alternative agents 

include vasopressin, dopamine, dobutamine, and 

epinephrine. Vasopressin acts primarily by augmenting the effects of existing catecholamines. Dopamine 

has a dose-related response at different receptors. 

Dobutamine, which is considered an inotrope, acts 

primarily on β-receptors and increases contractility 

(and thus stroke volume). Epinephrine has both β

and α properties. 

The cardiac implications of physical activity during 

rehabilitation are extremely important. Casualties who 

have inadequate preload, as determined by central venous pressure or PCWP, are likely to exhibit orthostatic 

symptoms when going from the supine position to an 

upright chair or standing position. Inadequate preload, 

when further decreased by gravity via venous pooling 

in the lower extremities, can lead to tachycardia and 

hypotension because the casualty cannot maintain or 

augment sufficient cardiac output. In these instances, 

intravascular volume loading (with crystalloid, colloid, 

or blood products) may allow the casualty to tolerate 

positioning changes more readily. 

Contractility and afterload varies in the post-burn 

period. Early on, physical activity may not be tolerated due to depressed myocardial function. Later, 

profound tachycardia may prohibit activity and limit 

rehabilitation potential. A casualty may also be hemodynamically unstable, requiring vasopressor support, 

and unable to tolerate rehabilitation. Physical activity 

is not necessarily prohibited when a vasopressor is 

required. Constant communication between the rehabilitation team and the critical care team is vital to 

determine a casualty’s threshold for any type of activity. An understanding of cardiovascular physiology 

and its impact in the post-burn period is important 

in order to optimize rehabilitation and promotion to 

functional recovery. 
294

Care of the Combat Amputee

Hematological Considerations

Severely burned casualties develop a variety of 

hematologic conditions that may impact the rehabilitative process.

Anemia

Over the last 10 years, restrictive transfusion 

practices have led to clinicians being more tolerant 

of lower hemoglobin and hematocrit levels; studies 

demonstrated improved outcomes for casualties who 

tolerated anemia with hemoglobin levels as low as 

7 g/dL.77 Unless anemia is acute, lower hemoglobin 

levels are not only well tolerated, limiting unnecessary, potentially harmful blood transfusions, but can 

save lives. Severely burned casualties are generally 

not transfused blood products unless they are symptomatic from anemia; it has become more common 

to transfuse blood only when hemoglobin levels fall 

below 7 g/dL, unless there is active bleeding, shock, or 

evidence of myocardial ischemia. Thus, rehabilitation 

occurs routinely in casualties with stable anemia and 

is, in most cases, well tolerated.

Thromboembolic complications

Thromboembolic complications were thought 

to be rare in the burn population; however, recent 

reports have suggested an incidence at an estimated 

2.9%.78 This is much lower than the general trauma 

population, but remains clinically significant. As a 

result, on admission, burn casualties are placed on 

chemoprophylaxis with either low-molecular–weight 

heparin or unfractionated heparin. Those who are 

at highest risk (eg, those who are morbidly obese or 

have sustained spinal cord trauma) may be considered 

for inferior vena cava filter placement. Development 

of deep venous thrombosis is not a contraindication 

for early mobilization out of bed. Generally, after a 

deep venous clot has been identified, the casualty is 

fully anticoagulated with IV heparin. Casualties may 

be as physically active as they can tolerate; there is 

no evidence that early activity increases risk of clot 

dislodgement and pulmonary embolism. However, 

anticoagulation is recommended for at least 24 hours 

prior to any activity. 

Nutritional Considerations

Severe burn injury results in a hypermetabolic and 

catabolic state. For burn casualties, adequate nutrition 

is vital for wound management and rehabilitation. 

Without it, wounds, grafts, and donor sites will not 

heal, and the casualty will become more susceptible to 

infection. Additionally, weight loss can be associated 

with impaired immune function, decreased wound 

healing, functional impairments, and morbidity.79 All 

the members of the interdisciplinary burn team must 

be familiar with the importance of providing nutrition 

to burn casualties. Providing adequate nutrition is a 

difficult task, considering that resting energy can be as 

high as double normal levels. The needs of casualties 

with less than 20% TBSA burns can usually be met with 

a high-calorie, high-protein diet and supplemental 

multivitamins. Casualties with greater than 20% to 

30% TBSA burned often require nutritional support 

via feeding tubes. Many complications and treatments 

can inhibit feeding, and careful monitoring is essential. 

The goals of nutrition support are to avoid malnutrition without overfeeding, to promote wound healing 

and graft retention, to preserve immune function and 

gut integrity, and to maximally support functional 

rehabilitation.

After burn injury, the body goes through ebb and 

flow phases. The ebb phase is characterized by decreased cardiac output, oxygen consumption, body 

temperature, blood volume, and insulin levels. The 

flow phase is characterized by increased cardiac output, oxygen consumption, body temperature, insulin 

levels, and gluconeogenesis.80 In 1979 Long et al discussed the ebb and flow phases in subjects with major 

burns, describing the loss of nitrogen through the urine 

and the REE by indirect calorimetry.81 Burn casualties 

have been shown to have a prolonged flow phase. 

Pereira et al found that the initial increase in REE can 

be as high as double, 150% at full healing, 140% at 6 

months, 120% at 9 months, and as high as 110% after 

12 months.82 The magnitude and duration of the flow 

phase can be minimized by placing casualties in a 

warm environment, providing adequate pain relief, 

completing early wound closure, applying occlusive 

wound dressings, and preventing sepsis. 

Burn injury results in major changes in metabolism 

that are believed to be largely hormone-mediated. These 

changes are likely due to increased catecholamines, 

glucocorticoids, and glucagon-to-insulin ratios, and 

they include increased gluconeogenesis, proteolysis, 

and ureagenesis, and decreased lipolysis and ketone 

utilization. In addition, skin barrier destruction results 

in physiologic losses of heat, water, and water-soluble 

nutrients. These changes result in increased energy 

expenditure, increased nitrogen losses, and changes in 

nutrient metabolism. The body’s available kilocalorie 

stores are quickly consumed after a burn injury, and gluconeogenesis must occur to further fuel the body (Table 

13-4). This results in the expense of lean body mass.

Nutritional support for burn casualties should be 
295

Rehabilitation of Burn Casualties

initiated early. Studies have shown early feeding after 

burn injury increases gut size in animals,83 promotes 

better nitrogen balance in humans,84 and can be safely 

initiated.83,85 Nutritional support should be monitored 

closely to ensure that nutritional needs are being met 

that promote wound healing. Underfeeding can affect 

wound healing and immunocompetence.86 Overfeeding can result in hyperglycemia, elevated carbon 

dioxide, and fatty liver, leading to delayed ventilator 

weaning and liver dysfunction.

Energy needs can be estimated using equations that 

are based on factors such as body size, age, activity 

level, and percentage of burn. A casualty’s preburn 

weight should be used in figuring energy needs because weight is affected by massive edema, as well 

as bulky dressings and external fixations. Many other 

factors affect a burn casualty’s metabolic rate, such 

as body composition, body temperature, circadian 

rhythm, ambient temperature,87 chemical paralysis,88

the energy costs of protein synthesis and respiratory 

stress, evaporative heat loss from wounds, infection,89

other trauma, pain, the thermogenic effect of food, and 

surgery. No metabolic rate equation can incorporate 

this vast range of variables. 

The most well-known equation for calculating burn 

energy needs was developed by Curreri et al, and 

uses weight and burn size to determine needs.90 Later 

studies show that it is likely that this formula overestimates the calorie needs.91,92 USAISR also developed 

an equation for determining calorie needs (Exhibit 13-

2).93 Carlson et al noted a linear relationship between 

burn size and REE,93 and Milner et al validated this 

formula during the first month following burn injury.94 Initial feeding based on the USAISR equation is 

an appropriate approach until a metabolic cart study 

can be completed. 

Because of the many factors affecting a burn casualty’s metabolic rate, the most precise method of 

measuring energy requirements is by taking serial 

measurements of REE by indirect calorimetry. Indirect 

calorimetry uses a portable metabolic cart at the casualty’s bedside that can be attached to the ventilator or 

to a canopy if the casualty is not on a ventilator. The 

cart measures respiratory gas exchange and calculates 

REE from this data. This measured energy expenditure 

includes increased needs because of the injury, but not 

the energy needed for activity because it is performed 

when the casualty is at rest. Total calorie needs can 

be estimated by adding 10% to 40% to the measured 

expenditure to account for activity.

With the USAISR formula, Carlson et al used an 

TABLE 13-4

AVAILABLE ENERGY STORES

Source Type Available Kilocalories

Liver Glucose 300

Muscle Glucose 600

Liver Triglyceride 500

EXHIBIT 13-2

US ARMY INSTITUTE OF SURGICAL RESEARCH EQUATION FOR DETERMINING CALORIE 

NEEDS*

EER = [BMR† x (0.89142 + {.01335 x TBSA‡})] x BSA x 24 x AF§

Male BMR = 54.337821 – (1.19961 x Age) + (0.02548 x Age2) – (0.00018 x Age3)

Female BMR = 54.74942 – (1.54884 x Age) + (0.03580 x Age2) – (0.00026 x Age3)

BSA (m2) = square root of:

Ht(cm) x Wt (kg) or Ht (in.) x Wt (lb)

3600 3131

*This applies to burns ≥ 20%total body surface area; for burns < 20% total body surface area, use 30–35 kcal/kg. †This isdetermined using the Fleisch equation. ‡For example, for 30% TBSA burn, use “30.”

§

Use 1.25 or a value appropriate for the specific patient.

AF: activity factor 

BMR: basal metabolic rate 

BSA: body surface area 

EER: estimated energy requirement

Ht: height

TBSA: total-body surface area burn (eg, for 30% TBSA, use “30”)

Wt: weight
296

Care of the Combat Amputee

estimated activity factor of 1.25.93 Wall-Alonso et al 

used the doubly labeled water technique, along with 

resting metabolic rate, and determined an activity factor of 1.05 to 1.15.95 Hart et al found that an activity 

factor of 1.4 can lead to weight maintenance but results 

in an increase in body fat, while an activity factor of 

1.2 can maximize lean body mass retention.89 

If tube feeds are a patient’s only source of calories, 

a goal rate derived from the REE times 1.4 is appropriate. At least the REE times 1.2 must be provided. Many 

sources of calories need to be considered in tube-fed 

patients, including food and beverages taken orally 

and IV fluids (eg, a solution of 5% dextrose in water 

contains 170 cal/L; albumin contains 200 cal/L in a 5% 

solution, 1,000 cal/L in a 25% solution; and propofol 

contains 1,100 cal/L). 

Burn injury results in profound changes in protein 

metabolism, increasing liver synthesis of acute phase 

proteins. Energy needs are met by muscle proteolysis. 

In addition, significant amounts of protein are lost 

through urine, feces, and open wounds. Losses can 

lead to as much as 2 to 3 lb of muscle in a day. The protein needs of burn casualties are difficult to determine 

with available data. It is currently recommended that 

20% to 25% of a burn casualty’s calories come from 

protein.96–98 Protein intake should be adjusted serially, 

based on nitrogen balance. The Waxman formula 

is used to determine nitrogen loss from open burn 

wounds.99 Total body nitrogen losses are determined 

by urinary urea nitrogen, insensible losses, and wound 

losses. The surface area of open wounds is entered into 

the Waxman formula for the appropriate post-burn day 

to determine nitrogen lost through the wound. The 

urinary, wound, and estimated insensible losses are 

added to determine the current rate of nitrogen loss. 

The goal is to provide more nitrogen to the casualty 

than what is being lost, promoting overall anabolism. 

Increased nutritional protein does not stop catabolism; 

rather, it serves in anabolism to replace lost tissue.

Recent studies have focused on the role of specific 

amino acids in nutritional support of the burn casualty. 

In the past, arginine supplementation was shown to 

improve cell-mediated immunity and wound healing 

and decrease morbidity and mortality.100–102 However, 

its safety has been called into question, especially in 

septic casualties. Use of another amino acid, glutamine, 

is now advocated because it is the primary fuel for 

enterocytes and immune cells. Its use purportedly 

preserves gut integrity and decreases translocation 

and infections.103 Branched-chain amino acids, leucine, 

isoleucine, and valine, although once believed to spare 

endogenous muscle catabolism, have not been proven 

to improve outcomes in burn casualties.104–108 More research is needed to determine the utility and proper use 

of amino acids and to examine safety and efficacy.

Carbohydrate metabolism is altered during the 

acute post-burn phase. For example, glucose is produced from gluconeogenesis. Carbohydrates are the 

primary energy substrate during this period, and a 

high carbohydrate diet (3% fat) may decrease muscle 

protein degradation.109 Although this may be convincing evidence to provide high-carbohydrate, low-fat nutritional support, excess carbohydrate use is also likely 

to lead to increased carbon dioxide production.

The optimal amount and type of lipid to use in 

nutritional support of the burn casualty is controversial and currently the subject of extensive research. 

During the acute post-burn phase, lipolysis decreases 

because protein is the preferred fuel source, and serum 

free fatty acids and triglycerides increase. Lipids are 

a concentrated source of calories for burn casualties, 

but high levels of lipid intake may impair immune 

function. Because adequate essential fatty acids aid in 

wound healing (among other things), it is necessary to 

prevent their deficiency in burn casualties.96,110,111 

Specific vitamin and mineral requirements for burn 

casualties have not been established, although it is 

believed there are increased needs for at least those 

nutrients involved in wound healing and tissue synthesis (zinc and vitamins C and A). Providing a vitaminmineral supplement equal to the recommended dietary 

allowances is commonly recommended. Additional 

daily supplements of 1 g ascorbic acid and 250 mg zinc 

sulfate are also recommended.112–114

The levels of the trace elements copper, iron, selenium, and zinc are of interest because they decrease 

plasma levels in the acute phase after thermal injury.115

A deficiency in iron, which is involved in adenosine 

triphosphate production, can lead to decreased performance and decreased immunity.116 Copper is involved 

in wound healing and collagen production.117,118 A 

copper deficiency can lead to decreased synthesis,117

decreased immune function,119 heart and lung dysfunction, and bone demineralization.120 The loss of copper 

in the first week after thermal injury is as high as 20% 

to 40% of the body’s stores.121 Selenium is involved in 

immunity, lipid peroxidation,122 tissue oxygenation,123

and the phagocytic activity of neutrophils.124 Selenium 

deficiency can cause cardiomyopathy,125 myalgia,126

and decreased immunity.127–129 A deficiency in zinc, 

which is involved in the function of metalloenzymes130

and bone metabolism,118 can lead to decreased wound 

healing and impaired immunity.130

Developing a nutritional care plan involves selecting the appropriate route of nutritional support and 

the specific formula, diet, or supplement to be used. 

Early enteral support (within the first 24 hours) is 

preferred.131 Nutritional support for burn casualties 

may include an oral diet, oral supplements, enteral 

nutrition, or parenteral nutrition. 
297

Rehabilitation of Burn Casualties

PAIN MANAGEMENT

acetaminophen relieve minor pain; however, NSAIDs 

are less commonly prescribed because of concerns 

over their antiplatelet and nephrotoxic effects. Other 

medications used or soon to be available may include 

topical sprays, salves, and creams or iontophoretic and 

lozenge-based fentanyl. Intranasal applications of ketamine, butorphanol, morphine, and hydromorphone 

are also being developed.

In addition to a pharmacological approach to 

pain management, an interdisciplinary approach has 

also been successful. Clinics with pain management 

specialists are a staple, but alternative and complementary medicine techniques, including acupressure, music therapy, and massage therapy, are also 

being welcomed.141 Additionally, virtual reality and 

hypnosis are being investigated as pain management 

techniques.147 Pain populations that were difficult to 

manage in the past, including those with phantom 

limb pain or sensation, have achieved some success 

with pain psychology professionals.148 Group therapy 

and counseling, support groups, psychotherapy, and 

behavioral modification, such as breathing and relaxation techniques, have all been used to deal with severe 

and life-altering pain.149

Burn pain is unique in many ways. Most pain 

decreases with time from the original insult and 

throughout the recovery period; however, burn pain 

may increase with time, increase with recovery (fullthickness burns are insensate initially) and are more 

likely to result in chronic pain (> 6 months’ duration).150

Predictors of burn pain include depth and location 

of burn. Extent, age, gender, ethnicity, educational 

history, occupation, history of drug or alcohol abuse, 

and other psychiatric illness do not predict the severity 

of burn pain.133 Although many people have lasting 

impressions of burn injury related to momentarily 

touching hot stoves or scalding water, few can actually 

understand the pain associated with a major burn. For 

example, with superficial partial-thickness burns, even 

air currents moving over the affected tissue may result 

in excruciating pain.

Chronic pain—an intense, prolonged pain—is common in burn casualties and is aggravated by the need 

for frequent wound care, dressing changes, and rehabilitation activities. The repetitive and extensive nature of 

dressing changes cause anxiety and depression, which 

can further decrease pain thresholds.151 The sequelae 

of poor pain control can affect the psyche, including 

self-image, motivation, and will to live.152 Burn injuries 

cause significant pain during the entire recovery period, 

and although complete elimination may not be possible 

without a general anesthetic, thorough assessment and 

planning can make pain more tolerable. 

Pain is a negative sensory or emotional response 

to a stimulus that may or may not be associated with 

actual tissue damage.132,133 Nociceptive pain results 

from stimulation of nocioreceptors within the body, 

neuropathic pain is due to nerve damage, and central 

pain is associated with central nervous system (CNS) 

lesions.134 Purely psychogenic pain, which is secondary 

to mental illness, is very rare in burn casualties.135

Pain impacts interpersonal relationships, as well as 

a casualty’s ability to carry out ADLs and participate 

in rehabilitation. Poor pain control is associated with 

increased incidence of posttraumatic stress disorder 

(PTSD), anxiety, conditioning, and development of 

avoidance behaviors,136 as well as a decreased willingness to remain actively engaged in the rehabilitation 

plan.137 Casualties frequently cite inadequate pain 

control as the reason for noncompliance with their 

medical treatment plans.138 Pain management can rely 

on both a multimodal pharmacological approach and 

an interdisciplinary approach.

The pharmacological management of pain is heavily dependent on opioids.139 Moderate- to long-acting 

medications, such as continuous release morphine and 

methadone, are generally used on a scheduled basis for 

background pain. Methadone is especially useful for 

prolonged treatment when casualties become intolerant to morphine.140 Rescue medications intended for 

breakthrough pain include short-acting agents, such as 

oxycodone and acetaminophen/oxycodone. Fentanyl 

transmucosal lozenges work in minutes and last longer 

than IV doses because they are absorbed through the 

stomach and the oral mucosa.141

Anxiolytics, such as benzodiazepines, alleviate anxiety in burn casualties.142 A casualty’s level of sedation 

must be closely monitored because of the synergism 

anxiolytics have with other drugs. Ketamine, commonly used with midazolam,143 is often used for burn 

dressing changes because it provides analgesia with 

minimal respiratory depression144; however, it may 

cause prolonged sedation, dysphoric reactions, and 

delusional hallucinations.

Several other classes of drugs also improve pain 

control and decrease narcotic use. Anticonvulsants, 

such as gabapentin, pregabalin, and carbamazepine, 

are especially useful as neuronal membrane stabilizers 

whenever there is a component of neuropathic pain.145

Local anesthetics, which act to block sodium channel 

conductance of the pain signal, can be used as topical 

analgesics and in regional anesthesia,146 which will be 

addressed later in this chapter. 

Antidepressants, such as tricyclics, are another class 

of drugs commonly used to manage chronic pain. 

Nonsteroidal antiinflammatory drugs (NSAIDs) and 
298

Care of the Combat Amputee

During the acute phase, burn pain is managed 

through emergency care. The American Burn Association recommends the use of morphine during this 

phase, but many other opioids could be titrated to be 

effective.153 Burn casualties experience intense pain 

and usually require large doses of opioids to remain 

comfortable, even in the absence of movement or 

surgical procedures. Because airway compromise is 

an ever-present concern, ketamine may also be considered to decrease opioid requirements.143 When possible, subcutaneous and intramuscular administration 

should be avoided in favor of IV delivery because the 

former result in unpredictable absorption. When IV 

access is unobtainable, intraosseous placement may 

be considered by skilled personnel in urgent need of 

temporary venous access.23

Inhalational agents, such as volatile anesthetic gases 

and IV agents, form the main portion of an intraoperative anesthetic regimen.154 Casualties may develop 

opioid tolerance. Regional anesthesia may also be 

indicated, either alone or combined with general anesthesia, but is often limited to casualties with small 

burns and for analgesia of donor sites. 

Operative intervention often leads to a change in 

pain focus because donor sites are commonly more 

painful than excision sites, which may be insensate.137

Neuraxial techniques, such as epidural or spinal 

anesthetics, may help with postoperative analgesia 

in affected areas, especially when more caudad. For 

example, femoral or iliac fascia compartment nerve 

block may be used to provide analgesia for the anterior 

flank donor site. Blood loss may be increased from the 

resultant sympathectomy after neuraxial techniques, 

and percutaneous technique risks infection.

Severe burn injuries often present significant perioperative challenges to providers and therapists 

secondary to reported inadequate pain management.155

A characteristic hospital course for burn casualties 

includes frequent operative visits, long hospital stays, 

and extended rehabilitation, during which casualties 

are placed on chronic opioid therapy to manage pain.156

Burn rehabilitation is unique because it is repetitive, 

painful, and prolonged, increasing the difficulty of 

achieving goals. 

In addition to use of systemic pain medications 

during potentially painful acute and intermediate rehabilitation sessions, regional anesthesia (in the form of 

peripheral nerve block) can be added to a multimodal 

pain management regimen. Historically, regional 

anesthesia has been used in the form of CNS block or 

neuraxial techniques to control intraoperative pain 

and labor-induced pain (eg, epidural and spinal anesthesia). However, advancements in peripheral nerve 

block techniques, with targeted placement of local 

anesthetic medications via peripheral nerve stimulation and ultrasound guidance, has created new interest 

in peripheral nerve blocks to control intraoperative, 

acute postoperative pain, and chronic pain syndromes 

during the recovery phase following burn. 

In addition to opioids, regional anesthesia of the 

extremities and of the trunk is useful for burn casualty rehabilitation. Intramuscular, oral, and IV opioid 

medications have a long history of use as part of acute 

and chronic pain control regimens. However, based on 

the known side effects of sedation, respiratory depression, and inadequate pain control, exclusive use of 

opioids for analgesia has been replaced by multimodal 

approaches, including regional anesthesia for the extremities. Benefits of regional anesthesia include reducing pain during rehabilitation, avoiding side effects of 

respiratory depression caused by opioid and sedative 

medication use, and minimizing limits imposed on 

therapists secondary to casualties’ intolerance to pain, 

allowing the advancement of rehabilitation goals.

In the extremities, regional anesthesia is given using 

a needle attached to a low-current electrical impulse 

generator, which stimulates motor fibers and identifies 

the targeted nerves.157 Once the nerve fibers are identified, large volumes (20–40 mL) of local anesthetic are 

injected to produce nerve block. An alternative technique uses an ultrasound probe to identify targeted 

nerve bundles and uses direct visualization of the 

needle during local anesthetic injection. 

Peripheral nerve block can be performed by a single 

injection or continuous catheter technique. Single injection techniques are limited in duration, based on the 

local anesthetic medication used, but can be extremely 

useful in immediate rehabilitation.157 The most commonly used local anesthetic medications for peripheral 

nerve block can be classified as either amide or ester 

local anesthetics. The local anesthetic drug class affects 

onset of action, duration of drug effects, rate of systemic absorption versus elimination, and distribution 

throughout the body. Commonly used local anesthetics 

for peripheral nerve block include lidocaine (short duration, 1–2 hrs), mepivacaine (intermediate duration, 

2–4 hrs), ropivacaine (long duration, 5–8 hrs), and 

bupivacaine (long duration, 4–12 hrs).157

Continuous catheter techniques can extend the 

duration of analgesia to the desired length of time. 

Continuous peripheral nerve catheters have commonly 

been reserved for the inpatient population, secondary 

to provider concerns over potential systemic toxicity, 

potential nerve toxicity, infection at the catheter site, 

and risk of accidental limb injury as outpatient. In 

an ambulatory setting, casualty selection is critical. 

Only casualties who are capable of accepting the additional responsibility of the catheter and infusion 
299

Rehabilitation of Burn Casualties

pump should be selected. Ambulatory use of continuous nerve block is contraindicated when a casualty is 

cognitively impaired and without a home caregiver, 

unable to attend scheduled follow-up catheter care, or 

is at high risk for systemic toxicity (ie, hepatic or renal 

insufficiency).158

During regional anesthesia procedures, casualties 

frequently require minimal to moderate sedation to 

tolerate the pain from placing the peripheral nerve 

block. Preoperative fasting practices have been established to reduce the risk of pulmonary aspiration from 

gastric contents during elective procedures, based on 

American Society of Anesthesiologists Task Force on 

Preoperative Fasting guidelines.159 These guidelines 

do not apply to casualties who undergo procedures 

without anesthesia or with only local anesthesia, when 

upper airway protective reflexes are unimpaired, 

and when there is no apparent risk of pulmonary 

aspiration. An anesthesiologist should be consulted 

before discontinuing oral intake for peripheral nerve 

block.159 In addition, care must be taken to ensure the 

daily anticoagulation dose is discontinued prior to regional technique.160 Therapists, anesthesiologists, and 

primary team physicians should consult one another 

before performing regional block and discontinuing 

scheduled medication. 

Complications of peripheral nerve block, although 

rare, must be considered when weighing the risks and 

benefits of the procedure. When complications arise, it 

is imperative that the provider and therapist be aware 

of the symptoms and take appropriate action. Systemic 

drug toxicity is caused by excessive absorption or accidental injection of greater-than-recommended blood 

concentrations of local anesthetic. Signs of generalized 

CNS toxicity are dependent on plasma concentration. Lower plasma concentrations may cause CNS 

depression (eg, lightheadedness, tinnitus, numbness 

of tongue), whereas higher plasma concentrations 

of local anesthetic may result in CNS excitation (eg, 

seizures, unconsciousness, coma, respiratory arrest, 

cardiovascular depression).157 Additional procedure 

complications include the following:

	 •	 nerve injury during needle placement,

	 •	 bleeding from vascular puncture,

	 •	 intravascular injection of local anesthetic,

	 •	 allergic reaction to local anesthetic,

	 •	 lung injury during peripheral nerve block

placement in the upper extremities or trunk, 

	 •	 temporary phrenic nerve paralysis during

upper-extremity blocks, and 

	 •	 high local anesthetic cerebral spinalfluid level,

causing respiratory depression. 

During the long term, burn pain management relies on controlling both baseline (often chronic) and 

breakthrough pain. “Pain soup” refers to a group of 

pain medications that target different receptors to attempt synergistic pain management while minimizing 

adverse effects related to overuse of any one class of 

drugs. Chronic use often escalates the requirement 

for opioids, secondary to the development of drug 

tolerance. A multireceptor approach helps reduce 

drowsiness, nausea, vomiting, constipation and addiction potential seen with narcotics by interfacing 

with receptors other than just the μ-opioid receptor.150

Peripheral nerve block techniques can also be effective over the long term. When developing therapeutic plans, anesthesiologists or interventional pain 

specialists should be consulted. Outpatient follow-up 

at a pain clinic is often an ideal solution to best tailor a 

pain management plan for each burn casualty.161 Nonpharmacological pain control modalities to consider 

include behavior modification (conditioning),148 transcutaneous electrical nerve stimulation, acupressure (to 

the external ear), massage or music therapy, virtual 

reality,147 and counseling and group therapy. Enlisting the assistance of professionals, such as psychiatric 

nurses, psychotherapists, and fellow burn survivors, 

is also often advantageous.2

REHABILITATION OF THE BURN CASUALTY

Rehabilitative interventions are paramount to a 

casualty’s total functional outcome and are required 

through all phases (acute, intermediate, and long term) 

of the recovery process (Figure 13-15).162 On a daily 

basis, burn therapists treat burn casualties with the 

goal of achieving maximum physical and functional 

recovery.163 Occupational therapy and physical therapy 

evaluations performed throughout the rehabilitation 

community initially resemble typical burn rehabilitation evaluations. They include acquiring a baseline of 

neurocognitive function, ROM, strength, sensation, 

activity tolerance, and intervention response. These 

components of the evaluation are performed following an appropriate chart review to understand the 

expected physiological, psychological, and emotional 

involvement from the described injury or insult.

Burn Edema

Massive tissue edema develops following thermal 

injury (Figure 13-16).6 Current evidence indicates biochemical mediators, released in response to thermal 
300

Care of the Combat Amputee

injury, play a significant role in edema development.6

The pathogenesis of tissue edema following thermal 

injury involves changes in the physical forces controlling fluid flux across the capillary, as well as fluid 

accumulation in the interstitium.6 Edema forms at the 

expense of the vascular and extracellular compartments. Electrolyte concentrations can vary considerably, due in part to large potassium intracellular losses, 

urinary excretion, and large sodium intracellular and 

extracellular gains.164

Although edema is common to most significant 

burn injuries, no modalities have proven completely 

effective at managing it in severe burn casualties.6 To 

better understand edema formation, one must appreciate the basis of fluid management and its role in 

resuscitation, both positive and negative (see “Fluid 

Resuscitation” above). 

Edema Evaluation

Measuring edema is an important aspect of a burn 

casualty’s physical examination. Edema can impair 

joint ROM, slow wound healing, and compromise 

circulation.165 All areas of the body can be affected 

by edema that results from a burn. Hands are commonly affected and are particularly troublesome to 

rehabilitate. 

Typically, edema is first assessed on a subjective 

scale by a therapist and is rated as minimal, moderate, 

or severe. If edema persists or progresses, therapists 

use objective measurement to more accurately assess 

the quantity of edema and the effectiveness of treatment measures and to document progress.166 Although 

traditional methods of objectively assessing edema, 

especially in burns, are difficult to perform clinically 

or have limited validity, recent literature demonstrates 

an objective edema measurement that provides a more 

valid assessment and can be performed just as expeditiously as a subjective measure.167

The most commonly used methods of objective edema assessment include circumferential measurement, 

water volumetry, and the figure-of-eight measurement. 

Circumferential measurements give therapists a value 

to quantify edema at a specified site along an extremity. The therapist identifies a site along an edematous 

area to be evaluated, and the site is either marked or 

measured at a set distance from an anatomical landmark, allowing for future reference or measurement. 

A circumferential measurement is then taken at the 

designated point to quantify the edema.168 Circumferential measurements are practical for all body areas, 

but provide only a point estimate of volume for an 

area. Depending on the site chosen to measure, the 

results can be significantly different. This method is 

best reserved for use on areas of isolated edema, such 

as the fingers, or where other measurement techniques 

are not available, such as the trunk. Although they are 

clinically expedient and more useful for monitoring the 

effectiveness of treatment and progress than a subjective assessment, the limited reliability and validity of 

circumferential measurements limits their usefulness.168

Volumetry, a measurement based on the principle 

of water displacement as a measure of volume, is considered the “gold standard” for measuring edema.169

The volumeter is a standardized tool that allows a 

therapist to measure edema, most commonly of the 

hand and foot.166 Reliability and validity of volumetric measurements is well established169,170; however, 

volumetry has several limitations.171 For example, it 

is time consuming, requires expensive specialized 

equipment, and great care must be taken to ensure a 

consistent position for each measurement.168–170,172 Also, 

Figure 13-15. Interaction between medical care and rehabilitation of burn casualties. Patient Priority

Emergent

Care

Recovery Time

Acute

Rehabilitation

Intermediate

Rehabilitation

Long-term

Rehabilitation

Acute

Care

Figure 13-16. Burn casualty displaying massive facial edema.
301

Rehabilitation of Burn Casualties

whenever possible, open wounds and immature skin 

grafts should not be immersed in water. 

The figure-of-eight technique offers an alternative 

that is reliable, valid, and clinically expedient (Figure 

13-17).167,173–175 It uses a tape measure and defined anatomical landmarks to quantify edema. Although the 

reliability and validity of this technique are superior 

or equal to other forms of objective measurement, its 

applicability to areas of the body other than the ankle 

and hand are limited. 

Edema Management

Excessive edema can have severe, long-lasting 

consequences. The complications resulting from severe edema include tissue hypoxia and massive loss 

of intravascular fluid (which results in hypovolemia). 

Tissue hypoxia may develop as a result of increased 

tissue pressures from an impending compartment syndrome, and over-aggressive fluid therapy, often used 

to correct suspected hypovolemia, catalyzes the edema 

process.6 Organ systems, such as the brain, lungs, and 

heart, do not function well under the stress of severe 

edema. Circulation to an edematous extremity can 

also be compromised. Early escharotomy is indicated 

when massive edema is anticipated or observed to 

compromise tissue.

Severe edema that does not require escharotomy 

may also have a profound effect on a burn casualty. 

Loss of dexterity in edematous hands and digits can 

further compound a casualty’s feelings of helplessness 

following injury, leading to a cycle of decreased use, 

joint stiffness, contracture, tendon shortening, and 

long-term disability (Figure 13-18). It is imperative to 

provide adequate resuscitation to burn casualties while 

making every effort to minimize edema formation.

Acute Phase. Generally, edema peaks within 48 

hours following burn.165 Ongoing burn resuscitation 

can compound and prolong edema. If left untreated, 

edema can progress to critical levels, leading to eschar 

and compartment syndromes that require escharotomy 

or fasciotomy.165 During the acute phase, the burn 

team must regularly examine the casualty for signs of 

vascular compromise.

Initially, edema is managed by elevating the affected areas. To facilitate edema reduction, the upper 

and lower extremities should be positioned such that 

the hand or foot is above the elbow or knee, which is 

above or at the level of the heart (Figure 13-19). ROM 

exercises are also an effective edema reduction tool 

in the acute phase. Passive range-of-motion (PROM) 

and AROM exercises have been shown to be effective, 

depending on the responsiveness of the casualty.176,177

ROM exercise activates the muscle pump and 

Figure 13-17. Figure-of-eight technique for measuring hand 

edema.

Figure 13-18. Burn casualty with edematous hands resulting 

in decreased dexterity.

Figure 13-19. Positioning device used to elevate the upper 

extremity to facilitate edema reduction.
302

Care of the Combat Amputee

promotes edema reduction through enhanced venous and lymphatic flow.178 Hand edema should 

be measured using the figure-of-eight technique.167

The optimal position to control hand edema is placing the hand above the elbow and elbow above the 

heart.168,179,180 AROM exercise of the digits can also help 

control edema; however, muscle contraction must be 

sufficient enough to act as a pumping mechanism and 

help venous and lymph return.181

Compression with elastic wraps can reduce edema 

when combined with elevated positioning and ROM 

exercises. The wrap should be applied uniformly to 

prevent a tourniquet effect and must have a greater 

perpendicular pressure distal to proximal. Elastic 

wraps are typically applied in a figure eight (Figure 13-

20). For compression to be effective, the wrap must remain in place for prolonged periods of time. Generally, 

wraps are applied daily after completing wound care, 

and remain in place until wound care is performed 

the following day. Caution should be exercised when 

using compression in the acute phase because elastic 

wraps can contribute to increased compartment pressures or graft loss if applied too early or incorrectly. 

Therapists should frequently monitor vascular status 

distally on all areas being compressed. Burn casualties 

should be positioned with joints opposite the tendency 

for contracture. The individual’s medical history and 

potential comorbidities should be considered at this 

stage of developing a positioning plan. Previous arthritis, strokes, brain injury, or residual functional motion 

deficit may require a modification to the positioning 

plan. A thorough history, physical examination, and 

sensory evaluation will reveal accompanying injuries 

that must be considered when developing plans for 

prolonged positioning. After sustaining a burn, a casualty’s inflammatory response initiates a process by 

which any position maintained for more than 8 hours 

without active motion may cause early contracture 

formation. 

During the acute phase, appropriate positioning 

decreases the potential to develop contractures; assists 

venous return, minimizing edema and the risk for 

compartment syndromes; protects the neurovascular 

bundles from further trauma; assists proper respiratory function; and protects the healing wound. The 

typical anticontracture bed positioning method during this phase should hold the neck in extension, with 

the shoulders abducted to 110° and forward flexed 

15° or in the position of scaption.182 Elbows should 

be extended and in supination, wrists and hands 

in functional position, hips extended and abducted 

20° without external rotation, knees in extension, 

and ankles neutral. Although described as the anticontracture position, there is no single position that 

completely ameliorates contractures. For those at risk 

for ACS, preventive measures incorporate the reverse 

Trendelenburg’s position used to elevate the head of 

the bed while keeping the rest of the body straight, 

reducing intraabdominal pressure.183

As the initial, acute resuscitation process resides, 

the risk of compartment syndrome reduces; however, 

acute protective position techniques continue to assure optimal effectiveness for combating burn scar 

contracture, which will be addressed daily until the 

newly formed tissue matures. The incidence of joint 

contracture is high in this population and it is indicated 

that joint contracture has a significant detrimental 

impact on a burn casualty’s quality of life.51

Each burned part of the body must be considered 

independently and in conjunction with other parts 

when planning positioning. Independent considerations include the various positioning and splinting 

devices available or required to achieve maximum 

benefit from the intervention (Table 13-5 and Figure 

13-21). The concept of positioning must be well understood for optimal effectiveness in edema management and contracture prevention as well as to avoid 

adverse affects throughout the course of therapeutic 

interventions. Casualties with burn injuries are at high 

risk to develop pressure sores due to the nature of the 

injury and specifically identified risk factors related 

to the development of pressure sores. Although the 

cause of pressure sores is multifactorial, several of the 

factors listed include shear, friction, and unrelieved 

pressure.184 All opportunities must be taken to get 

casualties out of bed to the highest level of functional 

position and activity possible.

Requisite repositioning is essential in preventing 

tissue contracture. Repositioning is recommended, at 

a minimum, every 2 hours to alleviate pressure from 

susceptible areas, such as the sacrum, coccyx, and 

heels. Heels are extremely vulnerable to pressure sores 

and require additional protection beyond specialty 

beds.185 Other areas susceptible to pressure sores are 

the ankles, buttocks, and occipital area.

Figure 13-20. Figure-of-eight application of elastic wraps to 

the lower extremity.
303

Rehabilitation of Burn Casualties

TABLE 13-5

POSITIONING AND SPLINTING DEVICES USED TO MANAGE EDEMA

Position Device/Technique Indications

Bed Position, Supine

Head Gel donut Alternate flat to round every 2 hrs to avoid pressure sores 

to occipital region

Foam pad Used for custom requirements to maintain neutral alignment 

and avoid ear pressure

Face Wide tie tapes Used to distribute pressure over a larger area

Ears Pillows are removed Alleviates pressure and reduces edema

Gel or foam donut Used to prevent ear contact with the bed; irritation of ears 

increases the risk of chondritis 

Ear glock (see Figure 13-21a) Used to prevent contact to the ear if the risk of chondritis is 

high

Nose Foam or gel face support If the prone position is required, a foam face support with 

a cutout is used to prevent pressure on the nose; a gel 

horseshoe pad can also be used 

Wide tie tapes Used to distribute pressure under the nose for implementation of nasal airway, feeding, or gastrostomy tubes 

Mouth Bite block Used to position the jaw and oral opening

Microstomia Used to extend the oral commissures; uses an expansion 

screw

Neck Pillows are removed Allows for improved neck extension

Foam wedge Used if additional neck extension is required

Shoulder Arm slings Used to position the shoulder in a supported posture to 

achieve between 90° and 120° of abduction and 15° forward 

flexion, or scaption1

Elbow Positioned in extension with the Supination and scaption remove undue tension from the

forearm in supination on the sled neurovascular and muscular structures and elevate the 

of the shoulder sling upper extremity to improve vascular return

Wrist Volar-based functional position hand Wrist placed in functional position extended 20° to 25° and 

splint without ulnar or radial deviation

Hand Volar-based functional position hand Places the thumb in palmar abduction with the MCP and 

splint (see Figure 13-21b) IP joints in extension; the MCP joints of the index through 

small fingers is flexed to 70° and all IP joints are extended

Torso Body wedges or tumble forms Used to adjust the torso to relieve pressure from side to side 

and directly from the back

Hip Positioned in full extension with 20° Alleviates pressure and reduces edema

abduction and no external rotation

Abduction wedge Maintains full extension position when the casualty is unable 

to maintain the position due to concomitant injury

Elevation of lower extremity Assists with fluid return, reducing the risk of compartment 

syndromes; protects the neurovascular bundles from further trauma; protects the healing wound

Knee Extension Alleviates pressure and reduces edema

(Table 13-5 continues)
304

Care of the Combat Amputee

Techniques used in repositioning for pressure relief 

include various forms of ROM exercise. AROM, active assisted range-of-motion (AAROM), and PROM 

exercises allow for changes in body position to remove 

direct pressure from a susceptible area, therefore reducing the risk of pressure sores. Positioning order 

sets or turning schedules can be placed on a casualty’s 

order profile so nursing staff will know to reposition 

the casualty every 2 hours when active intervention 

is not occurring (eg, at night during a sleep pattern). 

Mobility training and activity progression help manage 

pressure relief as well. 

Postoperatively, casualties are placed in splinting 

and positioning devices to prevent disruption of new 

grafts. Positional splints and devices are used to assist in graft protection, pressure relief, and donor site 

healing. Most significantly noted are for the torso, 

elbow, and legs (Table 13-6 and Figure 13-22). Normal 

therapeutic ROM, mobility, and ADL activities are 

continued to the areas unaffected by surgery. 

Position Device/Technique Indications

Feet, ankles, and legs Inflatable booties Used to keep the ankle at 90° and the toes extended; removes 

pressure from the heel of the foot

L’nard boot Used if the foot begins to develop an equines deformity

Leg net Made with copper tubing and fittings with surgical netting 

stretched over the frame (see Figures 13-21c and 13-21d); 

used to elevate the leg to reduce the risk of compartment 

syndrome acutely; used to prevent pressure sores from 

developing on the heels, typically alternated with the inflatable bootie and positioned so that there is a bootie on 

the contra-lateral lower extremity; reduces the degree of 

direct pressure on the sacrum, therefore reducing the risk 

of pressure sores; helps dry donor sites postoperatively, 

and prevent maceration and further tissue damage2

Seated Position

Head, face, ears, nose, See above See above

mouth, neck, 

shoulder, elbow, 

wrist, and hand

Torso Body wedges, tumble forms Used to assure posture is maintained in a midline posture

Hip Positioned in flexion between 60° Alleviates pressure and reduces edema

and 90° through chair recline; hip 

abduction is maintained at 20° and 

external rotation is avoided

Knee Full extension while seated (can Alleviates pressure and reduces edema

alternate between flexion and 

extension if not contraindicated)

Feet and ankles Ankles are maintained at 90° and the Alleviates pressure and reduces edema

toes extended

Miscellaneous Total lift chair Used for its versatility in casualty transfer and positioning 

adaptability

Roho cushion Used to protect against pressure sores in the seated posture

Slings, sandbags, foam blocks, and Used to reduce edema and protect the healing wound

sponge positioning devices

IP: interphalangeal

MCP: metacarpophalangeal

(1) Chapman TT, Hedman TL, Quick CD, Dewey WS, Wolf SE, Holcomb JB. Airplane sling with seven degrees of freedom used to position 

the burned upper extremity. Poster presented at: Southern Region Burn Conference; November, 2006; Durham, NC. (2) Hedman TL, Chapman TT, Dewey WS, Quick CD, Wolf SE, Holcomb JB. Two simple leg net devices designed to protect lower-extremity skin grafts and donor 

sites and prevent decubitus ulcer. J Burn Care Res. 2007;28(1):115–119.

Table 13-5 continued
305

Rehabilitation of Burn Casualties

Intermediate Phase. The majority of edema resolves 

during the acute phase as the initial physiological response to burn injury, fluid resuscitation, and wound 

closure are completed. However, residual, chronic 

edema and the episodes of acute edema associated 

with ongoing surgical procedures pose the same limitations for casualties in the intermediate phase as they 

did in the acute phase. 

As in the acute phase, during the intermediate phase 

edema is managed through a combination of elevation, ROM exercises, and compression. A casualty’s 

responsiveness is typically improved and wounds are 

healed or nearly healed during this phase, allowing 

for more vigorous AROM and increased compression 

to mobilize edema. Compression wraps commonly 

used in this phase include elastic wraps and Isotoner 

(totesIsotoner Corporation, Cincinnati, Ohio) edema 

gloves. Dependent positioning of the affected areas 

must be avoided at night, and elevation at night is 

recommended to sustain the edema-reducing benefits 

of activity throughout the day. 

Retrograde massage may be beneficial for persistent 

edema during this phase. During the acute phase, the 

casualty’s wound status, pain tolerance, and risk for 

skin breakdown do not typically permit the use of 

retrograde massage. Therapists can use retrograde 

massage to mobilize persistent, chronic edema that 

has proven recalcitrant to more conservative edema 

management strategies.

Long-Term Phase. As casualties progress into the 

Figure 13-21. (a) Ear glock for protection of ear burns and 

grafts. (b) The Safe Position Burn Splint (Northcoast Medical, Morgan Hill, Calif) is a functional position hand splint 

that properly positions hands following burn. The (c) high 

profile leg net device and (d) low profile leg net device are 

used to position lower extremities.

Photograph (b): Courtesy of North Coast Medical Inc., Morgan Hill, California.

a

c

b

d
306

Care of the Combat Amputee

long-term rehabilitation phase, the focus of edema 

management shifts substantially. The persistent, 

chronic edema associated with this phase generally 

does not respond to passive elevation. Vigorous ROM 

exercises and retrograde massage, in conjunction with 

a comprehensive compression regimen, are the most 

effective ways to treat chronic edema.

Casualties generally receive custom compression 

garments during this phase. Casualties should wear 

compression garments 23 hours a day, removing them 

only for daily hygiene activities. A strict compression 

regimen and daily therapeutic activities effectively 

reduce edema.

Wound and Skin Care

Proper wound assessment and adequate wound care 

strategies are paramount during all phases of wound 

healing. Appropriate, timely, and effective wound care 

techniques can make the difference between successful healing and prolonged, problematic rehabilitation. 

Rehabilitation providers must be vigilant and aware 

of how wounds progress in order to recognize adverse 

changes and avoid setbacks in rehabilitation. 

Acute Phase

During the acute phase, strategies are developed 

to manipulate the wound healing process, minimize 

wound progression, and avoid involvement of deeper 

tissue.186 Goals of therapeutic intervention in this 

phase focus on reducing the chance or rate of further 

burn damage to the involved tissue; positioning and 

splinting devices, in conjunction with fluid mobilization techniques, improve tissue viability.187 Common 

rehabilitation goals during the acute phase include:

	 •	 educating casualties about the rehabilitation

processes and expectations,

	 •	 reducing edema,

	 •	 facilitating wound healing,

	 •	 preventing skin breakdown,

	 •	 protecting skin graft and donor sites,

	 •	 preserving ROM,

	 •	 maximizing ADLs,

	 •	 accomplishing mobilization, and

	 •	 managing psychological coping and

adjustment.

The acute phase of wound healing includes the 

initial injury assessment and evaluation. Loose tissue 

must be removed and the injury thoroughly cleansed 

to properly evaluate the extent of the burns and depth 

of the injury. IV narcotic medications are usually required to facilitate the initial wound cleansing. Small 

wounds can initially be cleaned in bed or in the shower. 

Additional space is often required to inspect larger 

wounds; shower carts and hand-held showerheads are 

TABLE 13-6

POSTOPERATIVE SPLINTING AND POSITIONING

Body Area Device/Position Indications

Torso Back net (see Figure 13-22) Used to air the donor site on the back; alternated on and off 

every 4 hrs1

Elbow Hyalite low-temperature Used to maintain the extended position following initial excision 

thermoplastic material is and grafting 

modeled to the elbow

Knee, feet, and ankles Leg splints Used to maintain the knee in extension, the ankle at 90°, and 

extend the toes; a heel dropout prevents pressure sores from 

developing 

Miscellaneous KinAir (Kinetic Concepts Inc, San Minimizes contractures

Antonio, Tex) bed

The grafted sites are immobilized Minimizes contractures

Splints and other positioning Keeps casualty immobile

devices

Bed rest Used only when immobility of the graft cannot be achieved 

through splinting and positioning devices

(1) Salinas RD, Hedman TL, Quick CD, Wolf SE, Holcomb JB. Ventilation back ramp designed to prevent suppurative donor sites and accelerate healing time. J Burn Care Res. 2007;28:S109.
307

Rehabilitation of Burn Casualties

used to adequately cleanse larger areas. Larger carts 

facilitate quick draining of water spray and provide 

an area that can be accessed by multiple caregivers. A 

shower cart basin can be covered in propylene drapes 

to guard against cross contamination. The use of Hubbard tanks (large full-body immersion tanks) has been 

largely abandoned due to the risk of cross contamination, space requirements, and difficulty in transferring 

casualties to and from beds. 

Infection related to skin loss can be life threatening 

for a burn casualty, making meticulous wound care 

crucial. All areas of the body should be exposed and 

inspected to determine the extent and depth of the 

injury on an interval basis. During wound care, plastic 

aprons, gloves, hats, masks, and protective eye wear 

should be used. Plastic aprons prevent scrubs from 

becoming contaminated with body fluids and also 

prevent cross contamination to other casualties.

Wounds are gently cleaned using a mild cleanser 

and loose damaged skin is removed and blisters debrided to prevent infection. Thick blisters of the palms 

or soles of feet may be aspirated instead of unroofed 

to reduce pain.188 Shaving body hair adjacent to the 

wound is beneficial in exposing the burn for evaluation and makes it easier to apply topical agents and 

dressings. Shaving is repeated as necessary until the 

wound is closed. Wound touch plate cultures are done 

on initial wound cleansing and thereafter for bacterial 

surveillance. Progression of wound healing is documented using the Lund and Browder chart. 

After evaluating a burn, a wound dressing is chosen 

based on the operative plan, if indicated. If a casualty 

has areas of all partial-thickness burns that have been 

recently debrided and may be lightly weeping serous 

fluid, a synthetic skin substitute may be considered 

(Figure 13-23). After applying the synthetic skin, the 

wound is wrapped first with dry gauze, then with an 

elastic bandage to ensure conformity and adherence 

of the contact dressing. After 24 to 48 hours, the outer 

dressing is removed and the synthetic skin is exposed 

to air. Keeping the skin substitute dry appears to aid 

in its adherence and overall performance. A synthetic 

skin substitute will spontaneously separate from the 

reepithelialized wound in 10 to 14 days. 

A contact dressing that uses a combination of silver 

fibers incorporated into nylon can be left in place for 

an extended period of time. Silver-nylon dressings 

may be useful when treating burns that are deeper 

partial-thickness burns that exude large amounts of 

serous fluid or are dry. Silver-nylon dressings are easy 

to apply, conform effectively, and, because silver ion 

is an antimicrobial agent, they can be left in place for 

up to 72 hours, making them very effective during 

long-range transport. All of these dressing materials 

are available in varying sizes, including glove-shaped 

designs for easier application over burned hands. 

Deeper partial-thickness, marginal full-thickness, 

and full-thickness burns that may require surgery 

can be treated with dressings that will facilitate daily 

wound care and evaluation. Most bacteria are found 

in the burn eschar, so dressings that guard against infection are preferred and topical, rather than systemic, 

antibiotics are effective.189 Gauze dressings soaked with 

antimicrobial agents (eg, mafenide acetate in a 5% solution) and placed in contact with the burn are known 

as “bolsters.” Bolster dressings provide the necessary 

wound protection and moist environment to improve 

wound outcome and aid in wound-bed preparation 

for future excision. Other solutions commonly used 

include dilute sodium hypochlorite (0.25% Dakin’s 

solution) or silver nitrate. Topical burn ointments and 

creams are also used for antimicrobial protection include mafenide acetate cream, 1% silver sulfadiazine, 

polymixin, and bacitracin. Mycostatin can be added to 

provide additional antifungal protection if indicated. 

Burn Wound Excision. Full-thickness burn wounds 

require excision and subsequent application of donor 

autograft, or temporary application of homograft (cadaver skin), a bilaminar dermal substitute, or xenograft 

Figure 13-22. Back net device used to provide protection and 

ventilation for skin grafts and donor sites on the back.

Figure 13-23. A synthetic skin substitute applied to partialthickness burn of the lower extremity.
308

Care of the Combat Amputee

if the casualty does not have adequate donor skin. 

Prompt application of split-thickness skin grafts expedites wound closure and decreases risk of infection, 

scarring, contracture, loss of function, and the time 

needed for dressing changes (see “Plastic and Reconstructive Surgery” below). A principle goal of burn 

care is to debride nonviable tissue and provide early 

and functional wound coverage. Estimation of wound 

depth determines whether the burn can be managed 

conservatively or will require surgical intervention. 

Superficial and full-thickness burns are generally 

readily determined, and appropriate management 

can be immediately initiated. Partial-thickness burns 

are more difficult to evaluate and often require a serial 

assessment of the burn over several days to determine 

the actual depth of injury and initiate the appropriate 

intervention. A partial-thickness burn may also vary in 

depth within a small area, thus, healing may be patchy 

or delayed. A burn that fails to heal by 21 days after 

injury typically requires skin grafting. 

For burns that require surgical intervention, expedited wound closure minimizes inflammation, wound 

contraction, and scar formation. Early excision and 

grafting are the modern standard of care for full-thickness burns. Early excision is based on the principles 

of general surgical wound management and has been 

clinically proven effective in diminishing morbidity in 

the burn casualty.190–194

The estimated depth of the burn wound often determines the choice of excision technique (tangential, 

sequential tangential, or fascial). Partial-thickness 

burns are generally excised with either tangential or 

sequential tangential methods until viable tissue is 

exposed. Hydrosurgery can provide an alternative to 

sharp excision. Full-thickness burns deep into subcutaneous fat are excised in segments to the fascia.

Tangential Excision. Dermal burns are excised with 

either a single pass (tangential) or multiple passes 

(sequential tangential) with the debridement instrument until viable tissue is reached (Figure 13-24). This 

method of debridement allows maximum preservation 

of viable dermis, which ultimately leads to better longterm results in the quality of the healed grafted skin.

There are a number of manual and mechanical 

instruments available for wound debridement. Debridement involves excising tissue in the range of 0.008 

to 0.012 inches for partial-thickness burns, and up to 

0.030 inches for full-thickness burns. Areas requiring 

intricate or delicate work, such as digit web spaces 

and the dorsum of the hand and fingers, are best approached using small instrumentation with shallow 

settings in multiple passes. 

Areas that have been adequately debrided show 

brisk punctate bleeding in healthy white dermis 

(Figure 13-25). Poor bleeding in grayish dermis indicates inadequate debridement and a need for further 

excision. As debridement progresses deeper into and 

through the dermis, more fat appears and capillary 

bleeding gives way to brisker flow from arterioles 

and veins.

Hemostasis of the debrided wound bed is accomplished using one or more proven methods, including 

directed electrocautery on larger vessels and dilute, 

epinephrine-soaked lap pads on the diffuse capillary 

bleeding bed. Local pressure and temporary elastic 

wraps can reduce bleeding. Topical epinephrine 

solutions in concentrations ranging from 1:10,000 to 

1:100,000 can be safely used with few systemic effects 

in acutely burned casualties. Topical thrombin spray 

has also been used for this purpose.

Figure 13-24. Tangential excision of a burn injury.

Figure 13-25. Punctate bleeding of healthy dermis following 

adequate burn excision.
309

Rehabilitation of Burn Casualties

It is important for a surgeon to consider a casualty’s 

overall status, the available resources, and the capabilities of the team when formulating the operative plan. 

Blood loss from a debrided wound bed can be significant and require serial monitoring of hemoglobin and 

hematocrit levels, platelet counts, levels of coagulation 

factors, body temperature, blood pressure, and urine 

output. With adequate planning and preparation, it 

is safe and practical for an experienced surgical team 

to rapidly excise and cover very large TBSA burns in 

a single operation. 

Excision to Fascia. Subdermal burns extending 

well into the subcutaneous tissue are often excised to 

the fascial plane using a combination of sharp dissection and electrocautery (Figure 13-26). Excision at this 

level can generally proceed rapidly with minimal to 

moderate blood loss. On extremity burns, blood loss 

can be minimized by tourniquets. To use a tourniquet, 

a surgeon must be confident of the level of injury because punctuate bleeding cannot be used to determine 

tissue viability until the tourniquet is released and 

perfusion restored. 

Engraftment on fascia is often more effective than 

placing autograft onto subcutaneous fat. However, 

this improved graft take can result in inferior cosmetic 

appearance, increased edema in distal extremities, 

decreased sensation, and inferior function, especially 

without early and progressive rehabilitation.

Skin Grafts.

Split-Thickness Skin Grafts. A split-thickness skin 

graft is usually harvested in a range from 0.007 to 0.012 

inches (Figure 13-27). Donor sites for split-thickness 

skin grafts heal in 7 to 10 days, may be reharvested 

once healed, and heal with little or no scar formation. 

Split-thickness skin grafts may be placed as either a 

sheet or meshed graft.

The typical healing time for a split-thickness skin 

graft is 3 to 5 days for adherence to the wound bed 

and up to 7 days for durable engraftment. Rehabilitation of areas that have been grafted should be 

implemented during the first 3 days after grafting. 

Mobilization activities, such as ROM exercise and 

transfers, can be performed during this time if the 

area of grafting can be protected from shear forces. As 

the split-thickness skin graft matures, rehabilitation 

activities may progress, but consideration must be 

given to the healing graft until approximately 7 days 

after grafting. Excellent functional outcomes with 

split-thickness skin graft coverage can be achieved 

with early and progressive rehabilitation and through 

the comprehensive development of a safe and effective rehabilitation plan. 

Sheet Grafts. Faster wound closure and cosmetic 

uniformity (without the appearance of a pattern) are 

some advantages of sheet grafting. Unlike meshed 

grafts, sheet grafts do not have perforations or incisions 

and are not expanded. Examples of areas best served 

by sheet grafting include the hands, face, and neck. The 

use of sheet grafts is often limited by the availability 

of adequate donor tissue.

When blood or serum collects under sheet grafts, the 

grafts may separate from the vascularized bed, resulting in graft loss. Hemostasis is critical to the success 

of a sheet graft. Large fluid collection can threaten the 

entire graft and may result in local drainage or aspiration to rescue the graft.

Figure 13-27. Harvesting of a split-thickness skin graft using 

a dermatome.

Figure 13-26. Fascial excision of subdermal burns to the 

lower extremities.
310

Care of the Combat Amputee

Meshed Skin Grafts. The instrumentation to accurately and reproducibly mesh skin (Figure 13-28) 

revolutionized burn care by providing a method of 

skin coverage for massively burned casualties. Skin 

expansion allows for greater graft coverage from limited donor sites. The surgeon has a choice of multiple 

expansion ratios, ranging from 1:5 to 9:1. One-to-one 

meshing is essentially uniform perforation without 

expansion. As the expansion ratio increases, the quality 

and cosmesis of the skin decreases, and healing time 

increases for the graft interstices or the perforations 

made in the skin graft because of the meshing and 

expansion process (Figure 13-29). As a general rule, 

most coverage is accomplished with a mesh ratio of 

3:1 or less.

Full-Thickness Skin Grafts. The depth of harvest 

for a full-thickness skin graft depends on the skin 

thickness of the designated donor site. The technique 

involves excising slightly into the subcutaneous layer, 

then preparing the full-thickness skin graft by removing as much of the subcutaneous tissue as possible 

from the bottom side of the dermis. A full-thickness 

skin graft provides appropriate wound coverage for 

small full-thickness and subdermal burns, especially 

over anatomical areas requiring durability, extensibility, or cosmesis, such as the hands and face (Figure 

13-30). Full-thickness skin grafts are associated with 

less wound contraction and scar formation than splitthickness skin grafts and are placed on the burn wound 

as a sheet graft only. Donor sites for full-thickness skin 

grafts may require grafting with a split-thickness skin 

graft for improved healing, minimizing wound contraction and scar formation. 

The typical healing time for a full-thickness skin 

graft is 10 to 14 days. Rehabilitation of areas with fullthickness skin grafts during this time should focus on 

graft protection through splinting and positioning. 

Mobilization activities, such as transfers and ambulation, can be performed during this time, depending on 

the location of the full-thickness skin graft and if the 

area of grafting can be safely protected. As the fullthickness skin graft matures, rehabilitation activities 

may progress, but consideration must be given to the 

healing graft until day 14 following operation. As with 

split-thickness skin grafts, functional outcomes are best 

achieved with early and progressive rehabilitation and 

through a safe and effective rehabilitation plan. 

Skin Graft Adherence. Skin graft adherence is a 

two-part process. The first phase, known as plasmatic 

imbibition, lasts for 24 to 48 hours. During this phase, 

the graft is held in place with fibrin bonding and nourished by direct diffusion. The second phase, inosculation, follows plasmatic imbibition and is marked by 

neovascularization.195

Figure 13-28. Meshed split-thickness skin graft applied to 

the lower extremity.

Figure 13-29. Interstices (perforations) in a meshed skin 

graft.

Figure 13-30. Full-thickness skin graft to the face of a burn 

casualty.
311

Rehabilitation of Burn Casualties

Proper management during the immediate postoperative period can significantly affect the final outcome 

of a scar graft. Graft movement or shear is generally 

the first cause of graft failure; infection is the second. 

Securing the graft to the wound bed is important to 

avoid shear. Grafts are often secured with staples or sutures. Sutures are typically used in sensitive areas, such 

as the eyelid. Biological glue is occasionally used to 

supplement adherence, such as in areas with irregular 

contours. Splints incorporated into the final dressing 

help maintain the desired position and prevent graft 

loss due to motion, especially over joints. Negativepressure wound dressings, such as vacuum-assisted 

closure devices, can also prevent shear and have been 

shown to significantly increase skin graft take when 

used over freshly grafted wounds (Figure 13-31).196

Techniques used to cover fresh skin grafts are wide 

ranging and often depend on surgeon preference. 

Skin grafts may be treated in either an open or closed 

fashion, which corresponds to the degree to which the 

graft is covered. Regardless of the exact type of dressing used, most fresh grafts are protected to prevent 

desiccation. This necessitates maintaining a moist 

environment while avoiding a wet wound bed. 

Generally, autografts can be left uncovered by the 

fifth day following grafting, and can be protected with 

an antimicrobial emollient, such as petrolatum impregnated gauze, to retain moisture in the recently grafted 

tissue and protect reepithelialization at the grafted 

site. Grafts can usually withstand gentle cleansing in 

a shower by day seven.

In contrast to the highly vascular peritendineum, 

exposed tendons have poor vascular supply and autograft will not “take” over an exposed tendon.44,197

Granulation tissue is needed to cover exposed tendon 

and allow the wound to be closed with skin grafting. 

Negative-pressure wound dressings can be used to promote wound bed granulation. Therapists should pay 

particular attention to exposed tendons over the PIP 

joint. If tendon exposure is noted, the PIP joint should 

be immobilized continuously in full extension to prevent stress on the central slip caused by PIP flexion.

Flap Grafts. Deep subdermal wounds that injure 

muscle and bone can be covered by flaps. A pedicle flap 

involves rotating tissue (typically a flexor surface) from 

an unburned area into the defect (Figure 13-32). When 

suitable donor tissue is not available directly adjacent 

to the defect, free tissue transfer may be required. This 

technique, requiring a surgical microscope, is commonly employed for complex injuries (Figure 13-33). 

Free flaps are also occasionally needed to cover areas 

prone to contracture, such as the neck. Some common 

flaps include the parascapular flap, anterolateral thigh 

flap, and groin flap.198

Figure 13-32. Pedicle flap to the nose of a burn casualty.

Figure 13-33. Free tissue transfer (free flap) on the torso of 

a burn casualty.

Figure 13-31. Application of a negative-pressure wound 

dressing following skin grafting to the hand.
312

Care of the Combat Amputee

Cultured Autologous Keratinocyte (Epidermal) 

Grafts. Human epithelial cells can now be grown in 

cultures with techniques developed by Rheinwald and 

Green199 and modified by Pittelkow and Scott.200 The 

multistep process starts with the harvesting of a small 

piece of thin skin from an unburned site. Epithelial 

cells are enzymatically cleaved and separated, then 

placed in a serum-free culture medium where, under 

ideal conditions, they grow rapidly. Thin, fragile keratinocyte sheets are approximately 7 to 10 cell layers 

thick and have the consistency of wet tissue paper 

(Figure 13-34).

Before grafting with cultured grafts, the wound 

bed must be carefully prepared. Most grafts adhere 

by fibrin adhesion. Casualties grafted with cultured 

epithelium do not develop hair, sweat or oil glands, 

or normal sensation in the grafted area. The epidermis 

remains relatively fragile and requires extra protection 

from exposure to sun, chemicals, and trauma. Rehabilitation is challenging because the epithelium does 

not tolerate exercise, splinting, or external supports. 

Casualties may have the cultured graft replaced with 

autograft as donor sites become healed enough for 

reharvesting.

Artificial Dermal Replacement. Another approach 

to providing more rapid coverage is through the use of 

an artificial dermis (Figure 13-35). One type of artificial 

dermis is composed of bovine collagen fibers bonded 

to chondroitin-6-sulfate, a component of shark cartilage.201 Thin split-thickness skin grafts are later placed 

on the neodermis, resulting in a closed wound. A multicenter controlled study of this dermal replacement 

system showed favorable results, concluding that the 

healed artificial dermis covered with thin epidermal 

graft is essentially equivalent to standard skin grafts 

but with faster healing at the donor sites.201

Biological Dressings. The ideal biological dressing 

would function as natural skin and come prepackaged 

off the shelf, ready to apply and perform as a complete 

skin replacement on a permanent basis. Synthetic 

dressings are laboratory designed to mimic their biological counterpart, skin. Because these act as biological 

dressings, for the purpose of this discussion, they will 

be reviewed along with true biologic dressings. Satisfactory biological dressings undergo the same bonding 

process as skin grafts. Most importantly, when they 

Figure 13-34. Multiple keratinocyte sheets applied to the 

lower extremity of a burn casualty. 

Figure 13-35. Artificial dermis applied to the lower extremity following excision.
313

Rehabilitation of Burn Casualties

adhere, the wound gains resistance to infection.

Biological dressings are designed to function in 

a similar manner as their more expensive natural 

counterpart, cadaver skin. There are many biological 

dressings available, but none is a true skin replacement. 

Biological dressings provide temporary coverage and 

time for adequate donor sites to become available for 

repeated graft harvest. This coverage is important in 

the overall physiological well being of a burn casualty 

because it provides better wound and pain management, helps decrease metabolic rate, reduces fluid 

losses through the wound, and suppresses the growth 

of granulation tissue.

Homograft or Allograft. Human cadaver skin is 

commonly used for grafting and is the standard against 

which other biological and synthetic dressings are measured. Banked frozen human skin is becoming more 

widely available, but is inferior to its fresh counterpart. 

Improved salvage of major burn casualties is based 

on early aggressive burn excision and coverage with 

homograft, followed by sequential replacement with 

autologous skin.

Fresh homograft adherence and capillary ingrowth 

is similar to that seen with autografts. Burn casualties with greater than 50% TBSA injury are autoimmunosuppressed. This state of immunosuppression 

can result in slowing of the natural rejection process, 

especially when the homograft skin is ABO compatible. Aside from providing excised wound coverage, 

homografts can also be used as overlay grafts to protect 

thin, widely expanded autografts or cultured keratinocytes, providing protection to the underlying grafts.

Homograft rejection occurs anywhere from 14 to 

more than 60 days after grafting, depending on the 

casualty’s immune status. Replacement homografts 

tend to reject at a faster rate than original grafts, and 

the rejection process affects the wound bed and may 

negatively influence further grafting. The wound bed 

should be completely excised prior to grafting with 

autograft.

Availability, cost, and the potential risk of viral 

transmission are the major drawbacks of fresh homograft. Procurement, preparation, and storage costs 

are relatively high. Despite testing, there remains the 

possibility of viral transmission, including hepatitis, 

cytomegalovirus, and human immunodeficiency 

virus (HIV). There is at least one known case of HIV 

transmission involving autograft from England in 

1987.202,203 Amnion is used for temporary coverage in 

underdeveloped countries but not in the United States, 

and carries the same infectious risks.204,205

Because cadaver graft take is expected to be prolonged, the area is protected postoperatively in a 

method similar to that used with autografts. Rehabilitation of cadaver-grafted areas can commence in 

3 to 7 days.

Heterograft and Synthetic Dressings. Porcine 

skin heterograft (xenograft) is occasionally used in 

the United States. However, it has limited value for 

short-term, temporary wound coverage. It has no 

advantage over homograft, but does have numerous 

disadvantages. Most importantly, xenograft does not 

incorporate into the wound, and therefore does not 

stimulate neovascularization.206 If used, rehabilitation 

activities should mirror those following grafting with 

homograft.

Numerous synthetic dressings are currently available, and many more are expected to be developed 

in the future. Some dressings have been designed for 

a specific purpose (eg, use in a combat zone), while 

others are adapted to a wide variety of clinical applications. The choice of a particular dressing is usually 

based on a mixture of tradition, art, and science.

Synthetic dressings range from simple transparent 

polyurethane or polyurethane membranes to a more 

complicated bilaminate membrane. The former often 

work well to relieve pain and protect skin donor sites, 

as well as to decrease pain, protect, and decrease 

fluid loss in small, isolated, minor burns treated in an 

outpatient burn clinic. There is no restriction in ROM 

exercises with these products. A bilaminate membrane 

dressing is composed of collagen peptides bound to 

a silicone nylon mesh. To function properly, it must 

be bound to the tissue by ingrowth into the collagen 

network. Bilaminate membrane dressings have proven 

effective on partial-thickness burns and excised wound 

beds,207 but they are contraindicated for use over fullthickness burns. To allow for adequate adhesion, ROM 

exercises are temporarily restricted for 24 hours following application of a bilaminate membrane dressing.

Donor Sites. As burn size increases, the donor site 

takes on added importance (Figure 13-36). The donor 

site can be considered analogous to a partial-thickness 

burn, which heals in the same way. Essentially, donorsite healing involves epithelial regeneration via migration of replicating epithelial cells, which originate from 

remaining hair follicle shafts and adnexal structures 

left in the dermis.208 It is imperative that donor sites 

heal quickly because numerous repeat harvestings 

are required to close massive burns. The scalp is an 

ideal donor site because it heals rapidly and has few 

associated complications. A scalp donor site covered 

with an appropriate dressing can be expected to heal 

in 5 to 7 days for a graft harvested at 0.0008 to 0.010 

inches. As a general rule, the further the donor site is 

from the heart, the longer it will take to heal. 

Donor sites are dressed to decrease pain and promote rapid healing. Donor site dressings can consist 
314

Care of the Combat Amputee

of fine mesh gauze with or without antibiotics or ointments (Figure 13-37). An open-to-air technique may 

also be used, but is not typically tolerated as well by 

casualties. Donor site dressing should be applied so 

that it overlaps by several centimeters onto the normal 

skin surrounding the site. If a donor site exceeds the 

size of the largest dressing, multiple dressings can be 

patched together to achieve complete coverage. Elastic or tubular support bandages may be applied over 

donor site dressings to provide external compression 

to the site microvasculature, especially in the case of 

the lower extremities. This technique decreases pain 

and the potential for tattooing of the donor site when 

rehabilitation activities force the extremity into various 

dependent positions.

The donor site dressing becomes problematic when 

the site is adjacent to or between burns, as it often is in 

massive burn casualties. If this donor site is covered 

with a traditional dressing, it may rapidly become 

infected, so it is preferable to treat the donor site with 

a nonadherent dressing and a topical antimicrobial, 

similar to the way the adjacent burned or grafted areas 

are treated.

Donor sites can also cause problems when the harvested grafts increase in depth, such as in the case of 

a full-thickness skin graft. The donor site may become 

as deep as the original burn and often heals slowly, 

and hypertrophy of the donor site can occur, resulting 

in a cosmetic appearance that is less favorable than 

that at the grafted sites. To avoid problems with slow 

or nonhealing donor sites, a thin split-thickness skin 

graft can be harvested, expanded at a ratio of 3:1, and 

regrafted to the donor sites.209

Healed donor sites can have problems with blisters 

and pigmentation changes. To minimize splotchy 

pigmentation, sun exposure should be avoided for a 

year or more. Educating casualties on donor site care 

mitigates these occurrences.

Intermediate Phase

The intermediate phase of rehabilitation, which begins after grafting, can be a trying time for the casualty, 

family, and staff. Casualties may see it as a setback if 

they are unable to continue exercising areas that were 

grafted. Grafting and the period of immobilization 

should be thoroughly explained to casualties and their 

families to prepare them emotionally for the postoperative period. Postoperative positioning and splinting 

should be discussed with the physician, therapist, 

and nursing staff preoperatively. Whenever possible 

during preoperative teaching, the nurse should assist 

the casualty into the position that will be assumed 

postoperatively; this will help alleviate discomfort 

issues in advance. Preoperatively, a low-air–loss bed 

or air-fluidized bed should be considered, not only 

for comfort reasons, but also for pressure reduction 

on healed, unhealed, old, or new graft sites, as well 

as donor sites.

During the intermediate phase, rehabilitation efforts continue to focus on wound healing, managing 

edema, and restoring ROM; however, increased emphasis is now directed towards strength, endurance, 

independence with ADLs and mobility, psychological 

adjustment and initiation of scar management. Common goals during this phase include: 

	 •	 progressing toward independence withADLs

and mobility;

	 •	 preserving and restoring ROM;

	 •	 initiating strengthening;

Figure 13-36. Donor site on the chest and abdomen of a 

burn casualty.

Figure 13-37. Application of petrolatum gauze dressing to a 

donor site on the anterior thigh.
315

Rehabilitation of Burn Casualties

	 •	 developing self-management skills;

	 •	 facilitatingwoundclosurewithgraftadherence;

	 •	 modifying edema;

	 •	 preventing complications, such as skin breakdown;

	 •	 maintaining joint and skin mobility;

	 •	 educating the casualty and family about the

expected results;

	 •	 conducting behavioral interventions; and

	 •	 counseling to focus on the positive final outcome, rather than on loss of independence, 

pain, or inactivity.

During this phase, wounds in nonsurgical areas 

need to be cared for at least daily. Surgical areas should 

be observed for signs of increased bleeding and infection, or because of complaints of pain from splints or 

dressings throughout the period of immobilization.

Negative pressure wound dressings enable casualties to resume limited mobility earlier during the 

immediate period following grafting. The negative 

pressure effect of the dressing splints the graft into 

the wound bed and prevents disturbing the engraftment process. A nonadherent overlay dressing is 

applied directly over new grafts. Immediately after 

grafting, a nonadherent dressing can be soaked with 

bacitracin and used to protect and hold the graft in 

place. After applying the interface dressing over the 

graft, an open-cell sponge can be placed to fit slightly 

larger than the graft. The open-cell sponge must be 

applied with a nonadherent interface dressing. A thin, 

adhesive-backed occlusive film is applied over the 

sponge and adjacent wound area to form an airtight 

seal. The entire dressing is then negatively pressurized to 125 mmHg. This dressing decreases risk for 

maceration, improves engraftment, and provides an 

effective splint. It is usually placed on the casualty 

in the operating room and is removed after 3 to 5 

days at the direction of the physician.210 Secondary 

dressings also applied in the operating room include 

agent-soaked bolsters, tie-down bolsters, or negative 

pressure wound dressings. 

The first postoperative dressing change can be 

done at the bedside or in the shower area. Thoroughly 

soaking the gauze outer dressings with water or saline 

facilitates their removal without disrupting the underlying grafts or overlay dressings that may be used 

to secure and protect grafts. The contact dressing is 

usually left in place for 24 hours after the first dressing 

change. Bending the dressing back 180° as it is pulled 

away from the wound, rather than lifting it at 90°, is 

less disruptive to the graft. After this time, graft dressings can be changed daily. If the contact layer adheres 

to the graft, applying an antibiotic ointment or white 

petrolatum 1 hour prior to removal decreases sticking 

and bleeding. Acute pain management with IV narcotics and anesthesia may be necessary for larger, more 

extensive, or painful dressing changes that require 

removal of numerous staples, negative pressure dressings, or further debridement. Subsequent dressings are 

placed considering the location of the graft, facilitation 

of rehabilitation, and casualty tolerance. In general, 

moist bolsters are continued until interstices are closed 

or nearly closed, at which time a topical moisturizer 

and dry protective dressings may be applied. Splinting, 

compression, and mobilization facilitate the quickest 

time to mobility and function. 

Postoperative rehabilitation of a hand that has been 

grafted consists of an immediate protective phase of 

full-time immobilization. The hand can be immobilized 

with a splint or a negative-pressure wound dressing, 

and must be immobilized for 3 to 5 days for splitthickness skin grafts. If the dorsal hand is grafted, it 

should be immobilized in the resting position full time. 

A palmar split-thickness or full-thickness skin graft 

must be immobilized in finger extension and thumb 

radial abduction. Full-thickness grafts are usually 

immobilized continuously for 5 to 7 days following 

operation.

AROM and gentle PROM exercises usually begin 

3 to 5 days after operation for split-thickness skin 

grafts, and 5 to 7 days after full-thickness skin grafting. 

Dorsal hand ROM exercises following split-thickness 

skin grafts should emphasize composite flexion of the 

digits (concurrent MCP, PIP, and DIP flexion), thumb 

opposition, and thumb palmar abduction. Splinting 

should be discontinued after the protective phase if 

the casualty is able to perform adequate ROM. Continued splinting should be considered for nighttime 

and as needed during the day if adequate ROM is not 

obtained with ROM exercises and ADLs. 

Once the graft is well adhered, interim compression 

can be applied to the involved areas. Interim compression can be provided using self-adhesive elastic wrap 

and is usually initiated 7 to 10 days following splitthickness skin grafting. A nonadherent dressing can be 

used underneath the elastic wrap to prevent adherence 

of the compression dressing to the skin graft. ROM 

exercises should be performed as prescribed while 

wearing the interim compression. 

Topical Treatment. Burns are cleansed once or twice 

daily, followed by application of a topical agent. A 

soothing ointment can be applied to small wounds (less 

than 10% TBSA), such as bacitracin, which is relatively 

inexpensive but does not penetrate well and is ineffective against gram-negative bacteria. Mafenide acetate 

can be used as a solution in bolsters or in cream form. 

Bolsters soaked in 5% mafenide acetate are often used 
316

Care of the Combat Amputee

to improve marginally full-thickness burns. 

Alternating mafenide acetate with silver sulfadiazine and a dry protective dressing over deep burns 

with leathery eschar has proven effective in helping 

separate eschar from wound beds, and penetrates 

more effectively than other topical agents alone. Alternating these agents helps with tolerance because 

silver sulfadiazine is soothing after the irritating 

mafenide acetate cream. All previously applied 

agents must be thoroughly removed before applying 

subsequent topicals. Meticulous wound care between 

dressing changes is the hallmark of progressive burn 

healing. Although mafenide acetate has been shown 

to cause metabolic acidosis when applied over very 

large areas, it is the preferred treatment when dealing 

with burns to the outer ear because it penetrates well 

into cartilaginous tissues and is the most effective 

antimicrobial agent for preventing chondritis of the 

outer ear. Burns that are obviously full-thickness or 

are potentially infected are treated twice daily with 

mafenide acetate until the burn is healed or nearly 

healed,211 at which time transition is made to topical 

bacitracin ointment or plain white petrolatum. Silver 

sulfadiazine does not penetrate well, but has a good 

spectrum of coverage, is easy to apply, and is the least 

painful agent, but sensitivity and leukopenia are not 

uncommon. Silver sulfadiazine is avoided in casualties with sulfa drug allergy.

Topical treatments vary depending on location, 

extent of injury, and surgical excision and grafting. 

Wounds that do not appear they will heal within 2 to 

3 weeks are usually excised and grafted 1 to 5 days 

following burn. 

Wound care and wound management are large 

parts of the recovery process for injured casualties. 

Rehabilitation is also vital in returning the injured 

to normalcy or optimal function. Discharge criteria 

include particular levels of independence in ambulation, ADLs, hygiene, transfers, and ability to manage 

wounds. Pain and pain management must also be considered when determining discharge eligibility. Today, 

there are numerous wound dressings that require little 

more care than regular follow-up for progress evaluation. Pain medications traditionally given in IV form 

can now be given orally.

Long-Term Phase

Rehabilitation focus continues to shift in the longterm phase. By this time, edema, ROM, strength, ADLs, 

and mobility are typically well managed. Rehabilitation efforts are now more specifically targeted toward 

reintegration, psychological adjustment, return to 

duty, and continued scar management. However, if 

impairments persist from the acute or intermediate 

rehabilitation phases, continued focus for these will 

be required. Common goals include:

	 •	 societal reintegration;

	 •	 improving aerobic capacity;

	 •	 preventing hypertrophic scarring;

	 •	 remediating scar contracture;

	 •	 modifying edema;

	 •	 increasing joint and skin mobility;

	 •	 increasing strength;

	 •	 facilitating casualty and family participation

in resumption of family roles;

	 •	 learning self-care activities;

	 •	 mastering compensation techniques for exposure to friction, trauma, ultraviolet light, 

chemical irritants, and extremes of weather 

or temperature;

	 •	 developing a profile for active-duty training,

return to part-time modified duty, or to fulltime active duty; and

	 •	 continued counseling to deal with life and

psychological stresses regarding permanently 

changed appearance, altered ability levels, 

and difficulties with PTSD symptoms.

As a casualty transitions into the long-term rehabilitation phase, the healing burn is very fragile, and 

if not protected, is prone to shearing, pressure, and 

subsequent breakdown until matured. It is not uncommon to have small blisters form during this time, because the epidermal layer is not firmly attached to the 

underlying dermis for several months.212 All wound 

areas should be gently cleansed and rinsed well with 

water. Infection is no longer a significant consideration; 

therefore, antibiotic ointments are generally discontinued. However, multiple topical agents may be used for 

cleansing, barrier protection, and antimicrobial control, 

and may lead to complications of contact and irritant 

dermatitis, further complicating reepithelialization 

and wound healing.213 Blistered areas should have a 

light, nonadherent dressing applied for protection. 

The intact blister should not be opened or debrided. If 

the blister is large and spreads when external vascular 

support is applied, the blister should be drained and 

the wound protected with the dry skin. If the dry skin 

peels away, a protective nonadherent dressing can be 

applied and changed daily.

During the end stages of wound epithelialization, the wound is assessed to determine whether 

compression by elastic wraps, interim compression 

garments, or custom compression garments will be 

most effective. The integument should be continually 

inspected for changes resulting from increased activity, 
317

Rehabilitation of Burn Casualties

exercise, or in response to treatment procedures. External vascular support should be applied to the lower 

extremities prior to dependent positioning or ambulation.214 Standing in the shower with legs dependent 

is permitted only after all open areas are closed and 

purple color exhibited by dependent wounds in this 

position decreased.

After a burn, the number of sebaceous and apocrine 

glands are decreased, leaving healed skin dry and flaky. 

Casualties may be irritated by pruritus, but vigorous 

rubbing or scratching results in newly opened areas. 

Moisturizing lotions should be applied to all healed 

areas after bathing and routinely as needed. The lotion 

should not be perfumed, have an alcohol base, or be 

so viscous that it causes blisters during application. 

Long-acting oral antipruritic medications should be 

used215 in conjunction with lotion to relieve the itch. 

Fingernails should be kept trimmed, smooth, and clean 

to prevent excoriation of fragile skin. Desensitization 

exercises and vibration massage may reduce itching.216 

When exercising outside, a casualty’s healed burn or 

donor areas should be protected from sunlight until 

all the red color has faded. 

The long-term phase emphasizes addressing deficits 

to allow optimal return of function following a hand 

burn. Finger amputations, poor autograft take, age, 

full-thickness TBSA burned, and full-thickness hand 

burn area are all long-term predictors of hand function 

following a burn.217 Management during this phase is 

primarily dependent on scar maturation; mobility of 

skin, joint, and soft tissue; and neuropathy. 

Chronic Nonhealing Wounds. Occasionally, chronic 

nonhealing wounds will develop. In these instances, 

it is important to identify the underlying problem 

causing the healing delay. Pressure, shear forces, infections, and poor nutrition are common factors that 

delay healing. Interventions such as pressure relief, 

properly fitting compression garments, and nutritional 

counseling may be needed to promote healing. Occasionally hypertrophic granulation tissue may keep 

wound edges from migrating effectively, resulting in a 

chronically open wound. Silver nitrate as a cauterizing 

agent, surgical excision, and regrafting have all proven 

beneficial in managing chronically open wounds. 

Biomechanics of Skin and Scar 

A severe burn is both a physical injury to the integumentary system and a physiologic insult to several 

other organ systems. Skin is unique because one piece 

of tissue encapsulates the entire body while permitting 

unrestricted flexibility to the extremities and trunk. 

When naturally pliable skin is replaced by scar tissue 

or skin grafts, tissue contractures can develop.

The viscoelastic nature of native skin is derived from 

the interactive combination of a fibrous matrix of collagen and elastic fibers surrounded by an amorphous 

gel generically referred to as “ground substance.”218

Collagen fibers lend strength to the skin, while elastic 

fibers give the skin its extensibility and subsequent 

retraction after deformation. The ground substance 

lubricates the fibers and partially absorbs energy applied to the skin during movement.

The collagen network of the dermis in undamaged 

skin is made up of long, undulating fibers that are somewhat randomly oriented under relaxed conditions.218,219

Elastic fibers are straighter than individual collagen 

fibers and are interconnected as well as attached to the 

collagen strands. As traction is applied to the skin, the 

elastic fibers elongate, pulling on the collagen fibers to 

orient them in the direction of applied force.220 During 

this action, the viscous ground substance is displaced 

from between the fibrous network.218 

The interaction of these three biomechanical components of skin can be described on a stress-strain 

curve (Figure 13-38). Initially, skin can be significantly 

elongated with minimal force because mostly the 

highly pliable elastic fibers are being stretched.221 As 

additional tension is added to elongate the skin, more 

collagen fibers reorient themselves in the direction of 

the applied stress. As collagen fibers accumulate in 

the direction of the applied force, a greater force is 

required to overcome the resistance by the aligning 

collagen fibers to gain further length. Once all the collagen fibers have aligned parallel to one another in the 

direction of the force, the slope of the curve becomes 

linear, with little further elongation attainable despite 

the input of greater force. At the physical terminus of 

skin elongation, applying additional force causes the 

skin to rupture. Cessation of an elongating force allows 

Force

Phase I Phase II

Phase III

Yield

Point

Elongation

Break

Point

Phases and Critical Points

of Stress - Strain Curve

Figure 13-38. Stress-strain curve of tissue.
318

Care of the Combat Amputee

the fibrous network to revert back to its original resting 

length by a recoil action of the elastic fiber attached 

to the straightened collagen fibers (Figure 13-39).221

Undamaged skin has the capacity to elongate up to 

50% to 60% of its original resting length.222

The dermis injured by burn is replaced by scar 

tissue. Scar tissue differs from normal dermis in that 

elastic fibers do not regenerate,223 the composition of 

ground substance changes, and the fibrous portion is 

only collagen. Morphologically, untreated burn scar 

develops into a disarray of randomly oriented collagen fibers. Characteristically, nodules form in the 

extracellular matrix, which may be under the influence 

of ground substance changes.224 Biomechanically, burn 

scar behaves much like tendon, resisting deformation. 

Immature burn scar is only 16% extensible, which 

decreases to approximately 4% at maturity.225

Acute Phase

Burn scar must be managed while it is being produced. Physical intervention is an imperative part of 

the early rehabilitation phase. Arem and Madden have 

shown that stress applied to newly developing scar 

tissue causes it to orient in the direction of the force.226

Burn scar begins to form during the proliferative stage 

of wound healing, which begins approximately 5 to 7 

days after injury.

The effect of burn rehabilitation interventions is 

based on biomechanics principles. Repeated ROM 

exercise or the use of reciprocal pulleys, for example, 

harness the principle of successive length induction.227

With successive length induction, each time the body 

segment is moved, the tissue further elongates (Figure 

13-40). However, tissue length increase from successive 

length induction is not permanent because as soon as 

stress is relieved from the tissue, the tissue begins to 

return to its original resting length. Also, it is important 

to consistently use ROM measurements from either 

the beginning of the treatment session or the end to 

accurately compare improvement between treatment 

sessions. Improvements in ROM achieved within a 

given treatment session are misleading because the 

improved ROM is temporary.

Positioning, static and static-progressive splinting, and serial casting incorporate the biomechanical 

principle of stress relaxation.228 With stress relaxation, 

tissue is elongated to a set point and held at that given 

length by the selected intervention. The set point 

should cause slight discomfort for the casualty. As 

time passes (within an hour), stress on the tissue eases 

and the tissue relaxes, making the intervention more 

tolerable (Figure 13-41). Stress relaxation prevents scar 

tissue from shortening.

Another biomechanical principle used in burn rehabilitation is based on tissue creep.229 When controlled 

stress is applied to tissue over a prolonged period of 

time, such as with dynamic splints, the tissue continually undergoes elongation (Figure 13-42). 

Strain rate, or how quickly tissue should be elongated, is another biomechanical consideration (Figure 

13-43).230 Tissue responds to stress that is applied either 

rapidly or over a prolonged period, as long as the 

force of the stress is at a therapeutic level. However, 

rapidly elongating tissue causes casualties more pain 

than if the intervention is performed or applied over 

a prolonged period of time. 

Regardless of the therapeutic approach or biomechanical principle, casualty tolerance of the procedure 

Force

Elongation

Loading Curve Hysteresis

(Unloading)

Curve

Stress - Strain Curve

with Hysteresis

Figure 13-39. Tissue hysteresis.

Successive Length

Induction Curves

1 5

Elongation

Force

Figure 13-40. Successive length induction.
319

Rehabilitation of Burn Casualties

should guide rehabilitation. Furthermore, a sustainedapproach treatment minimizes the chance of damaging 

tissue.

Intermediate Phase

Positioning during the intermediate phase is based 

on several factors relevant to tissue recruitment and 

creep. If a body part has a direct burn injury resulting 

in grafting or healing of native skin, positioning in the 

intermediate phase continues in the same fashion as 

it did acutely, so as to place the body part in anticontracture or a maximum wound length position while 

at rest or between active therapeutic interventions. 

If a body part has residual healthy native skin and is 

involved as recruited tissue due to close proximity to 

the burn wound, positioning in the intermediate phase 

continues in the same fashion while at rest or between 

active therapeutic interventions. 

Burn casualties increase their daily activity level 

in the intermediate phase. The primary function of 

positioning now becomes more focused on stressing 

the grafted and healing sites beyond what is accomplished in active therapeutic intervention to create 

tissue creep and increase native skin recruitment. 

Success in this phase requires creative interventions beyond the standard positioning and splinting devices. The therapist should always consider 

various interventions to prevent contracture; aside 

from positioning and repositioning, ROM exercise, 

strengthening, and ADLs are implemented to reduce 

contracture risk. 

Additional activity integrates postural awareness 

and dependant posture demands on wounds. A therapist will instruct a casualty in postural adaptations 

and explain the need to adjust from dependant to 

nondependent postures throughout the day, allowing 

the casualty to avoid undue stress to the wounds and 

preventing acute swelling. 

Long-Term Phase

Many different interventions applying these biomechanical principles have been successfully employed 

to treat established burn scar contractures. A study 

investigating approaches to remediating burn scar contracture documented that serial casting and splinting, 

as well as dynamic splinting, were the most efficacious 

methods to reverse burn scar contractures.231 By using 

one of these three interventions, contracture resolution 

took approximately half the time than it took using 

various other methods. These methods were effective 

on immature scar tissue.

Positioning requirements continue to be a key factor 

in contracture prevention and burn scar management 

until the wounds reach maturation. As the casualty 

Time

Force

Curve Displaying

Stress Relaxation of Tissue

Figure 13-41. Stress relaxation of tissue.

Elongation

Time

Curve Depicting Tissue

Property of Creep

Figure 13-42. Tissue creep.

Force

Fast

Slow

Elongation

Curves for Tissue

at Various Strain Rates

Figure 13-43. Graph displaying the difference in various 

strain rates of tissue.
320

Care of the Combat Amputee

reaches the long-term rehabilitation phase, wounds 

are closed and essentially healed. The casualty then 

endures the process of wound maturation as the scar 

tissue gradually slows in formation, flattens, and 

reestablishes a color presentation more similar to native skin. This process can last as long as 2 to 3 years 

after injury. 

The techniques for positioning during the long-term 

rehabilitation phase closely resemble those of the intermediate rehabilitation phase. The most significant 

adjustment in implementing contracture prevention 

techniques includes increased use of custom splinting 

and positioning devices. Initially, dependent positioning of the extremities will be painful, which will remind 

the casualty to elevate the hands or feet. By this time, 

casualties must take responsibility for varying their 

own positions while at rest. However, it will still be 

necessary to apply various splinting devices to critical areas that have lost strength or active motion to 

produce burn scar contracture. 

Splinting

A splint is defined as “an orthopedic device for 

immobilization, restraint, or support of any part of 

the body.”232 Splints can also mobilize, position, and 

protect a joint or specific body part.233 Different types 

of splints are used throughout a burn casualty’s rehabilitation, depending on the phase the casualty is in.

Acute Phase

There have been 93 splints used for burn rehabilitation described in the English language; An Atlas and 

Compendium of Burn Splints234 provides a description 

and summary of each. During the acute phase, the 

primary goal of splinting is to maintain proper positioning of the burn casualty’s extremities in order to 

reduce edema, prevent soft tissue contracture, and 

protect skin grafts, all of which minimize burn scar 

contracture and deformity. Proper positioning is vital 

because burn casualties may not be alert enough to 

maintain ROM with active movement. Static splints are 

used most frequently and may be custom or prefabricated, depending on the burn casualty’s specific needs. 

Splints are generally applied 72 hours after burn. If 

implemented during the first 72 hours after burn, 

complications may develop because of the confining 

nature of splints and the active edema accumulation 

from fluid resuscitation. 

A commonly used, prefabricated hand splint maintains the hand in the intrinsic plus position, also known 

as “the position of safe immobilization” (Figure 13-44). 

This position involves 20° to 30° of wrist extension, 

maximum flexion of the MCP joints, maximum extension of the IP joints, and palmar abduction of the thumb 

to avoid contracture of the first web space.235

Prefabricated burn splints are clinically expedient 

and generally meet the needs of burn casualties during 

this phase. Also, they are oversized and can accommodate bulky dressings. These early burn splints are 

secured with a gauze wrap; straps are contraindicated 

at this time because they do not accommodate for 

changing edema, have the potential to compromise 

circulation, and do not evenly distribute pressure over 

the edematous extremity.

When using splints, it is essential to constantly assess the burn casualty’s skin integrity. Pressure areas 

can increase the risk for skin breakdown, nerve compression, or burn wound conversion. The safe position 

can also be achieved with a custom splint, which may 

be more appropriate for a burn casualty with fluctuating edema, associated orthopaedic conditions, or digit 

amputations. Custom splints may also be indicated 

for the hand in the presence of full-thickness burns of 

the dorsal hand that result in exposed tendons. During the acute phase, static splinting can be used to 

maintain proper joint alignment and to help prevent 

contractures. 

Dorsal hand edema encourages wrist flexion, MCP 

joint hyperextension, and IP flexion.42 Intrinsic muscle 

edema encourages PIP joint flexion.236 Therefore, the 

resting hand splint is the most common splint used 

during this phase. The resting position maintains 20° 

of wrist extension and 60° to 70° of MCP flexion, and 

keeps the thumb in palmar abduction.42

The PIP joint can be immobilized with a gutter splint 

or with surgical placement of Kirschner wires, and 

the PIP should be immobilized until the tendon is no 

longer exposed. MCP and DIP joint motion should be 

maintained as long as there is no tendon exposure in 

these areas. If the tendon over the PIP joint is ruptured, 

immobilizing the PIP joint in extension for 6 weeks 

Figure 13-44. Hand splint secured with gauze wrap.
321

Rehabilitation of Burn Casualties

may prevent volar migration of the lateral bands that 

contributes to a boutonnière deformity. The scar over 

the PIP joint may form a pseudotendon that assists 

with PIP extension.237

A palmar burn will contract into thumb flexion, 

thumb adduction, and finger flexion. Splints or casts 

used for palmar burns should hold the hand in the position of thumb radial abduction and finger MCP, PIP, 

and DIP extension. Caution should be taken to avoid 

MCP hyperextension of the thumb when positioning 

into radial abduction. Exercises should emphasize finger extension and radial abduction. Flexion exercises 

can be performed to prevent joint capsule tightness 

of the MCP and IP joints; however, caution should be 

taken to avoid digital extension losses.

Splints are not usually necessary for superficial 

partial-thickness burns unless there is minimal active 

motion of the hand and poor exercise participation because of pain. Resting hand splints are more commonly 

used for deep partial-thickness or full-thickness burns 

because of the higher risk of joint or skin contracture. 

Prefabricated resting splints covered with gauze are 

primarily used during the acute phase. 

Intermediate Phase

Although reducing edema and preventing soft tissue contracture remain priorities, the primary goal of 

splinting is to protect skin grafts during the intermediate phase of rehabilitation. One of the most important 

responsibilities of the rehabilitation staff is to promote 

skin graft adherence. The most common type of splint 

indicated is a static splint, or a splint that does not 

allow movement. Newly grafted areas are generally 

immobilized with static splints for 3 to 5 days following operation for split-thickness skin grafts, and 5 to 

7 days for full-thickness skin grafts. Preventing burn 

scar contracture from forming is also important at this 

point and can be accomplished concurrently with skin 

graft protection using the appropriate splint.

Ears. An ear-dressing kit can be used to protect ears 

before and after grafting. A typical kit includes a hard 

plastic cup to cover the ear and is lined with gauze for 

wound protection

Mouth. A microstomia prevention appliance238 or a 

mouth spacer can maintain the horizontal component 

of mouth opening after a burn to the commissural 

region (Figure 13-45). 

Neck. There are several options for immobilizing 

the neck in the intermediate phase of recovery. A soft 

neck collar, consisting of foam placed circumferentially 

around the neck, can serve as a positioning device to 

promote neutral neck positioning (Figure 13-46).239

Custom thermoplastic splints may be fabricated to 

protect neck grafts or to provide optimal positioning, 

most commonly in neutral or slight neck extension. An 

anterior neck splint is conformed along the anterior 

neck, the upper chest, chin, and lower mandible.240

The splint can be secured with hook-and-loop fasteners around the posterior of the neck, and can protect 

the graft and provide optimal positioning to limit the 

formation of burn scar contracture. 

Both the soft collar and the anterior neck splint 

can provide contact pressure to help minimize scar 

hypertrophy while providing neutral or slight cervical 

extension. Both splints can be used past the immobilization phase to provide prolonged neck positioning. 

Providers must frequently perform skin integrity 

checks when using these splints, as both can cause 

Figure 13-45. Jouglard’s mouth spacer (Medical Z, San Antonio, Tex) for the prevention of correction of microstomia.

Photograph: Courtesy of Medical Z, San Antonio, Texas.

Figure 13-46. A soft neck collar for neutral positioning of 

the neck.
322

Care of the Combat Amputee

mechanical shear to skin grafts with any movement 

or excessive pressure.

A halo neck splint241and three-point anterior neck 

splint242 are two types of “open” neck splints that can 

immobilize the neck after grafting (Figure 13-47). These 

splints do not permit direct wound contact and allow 

the wounds to ventilate. The halo neck splint consists 

of a posterior thermoplastic post with a skull cup and 

a circumferential head strap. These are connected 

to a thermoplastic base over bilateral anterior and 

posterior shoulder girdles. The three-point anterior 

neck splint is similar to the anterior neck splint, but 

there is an opening over the anterior neck, with three 

thermoplastic posts connecting the chin and shoulder 

girdle components. 

Axilla. In the event that traditional positioning is 

not enough to immobilize and protect the axilla area, 

a thermoplastic splint may be fabricated. An airplane 

splint with a support rod243 can be custom fit to the 

burn casualty in order to keep the axilla positioned in 

at least 90° of flexion or abduction for optimal positioning after burning or grafting. This splint can also 

be used to protect lateral trunk grafting. 

Elbow. A static elbow splint, or elbow plank, is 

commonly used for graft protection or for optimal 

post-burn positioning (Figure 13-48). This splint can 

be fabricated out of thermoplastic material and can be 

placed posterior244 or anterior.245 The splint is usually 

worn until 3 to 5 days after split-thickness skin grafting 

when used for graft protection. 

Wrist and Hand. There are several splints that can 

immobilize the hand or wrist after skin grafting. A 

prefabricated splint is the most common type used 

for protection following grafting (see Figure 13-21b). 

An advantage of this oversized splint is that it can accommodate the typical bulky postoperative dressings. 

These splints are usually worn continuously until at 

least 3 to 5 days after grafting, when ROM exercises are 

again permitted. A custom resting splint is indicated if 

a proper fit is not obtained due to anatomical restrictions or dressing limitations.246 A custom splint is also 

indicated if specific positioning other than the “safe” 

position is indicated (Table 13-7 and Figure 13-49). 

Static or serial static splinting are the primary splint 

types used during the intermediate rehabilitation 

phase. Dynamic or static-progressive splints should be 

implemented if sufficient ROM gains are not achieved 

with static or serial static splinting. Serial casting is an 

effective alternative to splinting that provides the low 

force and long duration positioning needed for optimal tissue elongation.247 It can protect open wounds, 

facilitating healing. Antimicrobial wound dressings 

that remain effective for at least several days should 

be used underneath the casts on open wounds. ROM 

gains made in a cast can be maintained with static 

splinting or improved with static-progressive or dynamic splinting once casting is no longer indicated. 

Deep partial and full-thickness burns also require 

interim compression for scar control during the intermediate rehabilitation phase. Permanent custom 

compression garments are not appropriate during 

this phase because of open wounds, edema, and skin 

fragility. However, interim compression can help with 

edema control and protect fragile skin from friction. 

Figure 13-47. Halo neck splint used to position the head and 

neck after grafting.

Figure 13-48. Thermoplastic static elbow plank for optimal 

post-grafting positioning.
323

Rehabilitation of Burn Casualties

Figure 13-49. (a) C-bar splint for preventing and correcting 

contracture to the first web space (top view).

(b) Slot-through splint for combined wrist and palmar extension. (c) Slot-through splint with C-bar component for 

optimal thumb positioning. 

a

c

b

TABLE 13-7

CUSTOM HAND AND WRIST SPLINTS

Type Indication

C-bar Stretches first web space; places the thumb in palmar abduction for optimal dorsal web 

space positioning, or in radial abduction for optimal palmar or thenar positioning following burn or skin grafting (see Figure 13-49a)1,2

Slot-through Used when combined wrist and palmar extension is indicated following grafting to the 

palm or for adequate positioning after a palmar burn with or without volar wrist involvement (see Figure 13-49b); a C-bar component can be added to place the thumb into 

optimal radial abduction if the thenar eminence is involved (see Figure 13-49c)3

Volar wrist extension May be fabricated with thermoplastic material to immobilize the wrist following skin 

grafting or volar wrist burn; may also be indicated if wrist support is needed due to a 

neurological deficit, such as a radial neuropathy4

Finger gutter or finger tunnel Fabricated to hold interphalangeal joints in extension, protect exposed tendons, immobilize after skin grafting, or prevent a boutonniere deformity5,6

Data sources: (1) Fess EE, Philips CA. Hand splinting, Principles and Methods. 2nd ed. Saint Louis, Mo: Mosby; 1987. (2) Walters CJ. Splinting the 

Burn Patient. Laurel, MD: RAMSCO Publishing Company; 1987. (3) Forsyth-Brown E. The slot-through splint. Physiotherapy. 1983;69:43–44. 

(4) Miller H, Posch JL. Acute burns of the hand. Am J Surg. 1950;80(6):784–798. (5) Von Prince KMP, Yeakel MH. The Splinting of Burn Patients. 

Springfield, Ill: Thomas; 1974: 60–70. (6) Salisbury RE, Bevin AG. Atlas of Reconstructive Burn Surgery. Philadelphia, PA: WB Saunders; 1981: 164.
324

Care of the Combat Amputee

Interim compression options for the hands are selfadherent elastic wrap or commercially available nylon 

gloves. Superficial partial-thickness burns do not require scar compression, but a nylon glove can reduce 

edema or protect the involved hand from friction. 

Knee and Ankle. There are several options available to immobilize the knee and ankle after grafting 

or for proper positioning. A long leg splint—a static, 

prefabricated, metal-based splint lined with foam 

inserts, cast padding, and gauze dressing—may be 

indicated when it is necessary to simultaneously immobilize the knee and ankle (Figure 13-50). A long 

leg splint immobilizes the ankle in a neutral position 

and the knee in full extension. It extends posteriorly 

from the plantar surface of the foot to the posterior 

thigh and is typically applied to the burn casualty 

using gauze. When it is necessary to isolate either the 

knee or the ankle, a custom thermoplastic splint can 

be fabricated.244,246 Ankles can be isolated and immobilized or held in a neutral position with a prefabricated 

boot (Figure 13-51).

Long-Term Phase

The primary goal of splinting during the long-term 

rehabilitation phase is to prevent skin or joint contractures. Because collagen fibers are aligned along lines of 

stress,189 splinting is an important component of rehabilitation. The three types of splints used during this 

period are static, dynamic, and static progressive. Static 

splints are indicated if an achieved position needs 

to be maintained during the scar maturation phase. 

Static splints can also be serially fabricated. Serial static 

splints get remolded progressively at the maximum 

tolerable end ROM to increase tissue length.247

A dynamic splint allows for or provides movement. 

A dynamic splint can be used correctively or functionally. A corrective splint is indicated to correct burn scar 

or joint contracture. The movement provided should 

include a low-load force in the direction of tension.248

The most common dynamic force used for dynamic 

splinting is rubber band or elastic tension. If the goal 

for this splint is to gain motion, a period of 6 to 8 hours 

of cumulative wear time, with wear intervals lasting 

at least 30 minutes, is recommended. The key to successful dynamic splinting and tissue elongation is to 

provide a low-load force for a long duration.248 

Corrective dynamic splints are most frequently used 

for the elbow, wrist, and hand, and the involved area 

must be frequently inspected for skin breakdown. A 

90o angle of pull is required to provide optimal dynamic force.249 Dynamic splints for the elbow, wrist, 

forearm, hand, knee, and ankle are also commercially 

available, providing many options depending on the 

targeted movement or joint. However, commercially 

available splints may not adequately fit a casualty; 

therefore custom fabricated dynamic splints are sometimes indicated. A dynamic supination splint can be 

effective for increasing ROM if limited by burn scar 

or joint contracture.250 A thermoplastic wrist extension 

splint has also been used to address burn scar and joint 

limitations (Figure 13-52).251

Dynamic splints are also useful during this phase to 

substitute for loss of function from concomitant nerve 

injuries or amputations. The most commonly used 

Figure 13-50. A long leg splint used for simultaneous knee 

extension and ankle dorsiflexion positioning.

Figure 13-51. Commercial ankle-foot orthosis for ankle 

positioning.
325

Rehabilitation of Burn Casualties

adaptive splint for burn casualties is the mobilization 

splint for radial nerve palsy, originally designed at the 

Hand Rehabilitation Center in Chapel Hills, North 

Carolina, in 1978 (Figure 13-53).252 This mobilization 

splint reestablishes the tenodesis pattern of the hand253

and includes a dorsal base splint with a low-profile 

outrigger that spans from the wrist to each proximal 

phalanx.233

Another type of corrective splint, a static progressive splint, uses inelastic components to apply torque 

to a joint at end range to increase available ROM.254

Unlike the dynamic splint, the static progressive 

splint does not permit active-resisted ROM against 

the line of pull.255 Flowers states that static progressive 

splints are indicated when the targeted tissue is stiff 

and requires the most aggressive intervention.256 The 

principle of a low-load force for long duration should 

be implemented with static progressive splints. Wearing schedules and precautions are similar to those 

observed with dynamic splints. A variety of static 

progressive splints for the upper and lower extremities 

are also commercially available. 

There are several different types of static progressive splints used to correct contractures of the upper 

extremity. An elbow extension turnbuckle splint or 

elbow flexion splint may be used when joint or burn 

scar limitation results in elbow flexion or extension 

contractures.257 Wrist and hand splints can also be 

fabricated to address burn scar or joint limitations, 

and various other static progressive splints can be 

fabricated for the upper extremities, depending on 

the target joint or tissue.255 A common static progressive splint used to regain hand ROM following burn 

or skin grafting is a composite flexion splint, which 

includes combined flexion of the MCP, PIP, and DIP 

joints (Figure 13-54). 

Casting

Serial casting is typically recommended for managing burn scar contracture when the involved structures 

are resistant to traditional methods of treatment, such 

as AROM exercises, paraffin baths, massage, progressive resistive exercise, and splinting (Figure 13-55).258,259

Casting can help throughout the various phases of 

burn recovery.

Acute Phase

In the acute phase, casting can be used for immobilization, edema reduction, and tissue protection.260

Burn casualties often present with a significant soft 

tissue defect that leaves underlying structures exposed. 

Some of the qualities of Plaster of Paris make it the 

perfect material to intercede, including unparalleled 

conformity, decreased pressure (which is due to the 

conforming quality of the material), and reduced 

shear force compared to alternative materials.260,261 

Plaster of Paris is also porous and retains heat well, 

which is important for individuals with friable tissue. 

These qualities decrease the likelihood of maceration 

Figure 13-52. Fulcrum wrist extension splint.

Figure 13-53. Volar view of radial nerve palsy mobilization 

splint, displaying elastic straps around first phalanx that 

assist with metacarpophalangeal extension.

Figure 13-54. Static progressive finger composite flexion 

splint.
326

Care of the Combat Amputee

and create neutral warmth, required because casualties with large burns have difficulty regulating their 

temperature.260

Intermediate Phase

The clinical focus in the intermediate phase moves 

from tissue protection toward mobilization while 

maintaining emphasis on reducing and managing 

edema. The indication for casting as an intervention 

during the intermediate phase is based on the same 

factors as in splinting: tissue recruitment and creep. 

If a body part has healthy, native skin and is involved 

as recruited tissue because of close proximity to the 

burn wound, aggressive total active motion is sought 

throughout each intervention. All active components 

of ROM progression, such as AROM, sustained stretch, 

strengthening exercises, and daily functional activities, 

should precede casting. Keeping in mind that the chosen modality should help restore ROM, serial or dropout casting may be considered to stimulate tissue creep 

or native tissue recruitment. Skin and joint tightness 

suggest serial or dropout casting will be effective.260

The extended gentle stress of serial casting results in 

the repose of links between collagen fibers and realignment of collagen into a parallel and lengthened state. 

The realignment of collagen structures around the 

affected joint is also protected.262

Guidelines to Serial Casting

Serial casting is indicated for the following:

	 •	 casualties who have scar contractures for less

than 18 months, 

	 •	 casualties with contractures that are not responding to traditional methods of therapy, 

	 •	 casualties with exposed tendons,

	 •	 casualties who do not comply with traditional

therapy, 

	 •	 casualties willing to comply with inconveniences of wearing a cast,

	 •	 casualties with multiple joint involvement,

	 •	 casualties with increased muscle tone, and

	 •	 when extra contour or compression must be

applied for scar management. 

Serial casting is contraindicated when a casualty exhibits heterotopic ossification (HO), excessive edema, 

or agitation, or does not comply with follow-up appointments.

A thorough chart review, followed by a complete 

physical examination, will help determine if serial 

casting will be therapeutically beneficial. The assessment must include radiographs to rule out HO in the 

affected joint. ROM and the functional components of 

the affected joint should be assessed to acquire joint 

feel and mobility while using proper alignment. The 

end range test should be concluded just beyond the 

point of resistance to achieve an appropriate end feel.262

Fragile or friable skin, open wounds, an insensate 

extremity, and cognitive or emotional impairments 

should be taken into account when considering serial 

casting. These considerations are weighed against the 

advantages of a noninvasive procedure. Serial casting 

allows for continuous intervention with total contact 

in addition to continuous stretch, which allows for 

more concentrated intervention on other affected 

areas.260,262

Long-Term Phase

Casting techniques during the long-term rehabilitation phase closely resemble the interventions of the 

intermediate rehabilitation phase, but with a focus 

on mobilization and edema management. Casting is 

key in reducing and preventing contracture until the 

wounds reach maturation and full active ROM can be 

achieved and sustained. A variety of casting techniques 

are available to help burn casualties recover ROM. Any 

design that can be made with splinting material can 

also be made with casting material.260

Range-of-Motion Exercise

Acute Phase

Burns heal naturally by contraction, and shortened 

connective tissue responds to the stress imparted by 

ROM exercise. A thorough history is required to determine the type of ROM exercises that will meet the 

casualty’s, physician’s, and therapist’s goals. Additionally, service members who sustain battlefront burns 

often incur accompanying injuries, such as penetratFigure 13-55. Elbow cast used to serially correct burn scar 

contracture.
327

Rehabilitation of Burn Casualties

ing wounds or fractures, which require consideration 

when selecting appropriate ROM exercise.

Acutely burned service members must move gently 

through full ROM each day to improve peripheral 

circulation, keep joints nourished, and prevent contractures or decubitus ulcers. All areas injured, including the face, neck, bilateral upper extremities, hands, 

bilateral lower extremities, feet, and trunk, require attention. Contractures of the flexor surfaces of joints are 

noted most frequently. However, exercise in all planes 

of motion must take place. Therapists and casualties 

collaborate to form the ROM exercise plan most appropriate to the individual injury (Exhibit 13-3). The 

progression of ROM differs based on the casualty and 

injury characteristics. All types of ROM exercise apply to all casualties at some point in the recovery and 

rehabilitation process. 

Casualties with larger burns (> 30% TBSA burned) 

are typically intubated, sedated, and admitted to the 

intensive care unit, rendering AROM impossible. 

In these cases, PROM is the mainstay of daily ROM 

treatment. In the case of smaller burns, casualties are 

capable of beginning with AAROM or AROM in the 

acute phase. Casualties admitted with acute hand 

burns should be evaluated by a therapist within 24 

hours of admission. 

Although PROM may be the least desirable type of 

ROM exercise, it can be useful when treating a comatose casualty, and it helps maintain joint mobility and 

integrity.263 PROM should be performed gently, slowly 

and cautiously by a therapist, and precautions should 

be taken to avoid overstretching joint structures.177

PROM should be performed in the appropriate planes 

of motion for each joint while stabilizing the joints 

above and below. Some clinicians believe that PROM 

may cause tissue damage that leads to increased scarring, but this theory has not been substantiated.263–265

Scar tissue responds well to passive force when applied 

in a steady, controlled manner (Exhibit 13-4).177 Special 

instances where PROM is called for include after an 

escharotomy or fasciotomy, or when it is necessary to 

preserve tendon gliding and the casualty is unable to 

perform AAROM or AROM exercises.177,263 Caution 

should be exercised when tendons are exposed, especially at the PIP joint of the finger. PROM exercise 

should be restricted to the amount of force required for 

an observable tendon excursion to occur.177 Additional 

force provides no increased benefit and places exposed 

tendons at risk for rupture, leading to joint deformities. Once hemostasis has been achieved, any type of 

ROM exercise is permissible to obtain full ROM and 

preserve joint integrity.177

Continuous passive motion (CPM) devices reduce 

edema266 and preserve motion. The deleterious effects 

EXHIBIT 13-3

RANGE-OF-MOTION EXERCISE CATEGORIES

	 •	 Passive range of motion (PROM) is movement of the joint through the range of movement, which is produced

entirely by an external force.1 The prime mover muscle for the joint does not voluntarily contract to complete 

the range of movement. Movement performed without assistance on the part of the casualty is considered 

passive exercise.

	 •	 Active assistive range of motion (AAROM) is movement in which AROM by the casualty is supplemented

with assistance by an external force.1 The prime mover muscle for the joint needs assistance to complete the 

range of movement. AROM with terminal stretch means the casualty vigorously moves the joint through 

available motion, then the therapist gently stretches the joint in its proper plane of motion, toward the extremes of full motion.

	 •	 Active range of motion (AROM) is movement within the range of movement, which is produced by voluntary

active contraction of the muscles crossing that joint by the casualty.1 The prime mover muscle for the joint 

voluntarily contracts to complete the range of movement.

	 •	 Low-load prolonged stretch is a relatively long-term stretch, applied in a controlled manner at a tolerable

load.2 Typically achieved through positioning, splinting, casting or with the use of equipment, this type of 

stretch is used for a prolonged time and therefore must be tolerable for the long-term benefit to be realized. 

As it is characterized by length of time rather than number of repetitions, it is different from all other rangeof-motion definitions.

Data sources: (1) Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 3rd ed. Philadelphia, Pa: FA Davis; 1996. (2) 

Humphrey C, Richard RL, Staley MJ. Soft tissue management and exercise. In: Richard R, Staley MJ, eds. Burn Care and Rehabilitation: 

Principles and Practice. Philadelphia, Pa: FA Davis; 1994: 334.
328

Care of the Combat Amputee

of prolonged immobilization of the synovial joints, 

demonstrated by numerous orthopaedists,267 inspired 

the development of CPM machines. There are two 

basic CPM designs. One is an anatomical design that 

moves the joint in an arc of motion as similar to actual 

anatomical movement as is possible. The other design 

is free linkage, which moves body parts adjacent to 

the involved joint. For example, it can move the forearm while allowing the casualty to move an elbow or 

shoulder if possible. 

The anatomical motion machine is probably the 

more comfortable of the two devices. Most of the 

machines can be set to pause at the end range and 

resemble slow, prolonged stretch. Machines may be 

portable, free-standing, or attached to a bed or chair. 

Those who are most likely to benefit from use of CPM 

in addition to customary physical and occupational 

therapy include individuals who have burns involving multiple joints; comatose casualties; and casualties 

who refuse to perform active motion because of pain, 

swelling, or anxiety. The specific protocol of use for 

CPM machines depends on a casualty’s tolerance and 

limitations.

The hand CPM device restores hand ROM. It does 

not damage skin grafts or newly healed tissue, and the 

pain experienced is the same as that with conventional 

hand stretching and exercise therapy.266 Adaptations 

can be made to block MCP or PIP motion, and some 

splints can be used over the dorsum of the hand to 

achieve improved composite MCP and IP flexion. 

AROM exercise of the involved hand joints should 

be measured daily to assess for skin tightness and to 

evaluate joint mobility. If the casualty is able, hourly 

AROM exercise and ADL participation should be encouraged at home to maximize ROM. If the casualty 

is unable to participate in sufficient AROM exercise, 

then PROM exercise should be performed at least three 

times a day on the involved joints. Dressings should 

be applied with digits individually wrapped to permit 

participation in ROM exercises. To maximize tissue 

elongation, PROM activities should include low-load 

force with a long duration of hold.249

Shoulder CPM machines, which attach to a bed or 

chair and move the shoulder through 180° of flexion or 

abduction, help prevent axillary scar bands and nourish shoulder joint cartilage. Additional models move 

the shoulder in other planes, including a figure-eight 

pattern. Some models incorporate the elbow, providing 

ROM for both joints simultaneously.

The elbow CPM can be set for low-load stretching 

and auto reverse, so there is little risk of overloading 

the joint or surrounding tissues (Figure 13-56). The 

degree of elbow flexion, extension, pronation, and 

supination can be adjusted to the casualty’s tolerance. 

When set for gentle motion, this device provides thorough ROM while minimizing the risk of HO.

Knee CPM machines should be used when the casualty is not participating in active therapy (Figure 13-57). 

They provide improved motion at the knee and can be 

set up to address the ankle and hip joints, as well. These 

CPMs are useful until ambulation is possible, or longer 

if joints continue to exhibit ROM limitations.

Showering and dressing changes are good opportunities to perform ROM exercises. During these 

procedures, bandages and wraps that typically inhibit 

ROM are removed, allowing for more thorough treatFigure 13-56. Continuous passive motion device for the 

elbow.

EXHIBIT 13-4

CONSIDERATIONS FOR USE OF PASSIVE 

RANGE-OF-MOTION EXERCISE

	 •	 Level of consciousness

	 •	 Level of medication

	 •	 Severity of condition

	 •	 Decreased range of motion

	 •	 Scar contractures

	 •	 Peripheral nerve injury

	 •	 Preservation of joint mobility

	 •	 Anesthesia

	 •	 Area of escharatomy

	 •	 Preservation of tendon glide
329

Rehabilitation of Burn Casualties

ment. Therapists can see the affects of ROM exercise 

on the tissue and can ensure enough force is being 

exerted to elongate the tissue. Additionally, because the 

casualties’ pain will already be managed for the wound 

care procedure, ROM exercises will be better tolerated 

(however, casualties must not be overloaded with pain 

from both wound care and ROM exercises). 

When casualties are under anesthesia for skin grafting or debridement, ROM exercises can be used to 

evaluate range and determine the cause of limitations. 

ROM may be limited because of soft tissue contracture 

or pain; anesthetizing the casualty can help distinguish 

the cause. If the primary cause of the limitation is pain, 

the pain management plan can be adjusted to improve 

the casualty’s tolerance. If the primary cause is determined to be soft tissue contracture, the casualty should 

be encouraged to increase the frequency and vigor of 

rehabilitation. A gentle, slow, controlled force in the 

correct orientation is the key to safe ROM exercise, 

particularly when the casualty is anesthetized.

Intermediate Phase

Casualties generally regain responsiveness in the 

intermediate phase, and PROM exercise should be replaced with AAROM exercise if full ROM has not been 

achieved. AROM exercises should be initiated when 

the casualty has full ROM. Alert casualties must learn 

to move past the painful range to the extremes of joint 

motion; this can be accomplished with gentle terminal 

stretching. AAROM exercises with terminal stretching 

teach casualties how to move the affected body part 

and achieve the extremes of motion that are not used 

spontaneously during activity (Exhibit 13-5).177

For AAROM exercises, healing and healed tissue 

should be stretched to the point of tissue blanching 

and maintained until the tissue becomes more pliable 

or tissue color returns.177 A casualty’s tolerance to the 

force applied must also be considered. Typically, 1 to 

2 lb of force is required to cause blanching.177 Several 

preliminary repetitions must be performed to ensure 

tissue is at its optimal length prior to sustaining the 

force applied.177 Best results are achieved when a casualty performs AROM exercises to the limits of pain 

or tissue restriction, and then the therapist applies the 

required slow and controlled overpressure to complete 

the ROM exercise. 

Additional AAROM exercises can be performed 

with various devices, such as pulleys, finger and dowel 

ladders, and weights. These activities use the casualty’s unaffected limbs as the source of overpressure 

to achieve full ROM at the affected joint. A stationary 

bike or upper-body ergometer can also be used for 

AAROM exercise, as can the casualty’s body weight. 

These AAROM techniques allow casualties some control, improving tolerance and promoting compliance 

and independence.

AROM is the most desirable form of ROM exercise.265 It tends to be less painful and activates the 

muscle pump, enhancing venous and lymphatic return 

and reducing edema.178 However, AROM should only 

be used with casualties who can achieve full ROM 

within a reasonable amount of time (Exhibit 13-6).177

AROM is also the safest form of ROM exercise and 

is recommended for joints with exposed tendons or 

immature skin grafts, or those at risk for HO, where 

PROM exercise and AAROM exercise must be used 

sparingly and cautiously. Casualties generally self-limit voluntary muscle contractions because of pain and 

will not produce the force required to rupture a tendon 

or disrupt skin grafts.265 Active motion decreases the 

risk of HO at the elbow joint.268,269 Occasionally, casualties need encouragement and relaxation reminders in 

order to tolerate ROM exercises. If casualties are still 

unable to tolerate the force required to achieve scar 

tissue blanching, their pain management plan must 

Figure 13-57. Continuous passive motion device for the knee.

EXHIBIT 13-5

CONSIDERATIONS FOR USE OF ACTIVE 

ASSISTED RANGE-OF-MOTION EXERCISE

	 •	 Limited range of motion

	 •	 Scar contractures

	 •	 Area of escharotomy

	 •	 Skin graft adherence

	 •	 Increased physiological demands

	 •	 Decreased cardiac reserve

	 •	 Poor ventilation and respiratory status

	 •	 Decreased strength secondary to prolonged

hospitalization
330

Care of the Combat Amputee

be reviewed and modified to improve tolerance of 

ROM exercise.

Full ROM returns most quickly when inflammation 

is minimal, wound healing is complete, and a casualty 

complies with rehabilitation. Applying heat prior to 

ROM exercises may also be beneficial.263,265,270–272 Joint 

mobilization and distraction of joint surfaces, in conjunction with stretching, may decrease pain and muscle 

spasm and increase the effectiveness of stretching.273

Casualties must invest a significant amount of 

mental concentration and vigorous physical energy 

for ROM exercises to be effective. Distractions, such 

as visitors, should be minimized to allow casualties to 

concentrate on restoring greater function. 

A clock that announces time intervals, such as one 

that rings every 15 minutes, can help a casualty remember to stretch eyelids or other important contractures 

throughout the day without the verbal cues that may 

come to seem like nagging from a therapist. A casualty 

may also be able to relax and benefit more from ROM 

exercises when the therapist uses another activity, such 

as conversation, to distract the casualty from the pain at 

the treatment site. During the latter phases of recovery, 

casualties wear external vascular supports, which may 

need to be removed for 10-minute periods for ROM 

exercises but donned immediately after.

Post-burn management of a superficial partialthickness burn differs from management of a deep 

partial-thickness or full-thickness burn. Superficial 

partial-thickness burns are at minimal risk for contracture.274 Full ROM is usually restored with AROM 

exercises performed in a home program, and AROM 

exercises are initiated as soon as possible. Adequate 

pain control is imperative to allow participation in 

a home program. Splinting is only necessary if poor 

exercise participation is noted over a prolonged period 

of time and ROM gains are not being made. 

Deep partial-thickness and full-thickness burns are 

at a high risk for contracture.274 AROM and PROM 

exercises should be consistently performed throughout 

the intermediate rehabilitation phase. Home exercises 

and supervised therapy should include low-load force 

and long duration PROM exercises and should place 

the involved tissue at its greatest length. Isolated joints 

should be stretched, with the involved skin in a shortened 

position prior to elongation. For example, isolated MCP, 

PIP, and DIP PROM exercises should precede a composite 

stretch involving combined MCP, PIP, and DIP flexion 

stretching. AROM exercises in the same movement 

pattern should immediately follow passive exercises. 

Long-Term Phase

During the long-term rehabilitation phase, as with 

the early phases, low-load, prolonged stress is recommended for minimizing and preventing burn scar and 

joint contractures.275 Gentle, graded, and prolonged 

ROM stretching, preferably achieved actively by the 

casualty, will help collagen fiber realign into a longer, less tightly convoluted, mat-like configuration. 

At this point, if burn scar contractures are present, 

they are usually so severe that they will not resolve 

with prolonged ROM stretching alone. Additional 

interventions, such as positioning, splinting, casting, 

strengthening exercises, and functional activities will 

be required. However, the burn therapist must reserve 

adequate time for prolonged individual joint and composite ROM stretching because casualties will need 

encouragement, supervision, and hands-on treatment 

during this phase of rehabilitation. 

Low-load, prolonged ROM stretching has the additional benefit of gently, slowly overcoming muscular 

cocontraction in casualties who fear pain. With prompting, casualties who have had adequate analgesia during the first two phases will put forth maximum effort 

to move through the extremes of motion, preventing 

joint motion from becoming painful, nourishing joint 

cartilage, and elongating surrounding burn scar and 

soft tissue. Low-load, prolonged ROM stretching may 

also be combined with work-equivalent activities. All 

other types of ROM exercise should be applied and 

incorporated into written home programs during the 

long-term rehabilitation phase. 

Strengthening and Conditioning

Acute Phase

Casualties recovering from burn injuries will require 

strength training and cardiovascular reconditioning. 

These treatments can begin as soon as the casualty is 

EXHIBIT 13-6

CONSIDERATIONS FOR USE OF ACTIVE 

RANGE-OF-MOTION EXERCISE

	 •	 Edema reduction from muscle pumping

	 •	 Increased circulation

	 •	 Initiation of exercise first week after skin

grafting

	 •	 Conditioning of uninvolved areas

	 •	 Exposed tendons (except the proximal interphalangeal joint)

	 •	 Prevention of soft tissue shortening

	 •	 Prevention of muscle atrophy
331

Rehabilitation of Burn Casualties

admitted to the hospital, and may continue throughout 

several years. Although each burn casualty is unique, 

all will experience some form of deconditioning. 

When designing a rehabilitation program, therapists 

should consider the casualty’s phase of recovery, the 

percentage of TBSA burned, the etiology of the burn, 

comorbitities (including inhalation injuries), postsurgical skin grafting precautions, and prior level of function.276 Depending on the casualty’s status, strength 

and conditioning programs can commence on the same 

day as admission.

In the sitting position, casualties experience reduced 

pulmonary congestion, facilitated diaphragmatic 

expansion and ventilation, and ease of dyspnea. If 

possible, a casualty can be transferred to a bedside 

chair, with or without assistance, and remain sitting 

for as long as tolerated. When a casualty is sedated 

or otherwise unable to assist with the transfer, a total 

lift chair may be used (Figure 13-58). A casualty can 

be transferred laterally from a bed to a chair in a flattened position. From there, a therapist can manipulate 

the chair into an upright sitting position, where the 

casualty may remain for as long as tolerated to receive 

the benefits of upright sitting. Some hospital beds may 

also have specific settings that move the bed from a 

supine position to an upright sitting position if the 

casualty is unable to be laterally transferred to the 

total lift chair.

When a casualty is medically cleared for lower-extremity weight bearing but is unable to stand without 

great assistance, a therapist may use a tilt table. With 

a tilt table, the casualty is secured to the plinth with a 

series of straps while in the supine position. A therapist 

can mechanically tilt the table into the upright position 

and can pause the tilt at any interval to allow a casualty 

to slowly become acclimatized to the upright standing position. The casualty’s response to the activity 

will dictate the progress of the tilt. Because the straps 

restrict casualty movement, the motion is generally 

passive and recruits mainly postural muscles. The 

primary benefit of a tilt table is its ability to decrease 

orthostatic hypotension through gradual retraining of 

the cardiovascular system to the upright position.277 It 

also allows gradual weight bearing through the lower 

extremities.

If a casualty is able to tolerate the standing position 

of the tilt table but does not have the endurance to 

stand for any great length of time, the standing frame 

may be appropriate. The standing frame uses a system 

of levers to raise a casualty from the sitting position to 

the standing position with a solid support, allowing 

the casualty to receive the cardiovascular benefits of an 

upright position while experiencing weight bearing to 

increase lower-extremity and trunk strength.

If a casualty is cleared for lower-extremity weight 

bearing but still unable to stand without great effort, 

a therapist may use a modified tilt table (Figure 13-

59). The modified tilt table has a system of pins and 

locks that allow the plinth to slide so the casualty may 

Figure 13-58. Total lift chair used for early out-of-bed transfers. Figure 13-59. Modified tilt table.
332

Care of the Combat Amputee

perform an inclined squat unilaterally or bilaterally 

in an environment of decreased gravity resistance. 

This permits the casualty to increase lower-extremity 

strength in preparation for ambulation.277

Early ambulation is vital to the success of all casualties. Ambulation may begin while a casualty is still 

intubated if deemed safe. If the casualty is recovering 

from lower-extremity skin grafting over a joint, ambulation may begin as early as the third day following operation. Casualties that ambulate within this timeframe 

experience increased ROM, cardiopulmonary function, 

and muscular strength compared to those that remain 

immobilized for a longer period of time.278,279

ROM exercise also promotes cardiovascular reconditioning. PROM of all extremities requires the 

casualty to exert 1 metabolic equivalent (MET), AROM 

exercise of all extremities requires 1 to 1.5 METs, and 

AROM with moderate resistance requires 1.5 to 2 

METs. ROM exercises not only increase joint mobility 

and integumentary movement, but promote proper 

cardiovascular reconditioning and increase muscular 

strength.280

Intermediate Phase

When burn casualties have 50% to 100% wound closure, they transition to an outpatient program. Prior to 

discharge from the hospital, the casualty should be able 

to transfer and complete ADLs with little to no assistance. Practicing these activities is a functional method 

of increasing strength and cardiovascular endurance. 

When casualties are preparing for discharge, strengthening and conditioning therapy sessions should focus 

on increasing independence with ADLs.

Resisted ROM exercises can be provided by the 

therapist, resistance bands, or weight-lifting equipment, and should progress in accordance with the 

casualty’s treatment plan. Circuit training programs 

increase muscular strength and cardiovascular endurance while providing variety in the casualty’s program. 

Pilates exercises, on a mat or with equipment, increase 

strength, promote proper body alignment, and improve ROM.281

Casualties can use gym equipment to increase 

cardiovascular conditioning and muscle strength. 

Recumbent bicycles and elliptical machines increase 

cardiovascular strength without increasing weight 

bearing. The NuStep machine (NuStep Inc, Ann Arbor, Michigan), a recumbent cross-training machine, 

promotes lower-extremity strength and ROM without 

increasing weight bearing in the hip and knee joints. 

The American College of Sports Medicine recommends that adults exercise at moderate intensity for 

at least 30 minutes on most, if not all, days of the 

week.282 Casualties with burns are no exception to 

this recommendation. Casualties should begin their 

reconditioning slowly, with the long-term goal of 

meeting the American College of Sports Medicine 

standard.

Long-Term Phase

Once a casualty transitions to the long-term rehabilitation phase, high-level functional activities should 

be encouraged. In the rehabilitation gym, isokinetic 

exercises can be used to improve strength and power, 

in addition to maintaining ROM.283 When participating in outdoor activities, casualties should be aware 

of their own limitations concerning thermoregulation. 

Many areas of healed burn scar or skin grafts are unable to produce sweat to cool the body; therefore, the 

casualty is at a greater risk for overheating and should 

take the necessary precautions.284 Casualties should 

also keep water close at hand and remain in the shade 

when possible if outside.

Burn casualties have a higher resting metabolic rate 

than individuals without burns. Despite having an 

elevated resting metabolic rate, the stress on the casualty’s cardiopulmonary system resulting from activity 

increases resting metabolic rate proportional to that of 

an individual without burns.285 The Karvonen method 

should be used to determine the appropriate heart rate 

range because it takes into consideration the casualty’s 

resting heart rate (Exhibit 13-7).276 Ultimately, proper 

rehabilitation for burn casualties should consist of a 

cardiovascular reconditioning and muscle strengthening program that maximizes functional outcome and 

return to duty.

EXHIBIT 13-7

THE KARVONEN METHOD FOR DETERMINING HEART RATE RANGE

Target heart rate = ([maximum heart rate − resting heart rate] • percent intensity) + resting heart rate
333

Rehabilitation of Burn Casualties

Activities of Daily Living

Acute Phase

Functional activities should be practiced around the 

clock when possible. Not only should the burn team be 

aware of what a casualty is capable of doing in areas 

of self-care, but the casualty’s family should know as 

well. Frequently, the burn team and family perform 

activities that a casualty is capable of performing 

independently. This is detrimental because casualties gain self-esteem and self-confidence by being as 

independent as possible. Families can be directed to 

participate with casualties in activities such as applying lotion, organizing get-well cards, answering mail, 

or playing games, rather than assisting with essential 

tasks, such as feeding, that a casualty must learn to 

perform independently.

ADLs, such as independent phone use, selffeeding, shaving, brushing teeth, and self-toileting, 

are beneficial exercises for the upper extremities. 

Repetitive calisthenics may be boring; however, 

casualties understand the importance of practicing daily living skills and are often motivated by 

the desire to regain independence. It is helpful for 

casualties to be reminded of the goals of regaining 

maximum independence with the fewest possible 

scar bands and with the least possible disfigurement 

while struggling with self-care or uncomfortable 

exercises.

Participation in functional ADLs is important in the 

rehabilitation of the burn casualty.286 The major ADL 

classifications are: 

	 •	 Mobility: including movement in bed, wheelchair mobility and transfers, indoor ambulation with special equipment, outdoor ambulation with special equipment, and management 

of public or private transportation. 

	 •	 Self-care: including feeding, bathing, toileting,

grooming, and dressing.

	 •	 Managing environmental hardware and devices: including the ability to use telephones, 

doors, faucets, light switches, scissors, keys, 

windows, and street control signals. 

	 •	 Communication skills: including the ability

to write, operate a personal computer, read, 

type, and use the telephone, a tape recorder, 

or a special communications device.

	 •	 Home management activities: including

shopping, meal planning and preparation, 

cleaning, doing laundry, caring for children, 

and operating household appliances.287

There are numerous benefits gained from independently performing functional tasks and activities. 

Physical benefits include improving ROM, fine motor 

dexterity, and overall endurance. The psychological 

benefits include increased self-reliance, improved 

self-esteem, and positive feelings about the future. 

Involving casualties in planning and implementing 

functional activities early on allows them to more 

easily resume social roles and decreases posttraumatic 

disability later. Independent performance of ADLs also 

hastens hospital discharge to home or a less-supervised 

setting.

Several factors can influence the overall outcome 

of a functional activity program, including medical 

status (percent of TBSA burned, degree, and location 

of burns); age; degree of cooperation and motivation; 

premorbid physical, psychological, educational, intellectual, economic, and functional status; and social 

resources. Additional factors that impact independent 

living include memory loss from medication, pain or 

severity of illness, cognitive changes due to anoxia or 

accompanying head injury, preburn or medicationinduced impaired judgment, depression, and pain. 

Successful programs involve the casualty and family 

in prioritization, goal setting, and problem solving for 

accomplishing functional activities.

Functional activity performance can be analyzed 

in terms of independence, speed of performance, and 

safety when considering how a casualty accomplishes 

tasks. Independence in ADLs can be achieved in a 

number of ways. Burned soldiers need to perform 

ADLs without adaptive equipment, using repetitions 

to improve strength and endurance. When adaptive 

equipment is used in the earliest phase of rehabilitation, it should be discontinued as soon as possible. 

Occupational therapists can make recommendations 

concerning adaptive equipment, task alteration, adaptive techniques, and environmental modifications.

Burn casualties are encouraged to self-feed, despite 

hand burns. Conventional silverware with handles 

enlarged by elastic rolls and an elevated table are often 

adequate to encourage self-feeding. Adaptations for 

self-care are discontinued as soon as possible to avoid 

dependence and to increase hand and upper-extremity 

ROM. Adaptive feeding devices include long-handled 

silverware, utensils with built-up handles, and universal cuffs (Figure 13-60). Universal cuffs with hook-andloop fasteners or D-ring attachments allow casualties to 

don them without assistance. Expanded universal cuffs 

can be fabricated for bulky dressings, casts, or splints. 

Additional devices, such as bent-angled silverware or 

bendable, foam-handled spoons, are available if wrist 

radial deviation is permanently limited (Figure 13-61). 
334

Care of the Combat Amputee

Utensils with extensions can be helpful when there is 

limited mobility in decreased shoulder or elbow flexion. Utensils with swivel attachments or horizontal 

handles replace forearm supination. Vertical handles 

can be used when the forearm is fixed for midposition. 

Long straws held in place by straw clips, adaptive 

mugs and glasses, easy-grip mugs with protruding 

handles, glasses with a cutout area for the nose, and 

bilateral glass holders can aid in drinking. Sealed 

mugs are also helpful when a casualty lacks hand 

control. Weighted mugs can be used when a casualty 

exhibits a tremor. When inhalation injuries result in 

swallowing difficulties, vacuum flow suction mugs 

can prevent choking by controlling the rate at which 

liquid is released.

There are several types of adaptive equipment that 

provide stabilization when a casualty has use of only 

one hand. Nonskid mats can be placed on counters or 

tabletops to prevent plates and bowls from slipping. 

Scoop dishes and plate guards provide stability for 

utensils (Figure 13-62). A rocker knife can be used for 

cutting when a casualty is permanently unable to use 

one hand. Pan and bowl holders also provide stability. 

Adaptive cutting boards have a nail to stabilize items 

for cutting, and built-up corners to hold bread while 

buttering. Special openers for jars, cans, or bottles are 

helpful for casualties with only one functional hand 

or decreased hand strength or control.

Grooming is another self-care activity that can be 

performed early. Oral care and hair brushing and 

combing are initiated when bathroom privileges 

begin. Although rarely needed, a built-up handle 

or universal cuff can compensate for the inability to 

grasp a toothbrush, hairbrush, or comb. A temporary 

extended handle can make teeth brushing easier while 

ROM improves. Toothpaste tube squeezers are available if fine motor dexterity is limited. Denture brushes 

with suction cups are also useful when only one hand 

is functional. Adding extended handles (straight or 

bent-angled) to hairbrushes and combs is useful when 

shoulder flexion, shoulder external rotation, or both 

are lacking.

Figure 13-60. Adaptive eating utensils with built-up handles.

Figure 13-61. Bendable foam-handled eating utensils.

Figure 13-62. Plate guard used to assist with self-feeding.
335

Rehabilitation of Burn Casualties

During the acute phase, toileting skills vary according to the extent of the burn. Casualties with 

larger TBSA burns may be unable to participate in 

self-toileting because of sedation, intubation, catherization, and limited upper-extremity use. Less-involved 

casualties can use a variety of large-handled urinals 

and spill-proof containers at the bedside, and can 

transfer to and from the bedside commode for bowel 

activities (which will help advance mobility as well as 

toileting skills). As casualties progress, they may be left 

with some level of deficit requiring use of a toileting 

aid to manipulate toilet paper, or they need to incorporate assistive technology such as a bidet, autoflush 

commodes, or a raised commode seat to assist with 

sit–stand transfers.

Communication is a functional activity that is very 

important in all phases of rehabilitation. This is a 

broad category that includes expression, reading, use 

of environmental controls, writing, and telephone and 

typewriter or computer use. Large button, programmable phones can be adapted with speakers, allowing 

early independent telephone use. Because telephones 

keep burn casualties in touch with their support systems, adaptations are requested early. An adjustable 

gooseneck phone holder allows a casualty to speak and 

hear without holding the telephone. The gooseneck 

holder affords more privacy than the speakerphone. 

There are also special phone holders for casualties 

with weak grasps. A phone flipper lever can be added 

to the base of a telephone to activate the connection 

button if a casualty cannot press it. A flipper can be 

operated by hand or by mouth stick. Another type 

of phone adaptation is a touchtone adapter, which 

enlarges regular push buttons and can be operated by 

a very light touch.

Expression is important because it allows casualties to interact with others in the environment and 

decreases fear and frustration. A casualty with a severe 

burn may be intubated, ventilator-dependent, and unable to speak. Prolonged exposure to smoke can result 

in vocal cord injuries, leaving speech unintelligible or 

contraindicated. Communication boards composed 

of letters, pictures, body maps, words, or complete 

sentences are commonly used to convey thoughts if 

the casualty can point to them. There are also sophisticated communication devices with voice outputs that 

can be operated by touch or by a light-activated beam. 

However, because casualties are often medicated or too 

ill, complicated communication devices are best used 

in the later stages of recovery.

As a casualty progresses, a number of environmental controls can be adapted for independent use. Environmental controls are available in a wide variety of 

switching systems with specific mounting devices. The 

basic plate, light touch plate, air cushion, rocker, foot, 

wobble, sip-and-puff control, and joystick are common 

switch options. The same switch and input device 

method can also be used to operate a communication 

device, computer, or electric wheelchair in other phases 

of rehabilitation. Switches can be specially ordered or 

can be purchased from electronics retail stores.

Reading can be a very important functional exercise 

when a casualty is confined to bed. There are several 

types of book and magazine stands that can assist with 

reading. Bed readers, positioned slightly overhead, 

are useful when an alert casualty must stay supine. 

A prone casualty can use a floor stand or music stand 

with pages stabilized by clothespins. Height- and 

angle-adjustable bookstands can be clamped to a bedside table or headboard. Bookstands with automatic 

page turners can be used if a casualty is unable to turn 

pages independently. A mouthstick can also be used to 

turn pages. Mouthstick devices have increased friction 

at the end and can be adapted to fit universal cuffs. 

Prism glasses allow a casualty to look down at pages 

to read while the head is positioned forward. In cases 

of preexisting visual acuity deficits, a variety of magnifiers can be used, in addition to large-print books.

Writing is another important self-care activity that 

can be performed in early stages of burn rehabilitation. Pen and pencil holders are useful temporary 

adaptations when a casualty’s ability to grasp or pinch 

is decreased. Built-up foam handles or plastic easygrip adapters facilitate holding a pen. Special splints 

or adaptive writing utensils can be fabricated out of 

thermoplastic materials, or commercially available 

splints can be obtained to customize writing devices. 

A clipboard can be used to stabilize paper when the 

nondominant hand is unable to hold it steady for writing. A writing device can be attached to a mouth stick 

if neither hand can write.

Intermediate Phase

As a casualty becomes more independent in the 

hospital, it is important to identify home management 

responsibilities, including general maneuvering, operating home appliances, cooking, and cleaning. It is 

important for casualties and their families to identify 

the tasks that the individual wants or needs to perform. 

Ideally, a survey of home needs is accomplished with 

the casualty, family, and a staff member, but it can also 

be performed by just the casualty and family. A home 

evaluation focusing on independence and safety can 

identify functional or environmental limitations, and 

casualties can use mobility aids and adaptive equipment in the home to determine the level of assistance 

that will be required after hospital discharge.
336

Care of the Combat Amputee

It is important to avoid trauma or shearing the skin 

surface while practicing ADLs during the intermediate 

phase. Functional activities, such as feeding, grooming, and communication, should be performed, and 

adaptive equipment can continue to be used. Applying 

lotion to healed or unburned areas increases sensory 

input and decreases hallucinations from sensory deprivation. 

Casualties usually view hospital discharge as a 

welcome termination of burn care, exercise, and pain, 

and they often eagerly anticipate what they believe is 

a well-deserved rest. Recalcitrant casualties who endure exercise and scar control devices at the hospital 

may abandon custom-made elastic stockings, traction, 

total contact splints, and activity once they feel safe at 

home. Many casualties believe returning home will 

restore their previous physical and emotional status. 

However, it quickly becomes obvious that achieving 

adequate epithelial healing at home is only the beginning of rehabilitation and return to active duty.288

Work-hardening programs—graded work activities 

that simulate a casualty’s work requirements— are appropriate for severely burned casualties. The activities 

are adapted to assure success in the simulated activity 

and are designed to lead to progress in work performance. Acitivities can be sequentially redesigned to 

require less adaptation until adaptation is minimized. 

Work hardening also reinforces protective measures 

for friction, trauma, chemical irritants, and extremes 

of weather or temperature.

The best outcomes result when the casualty, therapist, and physician formulate an appropriate activeduty limitation outline with each clinic visit. It can be 

helpful for casualties to return part time to as many 

active-duty tasks as possible, even if their ability to 

perform tasks is limited. Jobs done by habit eliminate 

the need for casualties to constantly think about the 

discomfort of exercising.

Long-Term Phase

In the long-term rehabilitation phase, casualties continue to actively participate in functional activities that 

are consistent with life roles and return to active duty. 

As they become medically stable and burn scars and 

skin grafts become more durable, casualties can pursue 

a variety of activities; however, caution is required 

because maturing burn scars and skin grafts remain 

fragile in this phase. Casualties must learn proper interventions to compensate for sensory, pigmentation, 

and circulatory changes while performing ADLs. At 

this time, casualties must begin to wean off adaptive 

equipment used in the initial phases of rehabilitation. 

However, casualties with electrical injuries, amputations, or burns greater than 70% TBSA may continue 

to use adaptive equipment if residual impairments 

exist. For severely impaired casualties, sophisticated 

orthoses and adaptive equipment should be used to 

reduce disability.

Adaptive silverware, drinking aids, and stabilization devices are rarely used in the long-term rehabilitation phase. If decreased shoulder ROM and proximal 

weakness are permanent, suspension slings or mobile 

arm supports can be used when a casualty is seated. 

These devices support the entire arm, assist shoulder 

flexion, and allow the elbow to move in a gravityeliminated plane. The mobile arm support is available 

in standard, elevating, and table-mounted models. 

Battery-powered or electric feeding machines operated 

by microswitch control are available for casualties in 

which severe burn has resulted in upper-extremity 

amputations. The switches can be operated by various body parts that can predictably and consistently 

control the machine.

Casualties can participate in additional grooming 

tasks, such as shaving with special holders for electric 

or regular razors (Figure 13-63). Casualties should 

regularly care for nails to prevent excoriation of skin 

during scratching. Mounted nail clippers (Figure 13-64) 

or files are available to assist with such activities.

At this stage, casualties should begin to assume responsibility for the condition of their skin, burn scars, 

and skin grafts, inspecting them regularly to identify 

any areas of concern. Flexible inspection mirrors are 

available to assist with this task. Casualties can also 

assume responsibility for wound care and should 

demonstrate the ability to safely cleanse and apply 

medication and dressings to any remaining wounds. 

Casualties should also massage scars and apply moisturizer as indicated.

Figure 13-63. Adaptive holding device for a shaving razor.
337

Rehabilitation of Burn Casualties

As casualties progress, they will want to perform 

toileting tasks independently. A variety of adaptive 

equipment is available to ensure safety and independence. Safety rails can be mounted on either side of 

the toilet to increase transfer stability. Use of a raised 

toilet seat is usually discouraged, but it can be helpful 

when a casualty permanently lacks strength or control 

in the lower extremities and cannot perform transfers 

with a standard seat. A bedside commode is necessary 

in the hospital or at home only when ambulation to 

the bathroom is not possible. Toilet aids are also helpful if a casualty lacks the necessary upper-extremity 

ROM for hygiene.

A number of adaptive safety aids also allow independent bathing. It is often safer for casualties to bathe 

in a seated position if endurance is low. Edema can be 

minimized by keeping burned legs elevated until bathing is finished and external vascular supports are reapplied. Shower seats, with or without backs, provide 

stability in walk-in showers. Extended tub benches 

allow casualties to bathe independently on a seat if 

they are unable to step over the tub safely. Grab bars 

can be mounted on the tub or wall to further increase 

stability with transfers. A flexible shower hose permits 

casualties to bathe independently in a seated position 

if they are unable to stand for a prolonged period of 

time. Long-handled sponges compensate for decreased 

trunk or upper-extremity ROM and allow a casualty 

to wash feet and back independently (Figure 13-65). 

A bath mitt can stabilize a bar of soap if the casualty’s 

grasp is weak. Safety features, such as nonskid surfaces 

or bath mats, can be applied to the bottom of the tub 

to prevent slipping.

Casualties assume total responsibility for donning 

external vascular support garments, orthoses, and 

clothing during the long-term rehabilitation phase. 

Casualties must be cautioned against pulling too rigorously on garments while donning them, which could 

injure fragile skin. A nylon stocking contact layer worn 

over wound dressings secures them and facilitates 

donning external vascular supports. Casualties must 

demonstrate donning facemasks, microstomia splints, 

hand splints, and lower extremity orthoses independently in front of a mirror to ensure proper fit.

There are a number of adaptive aids that assist with 

donning pressure garments and regular clothing. It 

is often more effective to use practice time donning 

items without adaptations when a casualty is expected 

to achieve enough ROM in a short period of time to 

make adaptations unnecessary. Long-handled aids are 

helpful in cases where there is decreased trunk, hip, 

and knee flexion, and hip external rotation. Many different “reachers” can be used to don pants; they are 

available in a standard size, extended length, and a 

self-closing model for decreased hand grasp (Figure 

13-66). Long-handled shoehorns and stocking aids 

help with donning shoes and socks (Figure 13-67). A 

dressing stick can be used for donning pants and shirts 

if upper-extremity ROM is limited.

Other adaptive aids are useful if finger dexterity is 

limited or if a casualty has use of only one hand. Elastic 

shoelaces and button and zipper aids are available in 

Figure 13-64. Commercially available adaptive mounted 

nail clippers and file.

Figure 13-65. Adaptive long-handled sponge for selfbathing.

Figure 13-66. Adaptive reaching device used for a variety 

of self-care activities.
338

Care of the Combat Amputee

standard and easy-grasp varieties (Figures 13-68 and 

13-69). Hook-and-loop fasteners can replace buttons 

and zippers, and large loops can be sewn onto pants to 

help casualties with donning. In general, some types 

of clothing are relatively easy to put on, such as large 

shirts, gym pants, and hook-and-loop closure tennis 

shoes, and many varieties of easy-to-don clothing are 

available through special-order catalogues.

A number of home accessibility aids can also facilitate independence. Wheelchair ramps are important 

modifications for some casualties. Stair glides are 

often used within a house to allow movement from 

one floor to another. High-rise furniture leg extenders make independent transfers to chairs and couches 

easier, and lamp and light switch extensions are helpful if a casualty has decreased finger dexterity or is 

functioning from a wheelchair. A variety of turning 

adaptations can help a casualty operate doors, faucets, 

stoves, and radiators when grasp is limited or weak 

(Figure 13-70).

As burn casualties continue in the rehabilitation 

process, they will generally resume kitchen activities. 

In addition to the adaptive kitchen and feeding tools 

already mentioned, home kitchen modifications can be 

made to make cooking safe and efficient. For example, 

special devices can be used to safely operate an oven. 

Push/pull devices can be used to manipulate hot oven 

racks when a casualty has limited finger dexterity or 

sensory impairments. Long oven mitts made of flameretardant fabric protect sensitive skin. Kitchen roll carts 

can move hot or heavy pans and dishes; if the cart is 

sturdy, it may also be used like a wheeled walker for 

stability. A positioning mirror placed over the stove 

allows wheelchair-bound casualties to better see the 

stovetop and cook safely.

As with many of the other functional activities, 

adaptive housekeeping aids compensate for a decreased ability to reach or grasp. Examples include 

extended dustpans and brushes, long-reach sponge 

mops, extended dusters, and housekeeping cuffs with 

hook-and-loop attachments that permit casualties with 

weak grasps to hold a broom or mop handle.

During the long-term rehabilitation phase, some 

of the communication devices used in earlier phases 

are unnecessary, although others will still be required. 

Casualties who are able to be out of bed in a seated 

position can practice typing and computer activities. 

Typing aids that fit over the hand and depress keys are 

commercially available or can be custom made. These 

aids are useful when fine motor dexterity is lacking 

and a casualty is unable to access the keyboard in a 

traditional way. If a casualty has limited ROM in the 

shoulders or elbows, a keyboard can be mounted on a 

special device to allow access. Detachable keyboards 

are also available for casualties unable to access the 

keys in the usual location. Key guards that separate 

keys are useful for casualties who have impaired coordination. One-handed users can use a key lock to 

simultaneously press multiple keys, and there are a 

variety of special switches casualties can use to operate 

environmental controls or activate computers. 

Mobility

Acute Phase

Early initiation and aggressive progression of mobility activities are critical during the acute rehabilitation 

phase. ADLs orient casualties to the upright position, 

Figure 13-67. Long-handled shoehorn for donning shoes.

Figure 13-68. Elastic shoelaces. Figure 13-69. Button aid for self-dressing.
339

Rehabilitation of Burn Casualties

decreasing risk for pulmonary infection and complications, improving cardiovascular function, preventing 

orthostatic hypotension, preventing skin breakdown 

and decubitus ulcers, and restoring strength and independent functional mobility.289 Exercise has also been 

shown to increase energy and decrease depression290 as 

well as facilitate wound healing and pain reduction by 

more rapidly decreasing edema and inflammation.289

Mobility activities are commonly divided into three 

categories: (1) bed mobilities, (2) transfers and pregait 

activities, and (3) gait or ambulation activities. Bed 

mobilities include rolling, scooting, bridging, bed chair 

positioning, bed tilts, and supine-to-sitting transfers. 

Pregait activities include transfers (sit-to-stand, squat 

pivot, stand pivot, and stand step), and out-of-bed activities, such as sitting upright in a chair and standing 

frame or tilt table sessions. Trees et al described a novel 

therapeutic device that allows casualties to be challenged orthostatically while simultaneously performing body-weight–resisted squatting exercises for lower 

extremity strengthening.277 This device has recently 

become commercially available (see Figure 13-59). Gait 

activities, or ambulation, complete the casualty’s progression of mobility activities. Casualties may require 

assistive devices, such as canes, crutches, or walkers, 

depending on medical status and associated injuries. 

Close communication and coordination of the interdisciplinary burn team is critical to developing a mobility plan that safely enhances the casualty’s recovery.

During the acute rehabilitation phase, several 

factors must be taken into consideration when determining the appropriate mobility activities. Factors to 

consider include the following:

	 •	 the casualty’s level of alertness andorientation,

	 •	 the casualty’s ability to follow commands,

	 •	 the casualty’s baseline vital signs,

	 •	 the presence of new (< 1–3 days old) skin grafts

that require immobilization or protection, 

	 •	 the casualty’s respiratory status (ie, on a ventilator, undergone a tracheostomy with oxygen 

support, or spontaneously breathing room air), 

	 •	 the casualty’s mobility activities, which may

be precluded by certain treatments or procedures (eg, blood transfusion, dialysis, or 

respiratory treatments), 

	 •	 the presence of orthopaedic issues thatrequire

accommodations,

	 •	 the need for vascular support wraps to the

dependant extremities, and 

	 •	 the physician’s expectations for mobility

activities. 

Generally, some type of mobility activity along the 

continuum of activities may be safely performed after 

close coordination with the interdisciplinary burn team 

(Figure 13-71).

Figure 13-70. Door knob extension.

Acute Intermediate Long

Elevate Head of Bed

Reverse Trendelenberg Position

Cardiac Position in Bed

Bed Mobilities

Log Roll

Side Lying

Side Lying to Sit

Sit Edge of Bed

Sit to Stand

Transfer

Stand Pivot

Stand/Step

Total Lift

Total Lift Chair/Cardiac Chair

Bedside Chair/Toileting/Shower

Tilt Table/Moveo Exercise Platform

Standing Frame

Walker/Rolling Walker

Mobility Progression Chart

Figure 13-71. Continuum of mobility activities throughout 

the phases of burn rehabilitation.
340

Care of the Combat Amputee

Depending on the severity of injury and the casualty’s status, a casualty may begin mobility activities anywhere along the continuum and progress as 

appropriate. For severely injured burn casualties 

(TBSA burned > 30%), the casualty is usually initially 

positioned in a bed chair position or bed tilt and alternated every 2 hours, or as indicated by a physician. 

As the casualty’s status improves, bed mobilities and 

lateral transfers to a chair are implemented. Casualties are encouraged to spend several hours (> 4 hrs) 

sitting in a chair each day. ROM, strengthening, and 

other functional activities are performed while in 

the chair and on the tilt table, and distract casualties 

enough to improve tolerance of the activity. When a 

casualty can tolerate 30 minutes of tilting to 70° for 

3 consecutive days, more advanced pregait or gait 

activities can begin.

It is not unusual for a casualty in the acute rehabilitation phase to require several IV lines, chest and feeding 

tubes, or a Foley catheter. In these cases, it is imperative 

that all lines and tubes are properly secured before, 

during, and after mobility activities. Chair positioning, 

tilting, standing frame activities, and ambulation all 

require use of gait belts at the torso, waist, buttocks, 

and thighs for safety. Gait belts may need to be placed 

in such a way as to protect skin graft sites and prevent 

shearing.

Intermediate Phase

During the intermediate rehabilitation phase, the 

emphasis of mobility activities shifts from reorientation and improving tolerance to the upright position 

to improving endurance and functional independence. 

In this phase, casualties are typically more medically 

stable and are capable of tolerating more aggressive 

mobility activities. However, some mobility activities 

may carry over from the acute rehabilitation phase and 

should continue until the casualty demonstrates the 

strength and endurance to progress to more advanced 

functional activities. 

The primary focus of this phase is independence 

with transfers, ambulation, and ADL training, such 

as bathing and toileting. Casualties are introduced to 

equipment in the rehabilitation gym, such as stationary bikes, upper-body ergometers, treadmills, parallel 

bars, and stair trainers to improve strength, endurance, 

and independence. An ADL room is also useful at this 

point in the casualty’s recovery. Casualties must be 

encouraged and motivated to participate in mobility 

activities on a daily basis. Maximum participation will 

result in the expeditious return of function and prepare 

the casualty for discharge from the burn center and 

return home.

Long-Term Phase

Advanced mobility activities are the mainstay 

of the long-term rehabilitation phase. By this time, 

casualties have already met the functional mobility 

requirements for discharge from the burn center and 

are ready to begin mobility activities that will prepare 

them to return to duty. Advanced mobility activities 

focus on transitioning back to duty through advanced 

physical training and simulated work activities. Mobility training, such as jogging, running, swimming, 

weight lifting, sports, driving, and firearm training 

simulation, is implemented to improve a casualty’s 

strength, cardiovascular endurance, and capacity to 

return to duty. At this time, it may be appropriate to 

refer a casualty to an advanced rehabilitation center, 

such as the Center for the Intrepid at Brooke Army 

Medical Center, Fort Sam Houston, Texas.

Psychosocial Aspects

Acute Phase

The psychological characteristics of the acute phase 

of rehabilitation include dealing with stressors of the 

intensive care environment, uncertainty about outcome, and the struggle for survival. Tremendous stress 

affects burn casualties’ mental abilities, including their 

alertness, attention to detail, perception, reasoning, 

comprehension, memory, motor responses, communication, self-control, and interpersonal relations. Shock, 

numbness, and detachment, which protect casualties 

while they collect emotional coping resources, are 

commonly noted at the time of injury. Reorientation 

helps increase trust and lower anxiety, and reassurance 

can help casualties feel optimistic and lower anxiety. 

Families are encouraged to learn deep breathing relaxation techniques, and humor is often used throughout 

rehabilitation to lower a casualty’s anxiety. Giving the 

casualty control and choices can also prevent serious 

psychological issues and can lead to a strong working 

relationship. 

Casualties with minor burns who will return to duty 

as soon as their wounds heal need to be treated using 

the principles of proximity, immediacy, and expectancy. The mental health section at the unit level can 

provide support that focuses on mild and moderate 

battle fatigue and burns. Keeping casualties as close as 

possible to their units makes it easier for them to return 

to normal duty. Expectancy refers to the understanding 

that casualties will return to normal duty when they 

are healed. Treatment using the principle of expectancy 

is appropriate not only for casualties returning to duty 

within a short recuperation time, but also for casualties 
341

Rehabilitation of Burn Casualties

who will require extensive rehabilitation.

For casualties with severe enough burns to be evacuated, early psychological intervention and support 

help with motivation and encourage cooperation with 

treatment. Burn casualties separated from their units 

do not have ready access to family or friends for psychological support; therefore, an important role of the 

treatment team at all echelons is to provide emotional 

support and reassurance to reduce casualties’ anxieties and fears. The evacuation team provides ongoing 

orientation information, including calling casualties 

by name. Part of the chaplain’s mission is to provide 

comfort, assurance, and encouragement. Positive affirmations and encouragement, even during initial 

delirium, reinforce a casualty’s motivation.291

The speed of physical recovery may be affected by 

the early emotional adjustment to an acute burn.292 It is 

important to continually provide preparatory information before performing procedures and to encourage 

simple relaxation techniques during treatments. It is 

also important to frequently repeat instructions, provide orientation, and allow verbalization of fears.

The immediate reaction of a massive burn casualty 

includes psychological shock. This reaction usually 

lasts a short time and may involve disorientation delirium, emotional instability and liability, and sleeping 

problems with nightmares of being burned.293 Fear 

and anxiety also accompany the initial part of the 

acute phase of burn recovery. Casualties should be 

allowed to express fears regarding death. These fears 

should be met with a realistic response regarding the 

chance of survival.294 Behavioral manifestations, such 

as increased startle response, difficulty concentrating or following instructions, withdrawal, resistance 

to treatment, overt hostility, or other inappropriate 

behavior, are often noted immediately after burn.295

Burn casualties may perceive a major threat to their 

survival. Information regarding the seriousness of the 

burn should be given, if possible, before pain medications cloud awareness.

Following resolution of the initial shock of the burn 

incident, casualties become more aware of the impact 

of their injuries. Orientation improves and survival 

anxiety diminishes. Thoughts are more focused on 

concerns about self, including the effects of changed 

appearance and altered function or lifestyle. The casualty’s preburn physical, emotional, intellectual, social, 

and spiritual characteristics provide the basis for initial 

coping skills. Rehabilitation counselors, psychologists, 

social workers, and chaplains help casualties focus on 

regaining as much control as possible and on redefining the meaning of the accident, desensitizing the reminders of the injury, dealing with stress in a positive 

way,296 and gradually accepting loss and trauma. 

Adequate pain control, correction of sleep disturbances, decreasing the fear of long-term consequences, 

and cooperation with the burn team are crucial for 

optimal outcome.293 Numerous interventions are appropriate and may include providing the casualty 

with as much physical comfort as possible; providing 

ongoing orientation information, including calling 

the casualty by name; mentioning the date and time 

of day; providing explanations about the procedures 

that are being used, even if the casualty is comatose; 

providing relaxation training after orientation is established; providing routine for bathing time, exercise, 

and meal times to decrease unexpected procedures; 

encouraging family involvement as soon as possible; 

and emphasizing individual control over as many 

situations as possible.

Losses and changes related to the burn injury affect each casualty differently. Casualties grow, find 

new strengths and coping mechanisms, recover from 

grief, and develop renewed goals sometime after 

realizing the impact and disruption they will experience from the injury. When casualties determine that 

there is potential for survival, their focus may turn to 

the perceived pain and its alleviation. This focus frequently results in increased reports of pain, as well as 

requests for analgesia. When adequate pain control is 

not provided, casualties begin to believe that pain will 

be associated with each treatment, which may result in 

poor compliance. The anticipation of pain may be complicated when painful procedures occur at different 

times, increasing a casualty’s anxiety level. Medication 

dosage for pain, anxiety, and sleep is increased because 

of the hypermetabolic state of the casualty. When IV 

lines are in place, patient-controlled analgesia is allowed during the day, interspersed with comfortable 

rest periods. This improves cooperation with antigravity positioning and elevated exercise that ultimately 

also results in diminished pain. Relaxation training, 

counseling, and behavioral management are effective, 

nonpharmacological ways to deal with pain. However, 

they cannot replace analgesic, hypnotic, or tranquilizing medications. The goals of pain management are 

to maximize comfort, minimize disruptive behavior, 

and increase cooperation and productivity.293

When casualties complain of dysesthesias and pain 

as medications are being tapered, short continuance of 

narcotics combined with desensitization techniques 

reduces the problem. Most neuropathies resolve 

slowly. However, in addition to being taught desensitization and compensation techniques, casualties 

will appreciate assistance with reintegrating sensory 

information. Relaxation techniques (eg, Benson’s relaxation technique, which involves slow breathing and 

repetition of a single, meaningless word296), practiced 
342

Care of the Combat Amputee

daily, can help casualties tune out sensations they 

would not have been aware of before the accident. For 

some casualties, dysesthesias from the healed tissue 

become a central, compelling part of their awareness. 

Individual counseling and reassurance by the physicians and therapists help casualties accept the return 

of sensation as a positive sign, even if it is temporarily 

distorted and therefore painful. Casualties slowly come 

to realize that the burn emergency has passed and, 

by using vision and tactile sensation from the burned 

and unburned parts, sensory information will be more 

quickly reintegrated.

As orientation improves, additional behavioral 

methods of relaxation may be implemented. These 

include Benson’s relaxation response, autogenic 

training, biofeedback, imagery, and distraction. Deep 

breathing exercises may also be used, though they 

may alter sensation in a negative way, especially if 

a casualty hyperventilates when attempting deep 

breathing. Progressive muscle relaxation is another 

option, though it can be painful if the overlying skin 

is burned. Combining familiar techniques with nonpharmacological techniques can provide the casualty 

with greater control of the situation.

Intermediate Phase

During the intermediate phase, burn casualties 

are able to communicate with others, including staff 

members, family, and friends. Behavioral health providers and other medical staff provide support and 

information related to their specialty. Pain control may 

remain an issue. Rehabilitation remains aggressive to 

maximize function. The surgeon and rehabilitation 

team help casualties see grafting operations positively and allay fears related to loss of control during 

anesthesia.

Casualties are unable to exercise the grafted area 

or perform many activities because of potential skin 

shearing from movement. The resultant lack of movement and sensory deprivation create the potential for 

confusion and hallucinations, but this is reduced by 

sensory stimulation, provided by staff or family.297

Rubbing lotion on closed areas controls itching and 

provides reassurance through therapeutic touch. Auditory and visual input may be emphasized through 

the use of television, radio, music, and frequent family 

and staff interaction.

Explaining procedures before they are performed 

can reassure casualties. Adequate analgesia and sedation, as well as the use of familiar relaxation exercises, 

help casualties tolerate discomfort during this phase. 

Avoiding repeated, unexpected, painful, and frightening treatments reduces the potential for developing PTSD. Staff should provide casualties as many 

choices as possible, and casualties should be invited 

to participate in procedures, such as staple removal, 

wound cleansing, and antigravity positioning, to reinforce the sense of control and responsibility in the 

healing process.

During this phase, burn casualties may come to 

terms with their injuries and prepare to leave the 

safe environment of the burn unit and reenter society. 

Reentry may be accomplished in steps, including 

excursions outside the burn unit, day passes for outings with family or friends, passes to restaurants, or 

trips home. These outings help casualties adjust to 

the rude reactions they may receive from the public. 

It can also help determine what adaptive equipment 

will be needed at home. At this stage, casualties can 

benefit from talking to other burn casualties, rehabilitation counselors, psychologists, psychiatrists, 

and social workers, and from viewing videos about 

other burn casualties and their families to learn how 

they coped. Along with physical and emotional recovery, ongoing social support is necessary. Nurses 

provide psychological support and encouragement 

to burn casualties as they prepare to leave acute care 

and return to society. Nurses also refer casualties to 

appropriate services, such as alcohol and drug treatment facilities (studies have confirmed that burn 

victims who abused drugs or alcohol before the 

accident are likely to do so again298) or chronic pain 

programs. Outpatient treatment may be indicated in 

these situations.

Long-Term Phase

Research on lifelong psychological issues as a result 

of combat-related burn injuries is limited. The Department of Defense and the Department of Veterans 

Affairs are taking proactive steps to identify and treat 

combat-related psychosocial issues stemming from 

Operation Iraqi Freedom and Operation Enduring 

Freedom.299

Normal responses to a major burn injury often include crying, degrees of fear, depression,300 grief, loss 

of hope, and other reactions unfamiliar to the casualty. Discharged casualties report it takes about 6 to 7 

months of being at home before they can cope, as they 

did before the injury, with emotions and activities that 

require concentration; however, distractibility gradually subsides. Impatience, irritability, and frustration 

are common. Casualties must learn to accept gradually 

improving function instead of perfection in activities. 

Family members can often help sort out the realistic 

reactions from overreactions.

Casualties at home or in the rehabilitation center 
343

Rehabilitation of Burn Casualties

must learn how to safely return to duty and routine 

life despite their injuries. Physical changes are often 

bothersome, and physical fitness is now a prolonged, 

daily struggle. Reconditioning may take place at a 

much slower pace than before the burn.301

Another factor to consider is psychological adjustment when a casualty returns to work in the area where 

the injury occurred. Few casualties return to the injury 

site easily. Referring a casualty to a psychologist is 

appropriate at this time. Return to duty at the earliest 

possible time provides casualties with the benefits of 

buddy support as well as routine and work. Strength 

and coordination improve much sooner from work 

than from therapy. Ego strength and social interaction are also improved with return to duty. Feelings of 

anger, fear, loneliness, or helplessness make casualties 

acutely aware of pain.302 Casualties benefit from sharing personal experiences of pain relief. Former burned 

casualties report being helped by participating in 

trauma survivors’ groups. With leadership from social 

workers and psychologists (or both), trauma survivors’ 

groups are able to deal positively with symptoms, 

including the following:

	 •	 disturbing dreams,

	 •	 appetite disturbances,

	 •	 difficulty with sleep,

	 •	 feelings of estrangement or detachment,

	 •	 recurrent intrusive memories of the event,

	 •	 memory impairment,

	 •	 difficulty concentrating,

	 •	 reluctance to accept a changed body image,

	 •	 decreased interest in sex,

	 •	 sensitivity to loud noises or other cues related

to the accident, 

	 •	 irritability, and

	 •	 fear of returning to field duty or other work.

Return to active duty improves the casualty’s 

self-concept. Burn physicians must consider the duty 

tasks and the progress of the healing burn scars and 

skin grafts when recommending return to active duty. 

Food handlers must remain off-duty until open areas 

are closed and wound cultures reveal no pathogens. 

Heavy laborers may need job modifications when they 

first return to duty. Often casualties need a transition 

period of half-day work, progressing slowly to fulltime work. Rehabilitation counselors, nurses, or occupational therapists can help with changes in the work 

setting when these are encountered. The adaptations 

are often inexpensive. For example, a footstool may 

be placed near a bench or counter, and casualties may 

alternately place their feet on it for half-hour periods. 

Similarly, items can be arranged so casualties avoid 

reaching beyond their center of balance when first 

returning to duty.

Appraising the extent of burn injury and objectively 

estimating residuals that affect performance are most 

accurate when based on objective criteria303 and experienced prediction. Rating permanent impairment is 

a physician’s function. Disability is related to performance loss, preinjury age, education, economic and 

social situations, sex, and the burn casualty’s attitude 

toward recovery. The physician has the final responsibility in determining when it is medically safe for 

casualties to return to active duty.

Community Reintegration

Acute Phase

The ultimate goal of burn casualty rehabilitation 

is reintegration into casualties’ previous roles in their 

homes, schools, workplaces, and communities. Until 

recently, the goal for burn casualties was simply survival, with little emphasis focused on the quality of 

life after a severe burn injury. Advances in the medical 

care of casualties with major burn injuries have led to 

increased focus and need for rehabilitation services, 

as well as the need to improve intervention programs 

at acute, intermediate, and long-term phases of burn 

recovery. For a more successful and complete reintegration into society, research has indicated the need for a 

multidisciplinary team approach to ensure all areas of 

reintegration are addressed appropriately.

Sheridan describes three things needed for burn 

casualties to successfully reintegrate into their previous 

roles: rehabilitation, reconstruction, and reintegration, 

with the emphasis placed on long-term rehabilitation.304 Sheridan further divided burn care into four 

general phases: initial resuscitation; initial excision 

and grafting; definitive wound closure; and the rehabilitation, reconstruction, and reintegration phase.304

Rehabilitation and reintegration begins at the acute 

stages and can continue up to 2 years after the casualty 

is discharged from inpatient care. 

In the acute stage, basic goals for rehabilitation 

and reintegration include positioning and splinting, 

reducing edema, and completing ROM exercises. This 

enables more functional mobility as the burn casualty 

continues to recover. These rehabilitation goals are 

important in the acute stage because they address the 

needs of the burn casualty and maximize the long-term 

functional outcome of reintegration into society. Educating families on positioning, splinting, and exercises 

to help maintain a burn casualty’s functional mobility 

is crucial to the casualty’s recovery and reintegration 

into society.
344

Care of the Combat Amputee

Intermediate Phase

In the intermediate rehabilitation phase, burn casualties begin to further comprehend the extent of their 

deficits secondary to their injuries and the potential 

impact on their previous functional roles. During this 

time, limited reintegration into society is accomplished 

with day passes and excursions outside the burn unit. 

Family education is another key element of successful reintegration. Proper training and information of 

assistance programs has led to family members and 

burn casualties reporting more successful reintegration into society and higher satisfaction with quality 

of life.305 Burn casualties should be put in contact with 

veterans’ service organizations as they reintegrate into 

their communities and seek to return to work. 

Long-Term Phase

Once discharged from the hospital, many burn casualties report feelings of self-consciousness, anxiety, 

sadness, and anger about their physical appearance 

as well as in everyday social interactions with other 

individuals.305 In the past, burn casualties reported 

receiving little assistance from burn care professionals 

beyond discharge from the hospital. Others, however, 

expressed empowerment from burn casualty organizations, such as the Phoenix Society, that provide support 

for burn casualties and their families in the challenges 

they face during reintegration into society.305 Most 

research on community reintegration has focused on 

the “psychological adjustment” versus the physical or 

social adjustments burn casualties face.

A community reintegration program must be designed to support the needs of burn casualties and 

their family members as they transition back into 

society or past performance roles. The purpose of 

such a program is to assist in the development of appropriate psychosocial skills, peer-to-peer interactions, 

executive functions, motor planning, and physical 

components. The program must also provide a realworld environment in which casualties can develop the 

skills required to handle social interactions and environmental challenges. Casualties should be screened 

by the interdisciplinary team to ensure that they are 

ready to participate in community outings and that 

the outings will be therapeutic. The goal of a community reintegration program is for the burn casualty to 

achieve complete reintegration into the community. In 

order for the casualty to complete a community reintegration program, the casualty must meet all short-term 

and long-term goals. Some common goals include 

interacting appropriately and independently with 

peers, the general public, and burn team members. 

Casualties have successfully completed a community 

reintegration program once they have developed effective coping skills or adaptive techniques to interact 

appropriately with the environment.

Casualties with associated injuries, such as traumatic brain injury or spinal cord injury, may require 

transfer to a Department of Veterans Affairs rehabilitation center. Casualties being transferred should be 

medically stable and able to tolerate and benefit from 

a minimum of 3 hours of therapy a day.

The decision for a burn casualty to transition to an 

outpatient burn clinic should be made by the interdisciplinary burn team, casualty, and family. However, this 

may be challenging when the casualty has unrealistic 

expectations or when there is a lack of family presence 

or involvement. The success of outpatient treatment 

involves proper wound care, pain management, and 

rehabilitation by experienced burn team members. A 

patient should be followed up with at least weekly for 

the first 30 days after discharge, then monthly for 3 

months, and finally every 3 months until the casualty’s 

outcome has been maximized. Casualties are evaluated 

and treated by several members of the burn team at 

each follow-up visit, including a surgeon, physician 

assistant, nurse, therapist, mental health professional, 

and case manager. 

In addition to a burn clinic, all outpatient casualties requiring continuing rehabilitative services are 

evaluated and treated by an outpatient rehabilitation 

service. These casualties must remain engaged in goaloriented and outcome-based rehabilitation programs 

supervised by therapists.

Sexuality

Resuming sexual activity and relationships is an 

important part of recovery after a burn injury.306 A 

casualty’s partner should to be included in discussions 

about changes that take place during recovery and 

the expected final outcome. Most partners appreciate 

participating in an open discussion prior to resuming 

sexual activity. Casualties often worry about rejection; 

counseling to encourage trusting, honest communication can become the basis of a loving, caring, and 

exciting relationship. Understanding, communication, imagination, and experimentation can expand 

opportunities for a fulfilling relationship.306 Potential 

problems related to sexual activity and birth control 

should be addressed by the physician. Friction or 

trauma to healed burns during sexual activity may 

cause blisters that are slow to heal. As burn scars and 

skin grafts mature and become more durable, blisters 

will be less likely to occur. Lubricants may help reduce 

friction and blister formation. 
345

Rehabilitation of Burn Casualties

The areas least affected by the burn can often be 

used to enhance sexual activity. Because the lips 

and tongue are rarely burned, patients and their 

partners should be encouraged to use their mouths 

as a means of sexual expression. The lips and tongue 

are also more sensitive to touch and temperature 

than other body parts. Any part of the body that 

can be made clean enough for oral contact should 

be explored. Pregnancy may cause hypertrophy of 

burn scars and should be avoided until scars are 

mature. Stretching the tissue away from the direction of contracture and frequent erections assist with 

burn scar and skin graft maturity. Vigorous exercise 

and stretching of these areas results in the best outcome. Contracture releases are possible if required 

to improve function.307

COMPLICATIONS ASSOCIATED WITH REHABILITATION

Orthopaedic Complications

Bone and joint changes are common complications 

of burns, especially following thermal and electrical 

injuries.308 Common changes include internal changes 

in bone, such as osteoporosis; bone necrosis; bone 

growth disorders in children; and periosteal bone 

formation. Early mobilization and weight bearing is 

thought to diminish the risk and severity of osteoporosis. Periarticular changes can include HO and calcific 

tendonitis. Generally, periarticular ossification is noted 

in the area of deep burn, although it has been noted in 

areas distant from the burn, as well.309

Joint changes, such as septic arthritis and ankylosis, 

occur when the injury is deep into the joint or when 

bacteremia seeds the joint. When a joint is thought to be 

infected, in addition to appropriate medical management, the joint should be positioned and rested using 

a static orthotic device in a functional position. If ankylosis does occur secondary to the septic process, the 

joint will then be at a maximal position of function. 

Dislocation can occur from improper positioning of an injured joint or, more commonly, by scar 

contracture. If a joint is subluxed by a contracture, 

orthotic management, such as an IP extension serial 

cast, should be instituted immediately. If the orthosis 

cannot adequately control the deformity, internal fixation or release of the contracture (or both) should be 

considered.310

Heterotopic Ossification

HO is the ectopic deposition of bone around joints 

and tendons.170 Incidence is variable in the literature, 

and ranges from 4% to 23%.268,310 When it occurs in 

muscle body, it is more appropriately termed “myositis 

ossificans.” It most frequently occurs at the elbow, hip, 

and shoulder, and to a lesser degree at the temporal 

mandibular joint, wrist, hand, knee, and ankle.268,310 

Usually the amount and location of the extra bone is 

clinically insignificant, but it can be severe enough to 

completely lock a joint in place. 

Occurrence seems most likely to be related to the 

extent of the burn, size of open areas, and bed rest.311

Inflammation may also contribute to HO or fibrosis.269

The exact etiology has yet to be determined. HO should 

be suspected if there is a sudden onset of joint pain, 

swelling, or redness. When the diagnosis is confirmed 

by plain radiograph or bone scan, rehabilitation consists of AROM exercises without passive stretching 

and orthotic positioning in the maximal functional 

position.

There is currently no prophylactic treatment available for HO. Etidronate disodium has been used to 

prevent HO in the treatment of spinal cord injury.309,312

However, a recent retrospective review found that it 

was ineffective in preventing HO in burn casualties.313 

Prospective studies need to be performed. Etidronate 

disodium has been used after early resection of HO, 

with significant improvement in functional ROM 

and without recurrence after periods of 6 months to 

2 years. Early resection has been supported in the 

literature.314 

Other techniques to prevent recurrence include irradiation and the use of NSAIDs, both of which may have 

significant complications in the burn population.310

There is also controversy regarding thermo exercise. 

Some data suggest that vigorous AROM exercise can 

cause HO.315 Splinting, combined with AROM exercise 

and PROM exercise, is appropriate unless HO occurs, 

in which case, ROM exercise should be limited to 

AROM activity only within the casualty’s pain-free 

range.315,316

Amputations

Amputation can occur as a separate injury concurrent with a burn, particularly with explosive 

mechanisms of injury. The use of improvised explosive 

devices in Operations Enduring Freedom and Iraqi 

Freedom has resulted in a high rate of amputations 

associated with burn injury.23,24

Amputation can also occur as the direct result of an 

electrical injury, or as the sequela of a full-thickness or 

subdermal burn. The rate of occurrence varies with 

the etiology. Amputations from burn injury usually 
346

Care of the Combat Amputee

occur in 2 to 4 weeks and are related to infection.317,318

Amputations are treated concurrently with the burn. 

Electrical burns are associated with a 10% to 50% 

incidence of amputation.317,319–323 An electrical current may result in an explosive loss of all or part of 

a limb. Because the current follows the path of least 

resistance, damage tends to follow the nerves, arteries, 

veins, and muscle tissue, with the potential for deep 

tissue necrosis. Generally, it takes 4 to 5 days for an 

electrical burn to completely declare itself and for the 

need for amputation to become apparent. The need 

for amputation may also arise later in the course of 

care, such as when neurologic function or sensation 

does not recover, leaving an extremity that appears 

healthy without function or sense of temperature, 

pressure, or pain. 

When considering amputation, preserving length 

is important; however, it should not result in a functional disadvantage or problematic prosthetic care, 

such as occurs with a knee or elbow disarticulation. 

Burn injury can often delay fitting and application of 

a prosthesis because of the healing status of the skin. 

Grafted and healed areas of burned skin may require 

a prolonged course of treatment before they are able 

to tolerate the shear and pressure requirements of 

prosthetic use. Applying compression to the residual 

limb with stump shrinkers or elasticized tubular, selfadhesive, or compression bandages is important in 

preventing complications and may offset the delay in 

actual prosthetic fitting if done early.

Fitting a prosthesis to an extremity with healed 

burns is problematic because of various factors, including irregular length and shape, inability to tolerate 

pressure and shear, inadequate tissue for suspension, 

and limited ROM and strength to power myoelectric 

devices. Fitting must be approached with patience and 

innovation. Skin must be diligently monitored because 

breakdown can occur even after months of seemingly 

normal wear. 

Another significant problem after amputation is 

phantom pain. It is normal for amputees to sense that 

an amputated limb is still attached, and the phantom 

limb may even seem to be in an odd position. Phantom 

sensation may last for many years and does not require 

any treatment other than education. However, if the 

sensation is painful, it should be aggressively treated 

using gabapentium or pregabalin and amitriptyline at 

night.324 Desensitization techniques, such as rubbing, 

tapping, and contrasting temperatures and textures, 

are also helpful. Compression wraps and prostheses 

may help or exacerbate the pain. Treatment can include 

a single modality or combinations of the above. Narcotics have not proven beneficial in treating phantom 

pain.324

Neurological Considerations

Neurologic problems result from various etiologies. 

Although there may not be direct CNS damage from a 

burn, most burn casualties notice changes in reflexes 

and their perception of tactile and visual information. It is important to understand the etiologies of 

these deficits so precautions can be taken for prevention. Peripheral neuropathies may occur, resulting in 

decreased motor, sensory, and proprioceptive input. 

Early recognition and treatment may help prevent 

permanent deformity. The itching and pain sensations 

associated with burns subside gradually and may benefit tremendously from desensitization techniques. 

A desensitization program can enhance the neurological recovery of a burn casualty and allows the 

casualty to control the level, frequency, duration, and 

pressure of differing external stimuli applied to a 

healed wound.325 As the casualty‘s tolerance increases, 

the ability to withstand unexpected stimuli improves. 

Sensations from the healed wound, such as pain and 

itching, decrease and return to preinjury sensation. 

This occurs more rapidly when a desensitization 

program, including massage, vibration, and exposure 

to varying textures and temperatures, is practiced 

regularly.325

Texture desensitization involves introducing 

various textures to the healing tissues. Desensitization 

through texture contrast is commonly accomplished 

using cloth-covered wooden dowels to produce differing stimuli over the affected area (Figure 13-72). The 

repeated use of graded contact increases the sensory 

Figure 13-72. Wooden dowels with varying textures used 

for desensitization.
347

Rehabilitation of Burn Casualties

tolerance of the affected area. A hand or foot may be 

immersed in a basin that contains various objects, 

such as cotton, rice, plastic squares, or beans. The use 

of fluidotherapy may also be beneficial for desensitizing the hands.

Temperature desensitization is performed through 

controlled exposure to warm and cool water. The 

affected area is maintained at heart level if possible, 

and water is allowed to run over the healed wound—

first cool water for 20 seconds, then warm water for 

5 seconds—repeated for up to 10 minutes. Contrast 

baths of warm, followed by cool, water may be used 

for dipping hands or feet.

Peripheral neuropathies are relatively common 

among burn survivors, yet the diagnosis is often 

delayed or missed. Clinical weakness or atrophy is 

attributed to disuse after prolonged hospitalization 

with periods of forced immobility. The incidence of 

peripheral neuropathy has been reported to be as high 

as 30%. There is a greater incidence of peripheral neuropathies as the burn size increases above 20% TBSA. 

Casualties with electrical burns develop neuropathies 

at an even higher rate. Predisposing factors, such as 

alcohol abuse and diabetes, also increase casualties’ 

susceptibility to neuropathies.15

The most frequently diagnosed neuromuscular abnormality observed in a burn casualty is generalized 

peripheral neuropathy, which commonly presents as 

distal weakness in the upper and lower extremities. 

The casualty’s complaint, however, is usually lack of 

endurance and easy fatigability, not weakness. When 

weakness is noted, it occurs in the burned as well as 

unburned extremity. The cause of generalized neuropathies is not entirely understood but is probably 

multifactorial, related to toxic, nutritional, management, and metabolic factors. 

Local peripheral neuropathies are also concerning because they are probably related to preventable 

causes, such as compression or stretch injuries of 

a peripheral nerve or damage from intramuscular 

injections.326 The ulnar, radial, and median nerves 

are the most commonly affected peripheral nerves. 

However, neuropathies of the peroneal (fibularis) 

nerve and brachial plexus have also been observed. For 

example, the ulnar nerve is at risk of compression as it 

passes through the cubital tunnel at the elbow. When 

a burn casualty is positioned, for purposes of edema 

reduction, with the elbow elevated on pillows or arm 

troughs, flexed at approximately 90° and pronated, 

the cubital tunnel is narrowed. In this position, the 

ulnar nerve receives both external and internal compression and can be damaged, resulting in weakness 

of the ulnar intrinsic muscles of the hand and a claw 

hand deformity with loss of sensation to the ulnar side 

of the hand. Neuropathies are best prevented with 

frequent position changes and positioning that limits 

external pressure and avoids positions that impose 

internal compression. Thorough initial and logitudinal 

neuromuscular examinations are essential to properly 

manage burn casualties. 

Manual muscle testing should be performed to 

evaluate for the presence of upper-extremity peripheral 

neuropathy, especially in the presence of circumferential, full-thickness burns. The resting position of the 

hand can be indicative of neuropathy. For example, 

radial nerve involvement should be suspected if the 

wrist is held in flexion and the casualty is unable to 

actively extend the wrist, MCP joints of the fingers, 

and the thumb. Signs of ulnar neuropathy are clawing 

of the fingers and the inability to adduct the thumb. A 

median neuropathy should be suspected if the casualty 

is unable to oppose or abduct the thumb.

Median, ulnar, and radial neuropathy also influence 

positioning needs. The loss of active palmar thumb abduction associated with a median neuropathy increases 

the risk for adduction contracture. Splinting should 

include a resting splint or a C-bar splint, positioning 

the thumb in palmar abduction. 

Emphasis should be placed on avoiding MCP joint 

extension and IP flexion contractures, which can result from an ulnar neuropathy and manifest with the 

fingers (especially the ring and small) maintaining a 

clawing position. When the skin is durable enough, an 

“anticlaw” splint can place the involved MCP joints 

into flexion and block hyperextension. 

The absence of wrist extension, finger MCP extension, and thumb radial abduction is indicative of a 

radial neuropathy. Positioning and exercise should 

prevent wrist flexion contracture or contracture of 

the flexor compartment in the volar forearm. Splinting should hold the wrist and fingers in extension 

and thumb in radial abduction. MCP joint extension 

contractures must be avoided if dorsal hand burns 

are present; thus splinting the casualty into a resting 

position of 70° of MCP flexion may be indicated. In 

this case, the therapist needs to modify the splinting 

program, which may include alternating each type of 

splint indicated for day or night use. 

Burn casualties often experience symptoms of pruritus.2 In some cases, these symptoms can be worse 

than other pain a casualty experiences. Histamine 

release was previously thought to be the cause of the 

itching, but this has been proven incorrect. The exact 

mechanism remains unknown. It may be that pruritus, in some cases, is a manifestation of neuropathic 

pain. Nevertheless, initial treatment of pruritus is 

antihistamines, which do clinically benefit the casualty by managing symptoms. Diphenhydramine 
348

Care of the Combat Amputee

hydrochloride or hydroxizine, taken alone or in combination, are reasonable choices. Neuropathic pain medication (gabapentium or pregabalin) may be reasonable 

for resistant cases. Massage and transcutaneous electrical nerve stimulation may also be helpful.216,327 Pruritus 

will improve over time, frequently in conjunction with 

scar maturation.

Psychological Considerations

The psychological effects of being burned in combat 

are complicated and challenging to identify and treat. 

While grief, bereavement, and sadness are understandable and natural feelings, when not managed appropriately, combat-related burn injuries can result in more 

serious reactions and lead to more debilitating mental 

illness.328 Significant psychological distress occurs in 

over a third of casualties. Psychological management 

must be initiated early on, because evidence shows 

there is little clinically significant, reliable change in 

symptom severity when casualties are followed as 

outpatients.329Operations Iraqi Freedom and Enduring 

Freedom have presented a unique opportunity to study 

the psychological effects of burns because the number 

of individuals affected by the same event permit comparison not possible in individual trauma.330

The following principles and presented guidelines, 

consolidated by Faber et al,331 should be implemented 

when managing burn casualties:

	 •	 Routine care. Psychological screening and 

support should be routine from the start for 

the casualty and family and continue well into 

the completion of physical care.

	 •	 Promotion of a casualty- and family-centered 

approach. In light of the complexity and cultural considerations, a holistic approach based 

on the casualty’s psychosocial needs should 

be addressed in conjunction with the requisite 

medical model.

	 •	 Staff should be sensitive, trained, and fully 

integrated members of the burn care team. 

Psychosocial support is critical to the degree 

that casualties’ long-term psychosocial adaptation is largely dependent on their successful 

community reintegration.305

	 •	 T h e s u r v i v o r i s a s s u m e d t o b e a 

“normal”person and is expected to fully recover. The burn casualty’s sense of well-being 

is contingent on the ease with which they 

relate with the nonburned community.305

	 •	 Difficulties are normal experiences. It is natural for a casualty to struggle to develop a new 

life, new body image, and new ways of feeling 

good. The entire process has been described 

as achieving a “new normal.” The burn center 

team plays a vital role in this process.

	 •	 The family is critical to success. Next to the 

casualty’s desire to reintegrate into societal 

roles, family support is the most important 

component to healthful recovery.331

Appropriate pain management is also important 

when providing psychological and emotional support. 

Special attention should be made to address pain, 

especially as it relates to wound care, patient activity, 

therapies, and patient expectations. Anxiety often 

amplifies pain and therefore must also be addressed. 

Providers should be aware that acute pain may become chronic if not treated early and aggressively. 

Both background and breakthrough pain need to be 

aggressively monitored and appropriately managed. 

In addition to medical interventions, modalities such 

as hypnosis, acupuncture, deep breathing relaxation 

exercises, and distractions (eg, music and positive 

imagery) may ameliorate pain and its deleterious 

emotional effects.332

Agitation is frequently observed in sedated and 

intubated casualties and must be assessed for cause 

(eg, pain, anxiety, or sleep deprivation). Sleep deprivation can cause various other conditions, such as 

stress, pessimism, and anger.333 Sleep deprivation and 

restriction diminish vigilance (which can negatively 

impact performance), alter neuroendocrine control, 

and negatively impact immune function.334 This deficit 

can be the difference between a successful outcome and 

one that is less than adequate. A sleep hygiene protocol that allows for uninterrupted sleep and reduced 

environmental stimuli can augment restorative sleep. 

Relaxing music or a cool dark room may also help a 

casualty fall asleep. 

Nightmares are common in burn casualties,335

which may explain agitation in sedated and intubated 

casualties. Atypical antipsychotic medication may 

prevent nightmares. Antihypertensive medications 

and β-blockers can block the adrenergic response to 

nightmares. One way casualties may confront the fears 

and issues in their nightmares is by recording them in 

a journal and changing their endings.335

Delirium is a common and usually reversible disorder that occurs during a period of illness and must be 

aggressively assessed and treated.336 Possible causes 

of delirium include pain, pain medications, sleep 

deprivation, and witnessing loss of life, limbs, and 

horrific trauma. Recognizing these triggers is crucial 

when assessing work in war-injured casualties. Reorientation, restorative sleep, reassurance, and relaxation 

techniques can be effective in preventing and mini-
349

Rehabilitation of Burn Casualties

mizing delirium symptoms.334 Atypical antipsychotic 

medication can also be extremely effective.337 Benzodiazepines are not recommended because casualties 

may have sustained traumatic brain injury, resulting 

disinhibition and respiratory depression.336

Armed conflicts have a long-lasting impact on the 

mental health of those affected.338 PTSD, acute stress 

disorder, and their associated anxiety disorders are 

common psychological problems secondary to combat-related burns.338 PTSD is the most common and 

predictable mental health problem that results from 

exposure to war and terrorism.339 Most casualties will 

have symptoms of PTSD weeks to months following 

the event. A high incidence of PTSD among burn casualties has been noted from current conflicts.328

A burn casualty’s response to a recognizable stressor 

signals PTSD if it evokes distress symptoms. Casualties 

also often experience vivid, intrusive dreams or recollections of the traumatic incident. Other frequently 

noted characteristics of PTSD are an exaggerated startle 

response, impaired memory, concentration problems, 

avoidance of cues of the accident, and withdrawal 

from normal social interaction, chores at home, tasks 

at work, or participation in active duty.340 Treatment 

is aimed at giving casualties as many choices as 

possible during recovery, thereby relieving a sense 

of helplessness. Stress reduction strategies and goaldirected individual counseling can also be beneficial. 

Short-term pharmacological intervention may also be 

appropriate. It is helpful for casualties returning to 

active duty to know that PTSD may be exacerbated by 

distant yet significant events, such as the dedication 

of a war memorial or reunion event.330 Reading about 

an individual who sustained a similar burn may also 

revive PTSD symptoms. 

Losing fellow service members during combat is a 

significant source of distress.341 Grief and depression

are common concurrent with combat-related burns.341

A number of medical interventions are effective in 

treating combat-related grief and depression, including 

antidepressant medications and grief counseling. Combat casualties have experienced numerous losses and 

changes that may take time to resolve, and they should 

be allowed to express their feelings and concerns.341

It is important to provide behavioral health support 

to casualties and their families from the earliest phases 

of hospitalization throughout the hospital course.342

The Red Cross may relay information between casualties and their families while separated, and can help 

families secure quarters near the medical treatment 

facilities where their loved ones will be treated. Intact 

and supportive families have been influential in the 

successful long-term psychosocial adjustment of casualties of severe burn injury.343 Family members may 

be interviewed by social workers, nurse specialists, 

psychologists, psychiatrists, and chaplains to get an 

accurate history of the casualty’s preburn personality, coping styles, and reactions. This facilitates the 

development of rehabilitation strategies.

It is important to involve casualties’ families in 

support groups and to provide them with educational 

classes to inform them about burn injuries and treatment. Families’ reactions to burn injuries and their 

ability to support casualties through recovery and 

reintegration into society is critical to casualties’ successful life adjustment.342 Support groups may help 

family members deal with the stress and uncertainty 

of caring for a combat-injured casualty.

Family members are often responsible for immediate communication with loved ones, extended family, 

colleagues, and community groups or churches. Family 

and friends at home can provide significant support 

and focus toward the future by letter writing and 

maintaining positive contacts with burn casualties. 

Evidence shows psychosocial adjustment is a function 

of both coping responses and social resources.340

Alcohol and substance abuse or dependence 

research over the past decade has demonstrated a 

strong association between PTSD and substance abuse 

and dependence.344 The assessment and treatment 

of alcohol withdrawal is challenging in burn casualties because hyperthermia, tachycardia, and narcotic 

medications may mask these symptoms. Some of these 

signs, symptoms, and behaviors may not reveal themselves until long after the casualty is discharged from 

the service.

Combat casualties who have sustained burns are 

neither exempt from, nor more prone to report, suicidal 

or homicidal ideations than other casualties who have 

experienced severe trauma. Risk assessment should be 

performed during the course of the behavior health assessment. Concerns for suicidal or homicidal ideations 

should be assessed and interventions provided by 

mental health professionals.

SCAR MANAGEMENT

Scar management is an essential component in 

burn casualty rehabilitation. Appropriately managing burn wounds can minimize the resultant functional limitations. As burn wounds heal, scar tissue, 

comprised of collagen fibers, forms over all affected 

areas. The impetus of the healing process is to achieve 

closure as quickly as possible to achieve tissue contraction.345 Tissue contracture protects a casualty’s 
350

Care of the Combat Amputee

survival, but also creates a setting for joint contracture 

and restrictive scarring that interferes with functional 

independence. 

Tissue Contracture

When considering the rehabilitation of burn casualties, most clinicians think about the deleterious physical effects of burn wound healing in the form of scar 

tissue contractures that appear after wound closure. 

However, burn scar contractures develop during the 

acute rehabilitation phase, making early therapist intervention important. Additionally, it is important to 

differentiate between burn scar contracture and burn 

scar hypertrophy. It is likewise important for clinicians 

to be able to differentiate between burn scar contracture, which occurs early, and contracture from muscle 

or joint capsule, which occurs following prolonged 

immobilization.346

During the inflammatory phase of wound healing, 

edema can cause body parts to become malaligned, 

positioning body segments to develop scar contractures.6

 In the proliferative phase of wound healing, 

granulation tissue, which contains the elements 

that can ultimately lead to scar tissue contracture, 

forms.347 Simultaneously, wounds naturally undergo 

contraction, which, by action of myofibroblasts, pulls 

the edges of the surrounding tissue centripetally, 

reducing the pliability of the surrounding tissue.348

All areas of the body do not contract to the same 

extent. Areas where skin is loose, such as over the 

abdomen or buttock, can contract further than areas 

where skin is tighter, such as around the leg. Because 

of these biological processes, casualties will develop 

burn scar contractures if proper interventions are not 

instituted, especially during the intermediate phase 

of burn rehabilitation.53

Because of known poor outcomes associated with 

the formation of granulation tissue, early excision of 

burn wound and skin grafting is a common practice.348

Nonetheless, burn wounds that are skin grafted still 

undergo contraction. Partial-thickness skin grafts 

contract more than full-thickness skin grafts.349 More 

important than the overall thickness of the skin graft 

is the makeup of the skin graft. Partial-thickness skin 

grafts from an area where skin is thin, but that transplant a large portion of the reticular layer of the dermis, 

contract less than skin grafts taken more superficially. 

Therefore, even if casualties are skin grafted, they will 

need rehabilitation beyond the intermediate phase 

of burn rehabilitation and well into the long term, 

until the tissue no longer demonstrates a tendency to 

contract.

Hypertrophic Scarring

Hypertrophic scarring is the most common and 

debilitating complication of burn injury and occurs 

when burns extending into the dermis of the skin heal 

through scar formation (Figure 13-73).350 Hypertrophic scarring is defined as an overgrowth of dermal 

elements that remains within the boundaries of the 

original wound, a distinguishing characteristic from 

keloid scarring (see below).350 Hypertrophic scarring 

frequently occurs in cases of burns extending into the 

deep layer of the dermis (the reticular layer) or if there 

is a delay in wound healing longer than 3 weeks.351,352

It also tends to occur in areas of full-thickness burns 

or where donor sites have been harvested too deeply, 

reharvested several times, or in which healing has been 

delayed because of infection or trauma.350 

Hypertrophic scarring may be painful, limit range of 

motion, impair sensation, and result in loss of function. 

Compression garments, scar massage, dynamic splinting, serial casting, and other conservative therapies 

may prevent or minimize hypertrophic scarring. Some 

burn casualties may need to undergo reconstructive 

surgery to deal with these scars. 

Keloid Scarring 

Another complication of scar formation in burn 

healing is keloid scarring. Keloid scarring occurs when 

an overgrowth of dermal elements extends beyond the 

boundaries of the original wound.189,350 According to 

Linares, keloid scarring is the most severe degree of 

hypertrophic scarring, with the differentiating factor 

being quantity.351

Keloid scarring is not as commonly observed as 

Figure 13-73. Severe hypertrophic scarring of the hands.
351

Rehabilitation of Burn Casualties

hypertrophic scarring, but depending on the location of development it can be, by its progressive and 

proliferative nature, more debilitating. Keloid scars 

go beyond limiting function because they are also disfiguring. Intradermal steroid injections, excision, and 

compression are often used to manage keloids. There 

is currently no preferred therapeutic modality to treat 

keloids. Location, size, disfigurement, debilitation, and 

depth of the scar are all considerations when deciding 

on a particular therapy.353

Hyperpigmentation

As a scar matures, it may become hyperpigmented 

(Figure 13-74). This occurs because newly formed 

epithelial cells eventually contain a relatively greater 

number of melanocytes than surrounding unburned 

tissue.354 The amount of color contrast varies from 

one individual to another. Exposure to sun must be 

gradual; avoiding sun exposure for about 1 year after 

injury is the best way to prevent permanent hyperpigmentation, and healed skin will tolerate graded sun 

exposure 3 to 18 months following injury. Damaged, 

thinned skin will turn very dark brown with even brief 

sun exposure. If sunscreen is being used, it is important 

to prescribe the type appropriate for the casualty’s 

natural skin condition. A commercially available, waterproof sunscreen with a sun protection factor rating 

of 15 or more should be applied to all burned areas. A 

wide-brimmed hat can protect the ears and nose during 

exercise in the sun. It is common for areas underneath 

custom-fitted, elastic, external vascular support garments to burn in the sun.

Once a scar has matured, steps can be taken to 

modify its appearance. The simplest modification is 

applying camouflage or makeup. When combined 

with prosthetic facial components, makeup can significantly change appearance. Skin may be lightened 

over a period of months with daily topical application of hydroquinone, which can be purchased over 

the counter in strengths up to 4%, or prescribed in 

strengths up to 10%. Ruby laser may also lighten the 

skin. Hydroquinone and ruby laser are most effective 

in lighter skinned casualties because of the greater 

contrast between the affected and nonaffected areas. 

Burn scar contractures can lead to decreased ROM 

and decreased mobility, resulting in a functional deficit 

in ADL performance as well as an altered aesthetic 

appearance and ending in a dysfunctional outcome. 

Various modalities can reduce the severity of burn scar 

contracture and the extent of surgical reconstruction 

required to preserve function. Appropriate burn scar 

control can effectively decrease the adverse affects of 

burn scar contractures and hypertrophic scarring.345

From the rehabilitation perspective, burn scar management includes using external vascular support to 

avoid excessive edema and compartment syndromes, 

positioning to create an environment for tissue elongation, and AROM and PROM exercises to retain joint 

motion and functional capacity as the healing tissue 

initiates typical contraction behavior.355 As the wound 

area heals and scar is formed, the immature scar tissue 

will receive heat treatment and massage to enhance 

tissue pliability. Rehabilitation will also include additional compression interventions, occlusive dressings for hydration, custom splinting devices for tissue 

elongation and flattening, more aggressive AROM 

exercise, and reintroduction of ADLs.

Characteristics of Burn Scars

An increased healing time can result in hypertrophic 

scarring. In such a case, the wound-healing process 

begins like it does with normal scarring, but the additional healing time results in a protracted course of 

repair matrix accumulation, increasing morphologic 

and biochemical abnormality.345 According to Burd 

and Huang, “although the hypertrophic scar follows the same cycle as the normal scar, time to heal 

is considerably prolonged and the adverse effects of 

the scar on form and function, particularly caused 

by contraction, are significantly worse than those of 

normal scars.”345 Hypertrophic scars also have an 

increased microcirculation compared to normal skin 

and mature scar tissue. Clinically, active lesions are 

firm and erythematous, resulting in maturation related 

Figure 13-74. Hyperpigmentation of burn scar on the lower 

extremities.
352

Care of the Combat Amputee

to microvascular regeneration.345 As scar tissue forms, 

the early, immature presentation is often described by 

appearance using the “3 Rs”: red, raised, and rigid (see 

Figure 13-73). 

Burn scar management begins at the time of insult. 

Following a dermal injury, a cascade of events results 

in the formation of a collagen-rich repair matrix; in 

normal scar tissue it presents clinically with increased 

height, firmness, and redness, indicating increased 

vascularity.345 At this time the interdisciplinary staff 

is focused on wound management and closure. 

Reepithelialization, or wound healing, following a 

split-thickness skin graft, can take from 2 days to 

several months; however, most wounds heal within 

a few weeks.356 Graft loss, hypergranulation tissue, 

and malnutrition can all result in lengthy healing of a 

split-thickness skin graft.356 

Compression

Pressure therapy helps restore the extracellular matrix organization identified in normal scar.357 External 

vascular support, begun early in the acute phase, uses 

a thin, moist contact layer to prevent the appliance 

from sticking to the epithelium at the wound edge. 

The initial purpose of external vascular support is to 

protect fragile, newly healed skin from blistering; improve venous and lymphatic return; decrease extremity 

pain; decrease itching; prevent sunburn or frostbite; 

moisturize the epithelium; modify overly bulky, 

thick, hard, scars; and elongate maturing contracture 

bands. Complete baseline descriptions of the healed 

wound, open areas, and areas of early scar symptoms 

or contractures are documented. Pressure must be 

adequate to decrease capillary circulation and must be 

continued until the scar matures. Pressure adequate to 

decrease edema and compress scar tissue cannot be applied to the middle of an extremity without impairing 

lymphatic return. Therefore, the principle of gradient 

pressure (the greatest support at the distal limb and the 

least at the proximal limb) must be observed.

For external vascular support of the hand, the 

fingers can be individually wrapped in a supportive, 

self-adherent elastic wrap (Figure 13-75). Several 

compression companies provide elastic digi-sleeves, 

also called edema sleeves. Isotoner gloves are an economical, off-the-shelf support glove manufactured in 

three sizes for hands that are not extraordinarily large 

or small. The most universally used early external 

vascular support is the elastic bandage wrap applied 

in a gradient figure eight, distal to proximal. Because 

early excision and grafting have become the norm, 

external vascular support is provided in the acute 

phase of healing primarily for the upper and lower 

extremities.358

Burned legs have generally been supported with figure-eight elastic bandage wraps from the acute phase 

through discharge from the hospital. This method of 

support facilitates ambulation and prevents pain and 

lower extremity edema or hemorrhage.214 Elastic wraps 

are applied while the casualty is recumbent to avoid 

edema and poor venous return when standing. The 

most distal part of the extremity (ie, the hand or foot) 

must be properly managed first; then the support can 

be worked proximally. 

Wound exudate may cause elastic wraps or garments to stick, so they should be soaked off during 

bathing to prevent denuding skin. Unless worn only 

for protection, the external vascular support appliance must apply continuous pressure in a gradient 

manner. 

Massage and Vibration

Massage may break up bands of scar tissue that can 

cause contracture and decrease sensitivity and pain in 

the healed scar.355 Massage therapy often helps desensitize the skin and scar and assists with venous return. 

It involves manipulating the soft tissues with the hands 

Figure 13-75. Self-adherent elastic wrap of the hand and 

fingers for vascular support.
353

Rehabilitation of Burn Casualties

to produce effects on the neuromuscular and circulatory systems. The massage should generally work in 

the direction of the venous and lymphatic circulation. 

Massage should be a slow, repetitive motion, moving 

distal to proximal, with the affected area elevated 

above the heart, if possible. However, applying too 

much pressure can cause pain or blisters.

Massage with lotion or mineral oil softens and 

increases the pliability of scar tissue. Nongreasy sunscreen and adequate medication to decrease pruritus 

help individuals avoid damaging newly healed tissue. 

In addition to increased pliability, massage with lotion 

lubricates dry scar tissue and skin grafts, which may 

prevent dehiscence of the less mature scar tissue.355

Topical silicone gel is effective in both preventing and 

managing hypertrophic scar.358,359 Silicone gel sheeting has been used for decades to effectively manage 

scars. Silicone therapy’s mechanism of action has not 

been completely determined, but is likely to involve 

occlusion and hydration of the stratum corneum.360

Applying self-adhesive silicone gel sheeting to a scar 

allows for a comfortable, reusable silicone product that 

implements the occlusion and hydration necessary to 

manage and prevent hypertrophic scarring. Silicone 

sheeting is also easy to apply under vascular support 

garments.

Vibration is a controlled method of massage that 

stimulates nerve endings and may lessen pain or irritation. An electric or battery-operated vibrator can 

be used to massage around affected areas. As tolerance 

increases, the vibrator can be placed directly over the 

healed wound, first with a stocking covering the skin 

and then directly against the healed skin. Vibration is 

used to decrease pruritus associated with healing scar 

tissue. It is also indicated for flattening scar tissue.361

Casualties and their families are typically taught vibration therapy in clinic instruction.

Range of Motion

ROM and stretching exercises increase joint movement and lengthen scar tissue to reduce the restrictions 

of joint ROM. Preparing the tissue with massage allows for less restrictive scar tissue while performing 

ROM and functional activities. Goal-directed progress 

in ROM is required daily throughout all phases of 

recovery to prevent contracture and deformity and to 

increase function.355,361

Splinting and Positioning 

Splints and casts are used to manage scar tissue. 

Compressive forces flatten scars and positional forces 

create a stretch by imposing a constant tension on 

the scar.355,361 These modalities are used from day of 

admission on all casualties and modified or advanced 

depending on a casualty’s needs. 

For casualties who have sustained facial burns, 

preventing and managing microstomia contracture 

is essential for maintaining premorbid quality of life. 

Mouth opening is imperative for speaking, eating, 

performing dental hygiene, interacting, and restoring 

psychosocial well-being. Opposing horizontal, vertical, 

and circumferential forces are necessary for effective 

scar management.362

Heat

Initially heat packs, and later paraffin, are used to 

increase pliability and tissue flexibility and to prepare 

the tissue for elongation stresses prior to progressive 

ROM exercise programs.355,361 Heat should not be applied to insensate areas.

Compression

Casualties wearing external vascular supports or 

orthoses for the face and neck must be closely observed 

for complications such as sleep apnea,363 changed 

bone growth,364 and posterior migration of the teeth. 

A separate nose orthosis may be fitted under the clear 

facial orthosis to maintain patent nostril openings. 

Custom-fitted inserts may be made of soft silicone 

or hard acrylic. If the ear meatus is scarring closed, it 

can be maintained with a silicone elastomer or acrylic 

insert or hard plastic.

It is difficult to properly fit a neck orthosis because 

there are no bony landmarks on the anterior neck, the 

larynx must be able to move during speech or swallowing, and the sternocleidomastoid muscles change as 

they contract and relax for neck movement. However, 

with practice, a neck orthosis may be fitted that reduces 

edema and supports the tissue between the sternal 

notch and the chin at the maximum possible length. 

Wearing an orthosis should never replace AROM exercises to improve the quality and length of the healing 

epithelium and underlying connective tissue.

When the extremity is healed, it is usually durable 

enough for tubular external vascular support on a foot 

and leg, or Isotoner gloves on a hand. The prefabricated 

garments are made of a variety of materials, including 

unidirectional, stretchable rubber; elasticized cotton; 

elasticized nylon; nylon/spandex; spandex; and rayon.365 Many casualties tolerate prefabricated cotton 

and rubber garments well; scars recede and no other 

support is needed.366 In addition, fabrics with varying 

elasticity are available from most custom garment 

manufacturers. Multiple types of custom-fitted or-
354

Care of the Combat Amputee

thoses are available for external vascular support and 

scar compression. Once wound closure is complete, 

a wide variety of commercially available support designs are available, as well.348

Transparent Facemasks

Casualties with extensive facial burns can use 

custom-made, silicone-lined, transparent facemasks 

(Figure 13-76). Facial skin is loosely connected to underlying structures, and permanent distortion of the 

nose, eyelids, mouth, ears, and neck may result if this 

connective tissue is allowed to contract around the face 

or neck. Face-scanning technology, which digitizes the 

complex surfaces of a burn casualty’s face, and rapid 

prototyping on a computer-controlled milling machine can create a transparent facemask that provides 

compression.367

Body Garments

Weight gain and loss should be stabilized before 

measuring for custom garments. Custom garments 

are usually measured circumferentially for the extremities and at the waist, hips, and chest for the 

trunk. Joints are marked on a circumferences record 

and measured on a pictorial form. Each garment 

company has its own forms, tapes, and measuring 

style. Measurements are usually taken by a company representative. Tape measure designs include 

longitudinal paper tape with cross-sections taped 

on an extremity, and lightly adhesive measuring 

devices placed directly on the body. Knowledge of 

the casualty’s injury and course of recovery helps 

in planning the proper design and individual options.368 Climate, employment conditions, physical 

limitations, and psychological status also influence 

the garment type. Casualties should be measured as 

early in the morning as possible, when extremities 

are the least edematous. Measurements are taken 

in direct contact with the casualty’s skin, not over 

clothing or dressings. The tape measure should be 

placed firmly but not tightly. When there are two 

adjacent garments—for example, a glove and an 

arm sleeve—measurements should be overlapped so 

the garments themselves overlap and do not gap or 

pinch. A tracing should be done with a thin marking 

pen. The garments are produced and mailed, and the 

casualty usually tries the garments on in the therapy 

department of a burn center. 

Burn site, casualty age, burn depth, the presence of 

split-thickness skin grafts, and wound healing time 

influence garment design. Of primary importance is 

predicting whether a wound will scar and the location and size of the potential scar area. The garment 

should completely cover the potential scar area with 

a 2- to 3-inch overlap at each end so that when the casualty moves, the garment will still be in contact with 

the area being treated. Because edema and deep vein 

thrombosis are always concerning, the garment design 

must include tissue distal to the burn. Fingertips and 

feet can be either open or closed, depending on the 

casualty’s needs. Liners can be placed around joints 

with bony prominences.

Garments need firm attachment points so they do 

not roll, slide down, or ride up. Attachment points 

could be at the waist, forearm, shoulders, or hips. 

Ending the garment on the muscle belly should be 

avoided because the edge may constrict when the 

muscle is flexed. Ending the garment directly on a joint 

can decrease circulation.

The initial, custom-measured, full glove with closed 

or open fingertips is appropriate for the hands. This 

glove should also have slanted interdigital seams and a 

thumb design that allows radial and palmar abduction 

without losing fit over the dorsum of the hand. The 

initial glove is often made of soft fabric; the density 

of the fabric is increased to heavy duty when the skin 

can tolerate it. 

For the thorax and limbs, basic designs can be varied 

to create several options. A thorax garment can be a 

basic sleeveless vest, or a full suit with long arms and 

thighs with a crotch that is opened, closed, or has a 

hook-and-loop fastener, zipper, or snap flap. If the vest 

rides up and a body brief is not desired, the vest can 

be made several inches longer, or a heavy-duty snap 

or hook-and-loop fastener crotch strap can be added. 

Hook-and-loop fasteners allow for some adjustment in 

tightness. For females, breast cups are measured and 

Figure 13-76. Transparent facemask providing compression 

for scar management.
355

Rehabilitation of Burn Casualties

front closures are used in vests. Unburned arms can 

have short sleeves, which are useful because the open 

armholes put little pressure on the chest and upper 

back. Vests with only one arm pull the neck opening 

away from the open side, take away chest and back 

pressure, and exaggerate poor posture. Various arm 

sleeve lengths are feasible. However, if the shoulder 

requires compression, a vest style is most effective. 

The axillary area may be made larger if no compression is needed there. Pants can be waist high, and 

wide clip-on suspenders or elastic bands may keep 

the waist from rolling down. If a vest is also required, 

overlapping hook-and-loop fastener tabs or heavyduty snaps can be used. Garter belts can be used to 

secure bilateral thigh-high stockings. A garter belt will 

not work on a unilateral thigh-high stocking. If the 

skin is durable enough, some skin adhesive or foam 

tape can be used. 

Anklets and knee-length stockings usually stay up 

well, especially if the skin is well moisturized before 

donning the stocking. Zippers can be placed on any 

of the extremities to assist initial donning and doffing 

when the skin is still fragile; however, zippers decrease 

the uniform compression of the garment and at times 

need to be padded, so it is best to avoid them if possible. Other options to add to compression garments 

are inserts, gussets, pads, and darts.

The initial fitting of a garment should always be 

done in the clinic to assure an accurate measurement 

and fit. To be therapeutic, the correct level of compression should slightly blanch the hypertrophic scar areas. 

There should not be any restrictions in motion, circulation, or skin integrity. Color, motion, and sensation 

should be checked before the casualty leaves the clinic. 

Fingers and toes should be observed for swelling, coolness, and dusking, as well as numbness or tingling. 

Casualties should be instructed to discontinue the 

garment, reapply elastic wraps, and call the therapist 

if problems occur at home.

Applying the new garment for the first time is challenging. It should fit tightly, like a wet suit, and should 

take several minutes to don. The fit can be checked 

by how the garment feels to the casualty and how the 

scars feel through the garment. The garment should 

be tight enough that it is not possible to grab hold of 

it easily and pull it away from the skin, and should 

not wrinkle. Shoulders, elbows, and knees should 

have adequate relief for full AROM without allowing 

open areas. Often the first garment does not fit correctly and alterations or new measurements may be 

required. Most commercial companies will replace a 

problematic garment.

The body garment is worn 23 hours a day throughout the duration of the skin maturation process. The 

garment must be removed for bathing, and occasionally it is necessary to remove it during vigorous 

exercise sessions when it causes blisters. It should be 

washed daily to remove perspiration, body oils, and 

dirt. Meticulous hygiene is essential for the skin, as 

well. Garments should be cared for according to the 

manufacturer’s recommendations. 

A light dusting with cornstarch or powder may help 

with garment donning; however, casualties should 

be reminded to wash the powder away each day to 

avoid plugging pores. Wearing nylon under the body 

garment can decrease the shear on skin and increase 

the ease of donning. Foam pads at the joint creases of 

the knee and ankle can prevent garments from cutting 

into underlying skin. A protective hydrocolloid patch 

on the olecranon, the antecubital area, or both, can 

prevent scrapes in these vulnerable spots. 

Initially, reassessment is best done weekly to ensure 

wearing tolerance and to watch for complications and 

changes in weight or muscle mass. If an aggressive 

therapy program is not required, the scars are becoming soft and light in color, and the casualty is doing 

well, visits can be decreased to biweekly, monthly, and 

bimonthly through the maturation process. Generally, prefabricated garments last only 1 to 2 months, 

depending on the casualty’s activity level. A weight 

change of 10 lb or more may require new measurements be taken. A new garment should be issued at 

each clinic visit until the casualty has five garments 

that fit well. Custom garments generally last 2 to 3 

months. Some casualties may require more than two 

sets, depending on their work or leisure situations. It 

may be necessary to set aside one set of garments for 

dress and use stained ones for daily activities.

Bothersome open areas should be checked for infection. If they interfere with motion or cause excessive 

pain, garments can be removed for exercise. It may 

be necessary to wear elastic bandages for a few days 

before reapplying the garments. 

Skin covered with support garments may develop 

offensive odors. Daily bathing, washing open areas 

and body wrinkles thoroughly, drying skin meticulously, and applying a lotion every day improves 

wound hygiene. Heavy petrolatum or oil-based lotions should be avoided because they liquefy natural 

sebum, and it is then washed away. Deodorant is 

appropriate if it does not cause contact dermatitis. 

If blisters form or open areas increase in size, the 

casualty should discontinue wearing the support 

garment, resume elastic wrapping of the extremity, 

and explore the causes of blistering. If excoriation has 

resulted from scratching, antihistamine medications 

can be increased or changed. Ambulation and exercise 

should be continued.
356

Care of the Combat Amputee

Inserts

A mature scar will never return to a high degree of 

organization of normal dermal architecture.345 However, an insert can accelerate hypertrophic scar maturation process.369 Inserts that fill in concave areas that 

a custom-measured garment cannot reach are usually 

placed between the skin and the compression garment 

over a thick hypertrophic scar, tight skin, contracture, 

or a concavity where a bridging area has begun. Some 

inserts have been used successfully alone, for small 

areas, without compression. Overlays are placed over 

the custom-measured garment with an elastic wrap or 

another garment to press the garment into concavities 

between bony prominences or anatomical structures 

that compression garments “tent” over. The overlay 

or insert fills in the negative spaces for a smooth, 

total-contact compression from the external vascular 

support garment. Inserts are also used to help flatten 

and soften the taut, rope-like contractures that are often 

noted over joints. 

As tissues eventually become longer, blanching decreases when the skin is stretched, and contractures decrease. Inserts add extra pressure over thick, nodular, 

hyperemic scars. When used in this manner, tapering 

the edges of the inserts assures total contact by preventing tenting from the elevated ridges. Inserts can be 

used as padding for protection over bony prominences, 

under zippers, and at the inner angle of flexor creases, 

such as the ankles or elbows, to prevent garments from 

cutting into the skin. Closed-cell inserts may need to 

be worn with an open-cell, fabric, or disposable gauze, 

or paper liner to absorb perspiration. 

Wounds must be healed before inserts can be used. 

Inserts can be fabricated prophylactically for areas of 

anatomical vulnerability, such as the thumb web space, 

or for concave areas, such as between the breasts. When 

the skin begins to shrink and before contracture can 

form, properly placed inserts can prevent more difficult problems later. As dynamic scars change, inserts 

can be serially made for increasingly larger anatomical 

spaces. As the scar flattens, impressions can be filled 

in until the insert is flush with the surface and the scar 

impression is no longer seen in the insert. 

There are a wide variety of materials to use for 

inserts or overlays to increase pressure over a hard 

scar. The creativity of both therapists and casualties 

has resulted in many successful scar modifications. 

Fabric, open-cell or closed-cell foam, rubber or plastic pieces, and silicones are all appropriate inserts 

or overlays (Figure 13-77). Silicone can be placed 

between two Isotoner gloves or between two tubular 

compression stockings to increase the pressure on the 

scar and prolong the life of the insert. When the insert 

causes contact dermatitis, it must be discontinued 

and, after the area is healed, a different insert material can be tried.

The insert and support must be applied to maintain gradient pressure. As with the vascular support 

garment, they cannot be applied like a tourniquet 

in the middle of an extremity, which would impair 

venous return and cause edema in the distal hand or 

foot. Even if edema is not severe enough to be seen 

with the naked eye, the distal circulation will change. 

Therefore, the insert must be placed under or over a 

support that is donned from the hand or foot to the 

shoulder, knee, or hip. Certain prefabricated, commercially available fabrics and foams can be used. 

Lamb’s wool, in coil form, is a very soft, natural fiber 

that absorbs moisture in interdigital web spaces and 

protects fragile areas. Fibers adhere and incorporate 

into open wounds, so wool should be covered if applied where open areas or drainage is present. Cushioned strapping materials made of thin foam work 

well as finger inserts. They are loose fabric compatible 

with hook-and-loop fasteners. 

Silicones and elastomers can also be useful, such 

as a protective skin care pad with a solid, gelatinous 

consistency (described as artificial fat). These pads 

are lightly adherent and can be cut into any shape 

to provide cooling comfort. Thicker pads eliminate 

friction and absorb pressure. Thinner flexible pads 

are effective on mobile joints, such as the elbow. Both 

increase compression. The pad’s surface is oily, and 

Figure 13-77. Variety of insert materials for scar management.
357

Rehabilitation of Burn Casualties

the scar must be protected or observed for maceration. 

Using these pads for periods of 8 to 12 hours, then 

leaving them off for 12 to 16 hours, may relieve skin 

over-moisturization. 

Silicone gel sheeting is another compression insert 

option. This clear, soft, slightly adherent, semiocclusive, flexible insert is made from medical-grade 

silicone polymers without fillers (Figure 13-78).242,370

One version is very tacky and stays in place well, but 

crumbles fairly easily. Another type has a netted back 

woven through and is advertised to modify a scar 

with or without pressure. It is effective when worn a 

minimum of 12 hours per day (rather than the usual 

23 hours).359,371

Putty-based, white silicone elastomers can also 

be used for compression. In this case, the elastomer 

is mixed with a red tube catalyst, resulting in a firm, 

pink, rubbery, closed-cell insert. It does not run, sets in 

5 minutes, is odorless, and is semirigid but flexible. It is 

easy to work with in small quantities, and works well 

for interdigital web spacers and as a shock absorber, 

decreasing contractures and filling in cavities.

A closed-cell, gray-liquid–based, taffy-like elastomer mixed with a clear catalyst can also be used. It 

cures to a rubbery texture, and the setting rate depends 

on the amount of catalyst used. Handling it can be 

challenging and requires a tongue depressor. It sticks 

to hair, so a protective layer of lotion or plastic wrap 

should be used. It stains before the catalyst is added, 

and it requires refrigeration or storage and has a 1-year 

shelf life. It picks up very fine detail and works well 

on large areas. Serial inserts can be made by filling 

in the scar impression with medical adhesive as it 

improves. Repetitive fabrications can be made on a 

revised scar until the insert is flush. On large body 

areas, a pattern can be made and the insert fabricated 

on old radiographic material; this works well on flatter 

surfaces with less mobility, such as the trunk, lateral 

ankle, or palmar arch. This elastomer can be mixed 

with prosthetic foam.

Hot and cold gel pads can be used under compression garments. They have a cloth covering on the back 

that protects the garment from oils. The pads are occlusive, can be used on open wounds, and can be cut 

to size, but should extend 1 to 2 inches beyond the 

wound or be 25% larger than the wound. They can be 

worn over topical medication and made waterproof 

by applying a film dressing over the top. They can be 

secured with tape, gauze, or elastic compression.

If both compression and silicone gel sheeting are 

used, they should only be worn together 12 hours a 

day. For the other 11 hours that compression garments 

should be worn, one or the other can be used separately; otherwise, skin irritation may develop and the 

gel sheet will disintegrate from too much wear.

Although scar tissue usually looks shiny and is 

lighter in color than surrounding tissue, the optimal 

final healed wound should appear flat, soft, mobile, 

durable, supple, of proper color, and have minimal 

thinning and wrinkling. The wound is mature when 

the skin texture is soft and the scar is flat and thin. 

There may be some loose, excess skin folds that appear 

to be wrinkled, but overall the skin should be more 

flexible and exhibit some extensibility. Erythema will 

have faded or lightened from purple to red, then pink, 

then dark brown or white. The skin will return closer 

to its normal pigmentation in darker-skinned individuals than in fairer-skinned individuals. Often a graft 

site that required mesh continues to present the mesh 

pattern. Even with optimal results, there is usually 

some change in color tone. External vascular supports 

decrease the amount of hyperpigmentation deposited 

in the wounds of casualties with darker skin.

When a scar appears to be mature, external vascular 

support is discontinued for a trial period lasting at 

least 1 to 3 days, but not longer than 1 to 2 weeks. If 

the symptoms or signs of active scar formation do not 

recur, the ultimate outcome has been achieved. 

For burned hands, compression should continue 

on burned or grafted areas until the scar is mature.192

Custom compression gloves should be introduced 

approximately 6 weeks following the burn for deep 

partial-thickness burns and full-thickness burns or 

after skin graft. All burn wounds should be closed and 

there should be minimal or no edema present. ROM 

exercises should continue during the long-term phase 

to emphasize tissue elongation. If adequate skin length 

is not obtained, the risk for joint capsular tightness 

Figure 13-78. Silicone gel sheeting for scar management.
358

Care of the Combat Amputee

increases. Therapists should continually assess for joint 

capsular tightness, skin tightness, tendon adherence, 

or intrinsic muscle tightness. ROM exercises should 

address the appropriate deficits. 

If adequate ROM gains are not achieved with exercise alone, splinting or serial casting should be considered. Dynamic or static-progressive splints are the most 

common splints used during the long-term rehabilitation phase, when the goal is to increase ROM. Static 

splints are usually sufficient if the goal is to maintain 

what was achieved with exercises. Static-progressive or 

dynamic splints should be worn for at least 6 to 8 hours 

a day, for intervals of at least 30 minutes, to provide 

the optimal duration for tissue elongation. 

PLASTIC AND RECONSTRUCTIVE SURGERY

Reconstructive surgery and subsequent rehabilitation must be appropriately timed for the casualty to 

improve functionally, cosmetically, and psychologically. Otherwise, when inaccurately timed, the inverse 

is probable, resulting in loss of function, wasted 

valuable donor areas, and failure to benefit from the 

procedure.

Burn surgery is reconstructive rather than cosmetic. 

The American Society of Plastic Surgery defines reconstructive surgery as a surgical intervention “performed on abnormal structures of the body, caused by 

birth defects, developmental abnormalities, trauma 

or injury, infection, tumors, or disease. It is generally 

performed to improve function, but may also be done 

to approximate a normal appearance.”372 In addition 

to reconstructive surgery, plastic surgeons recommend 

makeup to enhance appearance and self-confidence for 

both male and female casualties.

The phases of recovery addressed by plastic surgeons include the acute phase, during which the 

wounds are closing, and the long-term phase, during which the scars are maturing. The ideal time to 

undertake reconstructive surgery is after scars have 

matured; however, there are a few specific situations 

in which reconstruction must begin earlier. In many 

cases, casualties want reconstruction early, and they 

must be made aware of the disadvantages of increased 

inflammatory scar deposition during the early scar 

maturation phase. As time progresses and the scars 

mature, casualties often become more satisfied with 

the appearance of their scars.373 Additionally, as casualties become involved in former activities, they are less 

interested in prolonged interruptions for operations or 

in-hospital care.

The reconstructive process requires communication 

between members of the interdisciplinary team, including the surgeon and therapy staff, and the casualty. 

The process requires clinical evaluation, assessment, 

and planning to select the most troubling functional 

deficits or disfiguring scars. Casualties take an active part in the planning process. After considering 

multiple ways of correcting significant problems, the 

reconstruction surgeon chooses the optimal method for 

a particular casualty, as well as a backup procedure in 

case of postoperative complications or tissue loss. 

Surgical teams frequently perform multiple operations under the same anesthetic so procedure time is 

used efficiently and recovery time is minimal. For 

instance, a fifth finger flexion contracture is often 

released the same time a web space contracture is 

corrected with a Z-plasty (see “Flaps” below) on the 

same hand. Only one hand is operated on at a time, 

and early motion cases are not mixed with procedures 

that require immobilization. In most cases, external 

vascular support garments are not worn and compression is usually not helpful after reconstructive operations. If hypertrophic scarring becomes difficult after 

reconstruction, the rehabilitation team uses pressure, 

gel sheets, or intralesional steroids. 

Flaps

Skin flaps are frequently used in burn reconstruction 

when vital structures need coverage. They may be used 

in any phase of the reconstruction, and various flaps 

are used for different purposes. Musculocutaneous 

flaps, or muscle flaps, are often used acutely to cover 

bone, vascular grafts, or vital organs exposed by the 

burn. Musculocutaneous flaps are also used during 

reconstructive procedures. Muscle provides excellent 

blood supply, new lymphatics, and thick composite 

coverage. In some cases, the initial reconstructions are 

bulky and do not shrink adequately, so volume must 

be reduced at a later procedure.

Free flaps are used to provide blood supply to large 

avascular areas, such as the scalp, following electrical 

injury. These flaps require microvascular anastomosis 

and a specialized and individualized donor site. For 

example, a free flap of omentum may be used to cover 

a complete scalp defect. An overlying skin graft is 

then required. If abdominal burns or gastrointestinal 

pathology make this choice unwise, a latissimus dorsi 

flap may be used.374,375

A thin, free flap including skin, such as a dorsalis 

pedis flap, may be better than a muscle flap reconstruction, which requires an additional overlying skin graft. 

Free flaps are useful in all phases of burn healing and 

provide sufficient options for the plastic surgeon.
359

Rehabilitation of Burn Casualties

Axial flaps are long, cutaneous flaps that contain an 

anatomically recognized artery and vein. The flap is 

turned, rotated, or moved into position. Axial flaps are 

usually used for hand procedures, such as a pollicization or island pedicle finger pulp reconstruction.

Random, or local flaps, were the earliest flaps used. 

They do not contain a recognized artery and are used 

almost anywhere on the body surface. The skin flap 

survives on the subdermal plexus of vessels. A delay 

procedure may be needed to enlarge these flaps. Tissue 

expansion may expand the size of available tissue.

Z-plasty is a procedure using multiple small flaps 

to lengthen a contracture. Z-plasties may set multiple 

flaps around a specific joint or along a contraction 

line. These flaps are occasionally mixed with small 

skin grafts.

Timing a reconstruction may depend on the type 

of burn. Chemical and thermal burns may not need 

reconstruction because they slowly improve. In contrast, radiation burns tend to be chronic and gradually 

worsen. These injuries require late debridement and 

flap coverage years after the initial trauma. Skin grafts 

in these cases are ineffective; musculocutaneous flap 

coverage ideally provides a new blood supply.

Electrical burns often require reconstruction during 

the acute phase of burn rehabilitation because they 

usually expose vital structures, such as tendons, bones, 

or viscera. Split-thickness skin grafts rarely provide 

the quality of coverage needed, and flaps are vital to 

introducing new blood supply during the first few 

weeks following injury. Musculocutaneous flaps and 

free flaps are the most adaptable methods for coverage 

of electrical wounds.

In the face, reconstruction and function begin to 

merge. Functionally, facial skin identifies an individual, transmits emotion in communication, protects the 

corneas, and forms the mouth and nose. Eyelids, vital 

to the protection of the eye, may require reconstruction at a very early stage in the acute phase of burn 

recovery. To correct eyelid eversion or contraction, 

full-thickness donor skin must be obtained in sufficient 

quantity to replace the eyelid skin. If hair-bearing 

skin or scarred skin is used, the results may give an 

unacceptable appearance and rapid reoccurrence of 

ectropion. Reconstructing aesthetic units of the face 

during the acute phase provides an optimal appearance that may not be matched by another procedure 

until the casualty’s burn wounds have matured. In the 

interim, facial orthoses (eg, transparent facemasks) are 

the primary option for improving the appearance.376

Facial features are not reconstructed until scar tissue 

has become inactive, supple, and mature. In many 

cases spontaneous healing, with the use of a microstomia appliance, produces such favorable results that 

no further reconstruction is necessary.

Timing of functional hand burn surgery is fairly 

independent of reconstruction considerations for appearance. After initial wound closure, finger motion 

is vital and surgery assumes a secondary role until 

the wound has become mature. Once the skin starts 

to feel supple, reconstruction can begin. Skin grafts to 

the hand require immobilization for 10 to 14 days, followed by aggressive remobilization using prolonged 

stretch and AAROM, AROM, and CPM equipment as 

necessary. Extensor tenolysis is undertaken only when 

skin coverage is good. Casualties must start ROM 

exercises within 24 to 48 hours of extensor tenolysis 

surgery. Web space reconstruction using Z-plasties is 

managed like skin grafts, with 10 to 14 days of immobilization and 6 to 8 weeks of spacers at night. It is 

not unusual to need an unexpected skin graft during 

a web space release because, as the scars are incised 

and defects are opened, the need for additional skin 

coverage becomes obvious. Functional problems with 

hands, eyelids, mouth, axillae, elbows, and neck are 

the most important to the well-being of the casualty. 

Because muscles, tendons, and nerves shorten when 

the skin over a joint is contracted, reconstruction takes 

precedence, even if the maturation phase has not been 

completed.

It is important for all team members to understand 

the objectives and timing of reconstructive surgical 

interventions in the burn casualty. Proper postoperative rehabilitation is best directed by communication 

between the plastic surgeon, who knows the surgical 

intervention and proper timing to resume therapy, and 

the rehabilitation team, who understands splinting 

needs and a casualty’s independent activity. 

SPECIAL CONSIDERATIONS

Special Senses

Casualties injured from burns and explosives can 

sustain a variety of trauma and complications. For 

example, blast trauma can leave a casualty with a 

ruptured tympanic membrane as well as external 

injury to the ear, resulting in profound hearing loss. 

If a casualty is burned during the trauma, there may 

also be injuries to facial skin affecting the ears, eyes, 

nose, and throat, impairing the casualty’s ability to see, 

smell, taste, eat, or speak. Other types of exposure or 

idiopathic injury, such as chemical splashes or toxic 

epidural necrolysis, may result in a number of conditions (eg, purulent conjunctivitis, corneal abrasions, 
360

Care of the Combat Amputee

epithelial defects, and retinal detachments), leaving 

the casualty with temporary vision loss or a residual 

deficit. Rehabilitation professionals must be prepared 

to address these issues because they can affect the casualty’s ability to participate in rehabilitation and to 

recover critical independence with ADLs.

During the acute care phase, all deficits must be 

defined and addressed in the casualty’s care plan. 

Rehabilitation professionals must be familiar with the 

many types of equipment a casualty may present with 

(eg, protective ear coverings, moisture chambers or eye 

coverings that help protect the exposed cornea from 

drying injury, eye bolsters, a variety of lubricating and 

antibacterial creams for the injured eye, and eye patches). 

Casualties with reduced sensorium require increased safety measures as a daily part of their care. 

Clear and concise verbal cues enable casualties to follow commands and directions. Written signage above 

a casualty’s bed and daily rounds reports alert staff 

and family to the casualty’s needs. Casualties with significant speech and hearing loss must have alternative 

types of communication, including writing or pictures 

on a board to allow them to point and make their needs 

known. Manual expressions or demonstration of directions can also be used to perform ROM exercises.

As rehabilitation continues from acute care to 

intermediate care, the casualty’s ability to perform 

basic mobility tasks may improve, but some deficits 

will continue to be problematic, such as diminished 

vision or hearing. Rehabilitation goals must shift to 

accommodate this and advance a casualty’s mobility 

and ability to perform ADLs despite the continued 

deficits. Rehabilitation specialists should be proficient 

in adaptive technologies, techniques for low vision 

training, and assistive devices that may be introduced 

to continue towards rehabilitation goals. 

In the long-term recovery stage, it is hoped that 

casualties will have regained many of the lost sensory 

deficits; however, many casualties continue to have 

additional procedures that prolong visual and hearing deficits. Technologies for coping with permanent 

vision and hearing loss, and education to protect extremities with decreased protective sensation remain 

important throughout the rehabilitation process.

Thermoregulation

Full-thickness burns damage dermal appendages, 

including sweat glands, leading to a decreased ability 

to sweat in areas of deep burns.2 Skin grafting of these 

wounds does not replace the dermal appendages, and 

the density of sweat glands decreases in areas used for 

donor sites.284 Areas of superficial and partial-thickness 

burns will regenerate lost glands. 

As perspiratory function returns, it is common to see 

an increase in perspiration and sebum in both burned 

and nonburned tissue because of the body’s continued 

need for thermoregulation within the environment. 

The loss of glands in the deeper portion of the burn 

requires the remaining and regenerating sweat glands 

to work harder to maintain homeostasis.

Austin et al reported no significant difference in the 

rise of body temperature of subjects with burns after 

1 hour of cycle ergometer exercise in a 35°C environment.284 These subjects were able to maintain heat tolerance through increased sweat rates in areas of healthy 

skin, and whole body sweat rates were comparable 

to those of normal subjects.284 Other studies, however, 

have shown thermoregulation problems do exist, especially when exercising in warmer environments.377–379

These studies demonstrated that subjects with greater 

than 40% TBSA burned had increased sweat rates but 

were unable to adequately maintain thermoregulation 

after exercise in a 40°C environment,377,379 resulting in a 

significant increase in core temperature and heart rate.

If a casualty has sustained burns equal to or greater 

than 40% TBSA, there is potential for hyperthermia 

during exercise, especially in environments with 

high ambient temperatures. Prolonged exposure to 

temperatures above 35°C should be avoided. A fan or 

air conditioner may be needed to help body cooling 

by evaporation. Casualties must remove garments 

and orthoses and must shower and cool down after 

vigorous exercise or work-related activities. Clinical 

experience shows that the ability to maintain temperature homeostasis at rest and with minimal to extreme 

exertion is an individual response. Work and exercise 

tolerance has to be evaluated on a case-by-case basis 

and requires careful, supervised therapy to maximize 

a casualty’s potential.

Medical Evaluation Boards

An injured service member may remain on temporary physical profile for up to 1 year. During this 

time, the rehabilitation team makes every attempt to 

maximize the casualty’s recovery potential. Casualties are referred to the Physical Disability Evaluation 

System if they are unable to meet medical retention 

standards after ample time or if they are unable to 

return to duty.

The US Army Physical Disability Agency, under the 

operational control of the commander of the Human 

Resources Command, is responsible for operating the 

Physical Disability Evaluation System.380 According 

to Army Regulation 635-40, Physical Evaluation for 

Retention, Retirement, or Separation, the system’s 

goals are to: 
361

Rehabilitation of Burn Casualties

	 •	 maintain an effective and fit military organization with maximum use of available labor,

	 •	 provide benefits for eligible soldiers whose

military service is terminated because of 

service-connected disability, and

	 •	 provide prompt disability processing while

ensuring that the rights and interests of the 

government and the soldier are protected.381

The medical evaluation board process begins when 

optimal medical recovery has been reached, when the 

service member’s ability to perform further duties can 

be determined, when the service member has been 

on temporary profile exceeding 1 year, or when the 

service member has been given a permanent profile 

of a three (3) or a four (4), indicating a permanent 

functional deficit exists for which functional recovery 

is unlikely. The medical evaluation board is comprised 

of at least two physicians whose job is to assess and 

evaluate the medical history of a soldier and determine 

how the injury or disease will respond to treatment 

protocols.382

SUMMARY

Treatment of combat-related burn injuries includes 

recovering optimal function to maximize participation 

in societal, psychological, and physical roles. Increased 

rates of survival have led to greater concern for potential morbidity. Surgical and medical technology has 

improved to such an extent that now, in most cases, 

burn care providers must assume that burn casualties 

will survive. Even during the initial or acute phases 

of care, the burn team must be aware of what will be 

important to the casualties they treat in the long term. 

Burn casualties experience a series of traumatic assaults to the body and mind that present extraordinary 

challenges to their psychological resilience. Contrary 

to what might be expected, empirical data regarding 

the long-term sequelae of burn indicate that many 

burn casualties do achieve a satisfying quality of life 

and that most are judged to be well-adjusted individuals. Outcomes studies not only report status of burn 

casualties following treatment, but can also indicate 

those factors that seem necessary to good outcomes. 

These studies have also found that the extent of the 

injury, the depth of the burn, the area of the body 

burned, and even amputations are not determining 

factors of good psychosocial recovery. The two most 

important factors that have consistently been found 

to be related to psychological and social adjustment 

are the quality of family and social support received 

by the casualty and the willingness of the casualty to 

take social risks.383

Burn casualties must be reassured that confusion, 

mistrust, anger, guilt, sorrow, and other issues are 

normal when they consider that their experiences are 

part of a very abnormal situation. Casualties should be 

prepared to handle stares and insensitive comments. 

Casualties must focus on what they can still do and 

on what functionality they still have, and should be 

encouraged to keep a sense of humor and nourish 

their spirits by whatever means possible. Successful 

reintegration into the community is the ultimate goal 

for the remainder of their lives. Every individual who 

interacts with a casualty impacts the psychosocial 

world of that casualty. 

REFERENCES

1. Harden NG, Luster SH. Rehabilitation considerations in the care of the acute burn patient. Crit Care Nurs Clin North 

Am. 1991;3(2):245–253.

2. Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA. Burn rehabilitation: state of the science. Am J Phys Med 

Rehab. 2006;85:383–413.

3. Saffle JR, Davis B, Williams P. Recent outcomes in the treatment of burn injury in the United States: A report from the 

American Burn Association Patient Registry. J Burn Care Rehabil. 1995;16(3 pt 1):219–232.

4. Pruitt BA, Goodwin CW, Mason AD. Epidemiological, demographic, and outcome characteristics of burn injury. In: 

Herndon DN, ed. Total Burn Care. 2nd ed. New York, NY: WB Saunders; 2002: 16–30.

5. Cancio L. Burn care in Iraq. J Trauma Inj Infect Crit Care. 2007;62(6):S70.

6. Demling RH. The burn edema process: current concepts. J Burn Care Rehabil. 2005;26(3):207–227.
362

Care of the Combat Amputee

7. Pham TN, Cancio LC, Gibran NS. American Burn Association practice guidelines burn shock resuscitation. J Burn Care 

Res. 2008;29(1):257–266.

8. Demling RH, Kramer GC, Harms B. Role of thermal injury-induced hypoproteinemia on edema formation in burned 

and non-burned tissue. Surgery. 1984;95:136–144.

9. Gelin LE, Solvell L, Zederfeldt B. The plasma volume expanding effect of low viscous dextran and Macrodex. Acta 

Chir Scand. 1961;122:309–323.

10. Demling RH, Kramer GC, Gunther R, Nerlich M. Effect of nonprotein colloid on postburn edema formation in soft 

tissues and lung. Surgery. 1984;95:593–602.

11. Du GB, Slater H, Goldfarb IW. Influences of different resuscitation regimens on acute early weight gain in extensively 

burned patients. Burns. 1991;17(2):147–150.

12. Waxman K, Holness R, Tominaga G, Chela P, Grimes J. Hemodynamic and oxygen transport effects of pentastarch in 

burn resuscitation. Ann Surg. 1989;209(3):341–345.

13. Wallace BH, Caldwell FT Jr, Cone JB. Ibuprofen lowers body temperature and metabolic rate of humans with burn 

injury. J Trauma. 1992;32(2):154–157. 

14. Demling RH, Zhu D, Lalonde C. Early pulmonary and hemodynamic effects of a chest wall burn (effect of ibuprofen). 

Surgery. 1988;104(1):10–17.

15. Haberal M, Mavi V, Oner G. The stabilizing effect of vitamin E, selenium and zinc on leucocyte membrane permeability: a study in vitro. Burns Incl Therm Inj. 1987;13(2):118–122.

16. Matsuda T, Tanaka H, Williams S, Hanumadass M, Abcarian H, Reyes H. Reduced fluid volume requirement for 

resuscitation of third-degree burns with high-dose vitamin C. J Burn Care Rehabil. 1991;12:525–532.

17. Boykin JV Jr, Crute SL, Haynes BW Jr. Cimetidine therapy for burn shock: a quantitative assessment. J Trauma. 

1985;25:864–870.

18. Boykin JV Jr, Manson NH. Mechanisms of cimetidine protection following thermal injury. Am J Med. 1987;83:76–81.

19. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Pollock RE. Basic considerations, fluid management. 

Part I. In: Schwartz SI, Brunicardi FC, eds. Schwartz’s Principles of Surgery. 8th ed. New York, NY: McGraw-Hill Medical 

Publishing Division: 2005.

20. Cancio LC, Horvath EE, Barillo DJ, et al. Burn Support for Operation Iraqi Freedom and related operations, 2003 to 

2004. J Burn Care Rehabil. 2005;26:151–161.

21. Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profile of combat injury. J Trauma. 2003;54:S13–S19.

22. Thomas SJ, Kramer GC, Herndon DN. Burns: Military options and tactical solutions. J Trauma. 2003;54:S207–S218.

23. Wolf SE, Kauvar DS, Wade CE, et al. Comparison between civilian burns and combat burns from Operation Iraqi 

Freedom and Operation Enduring Freedom. Ann Surg. 2006;243(6):786–795.

24. Kauvar DS, Cancio LC, Wolf SE, Wade CE, Holcomb JB. Comparison of combat and non-combat burns from ongoing 

U.S. military operations. J Surg Res. 2006;132:195–200.

25. Kauvar DS, Wolf SE, Wade CE, Cancio LC, Renz EM, Holcomb JB. Burns sustained in combat explosions in Operations 

Iraqi and Enduring Freedom (OIF/OEF explosion burns). Burns. 2006;32:853–857.

26. Barillo DJ, Cancio LC, Goodwin CW. Treatment of white phosphorus and other chemical burn injuries at one burn 

center over a 51-year period. Burns. 2004;30:448–452.
363

Rehabilitation of Burn Casualties

27. Curreri PW, Asch MJ, Pruitt BA. The treatment of chemical burns: specialized diagnostic, therapeutic, and prognostic 

considerations. J Trauma. 1970;10:634–641.

28. McCarthy JG. Cold, chemical, and irradiation injuries. In: McCarthy JG, May JW, Littler JW, eds. The Hand. Part 2. In: 

McCarthy JG, May JW, Littler JW, eds. Plastic Surgery. Vol. 8. Philadelphia, Pa: W.B. Saunders; 1990: 5438.

29. Jurkiewicz MJ, Krizek TJ, Mathes SJ, Ariyan S. Plastic Surgery, Principles and Practice. Vol 2. Saint Louis, MO: CV Mosby; 

1990: 1399.

30. Khateri S, Ghanei M, Keshavarz S, Soroush M, Haines D. Incidence of lung, eye, and skin lesions as late complications 

in 34,000 Iranians with wartime exposure to mustard agent. J Occup Environ Med. 2003; 45(11):1136–1143.

31. Cox BM. Torald Sollmann’s studies of mustard gas. Mol Interv. 2007;7:124–128.

32. Hunt JL. Electrical injuries. In: Fisher SV, Helm PA, eds. Comprehensive Rehabilitation of Burns. Baltimore, Md: Williams 

& Wilkins; 1984: 249–266.

33. Ahrenholz DH, Schubert W, Solem LD. Creatine kinase as a prognostic indicator in electrical injury. Surgery. 

1988;104:741–747.

34. Zawacki BE, Azen SP, Imbus SH, Chang YT. Multifactorial probit analysis of mortality in burned patients. Ann Surg. 

1979;189:1–5.

35. Wolf S. Modern burn care. J Trauma Inj Infect Crit Care. 2007;62(6):S67.

36. Sheridan RL. Evaluating and managing burn wounds. Dermatol Nurs. 2000;12(1):17–28.

37. Knaysl GA, Crikelair GF, Cosman B. The role of nines: its history and accuracy. Plast Reconstr Surg. 1968;41:560–563.

38. Lund C, Browder N. The estimation of area of burns. Surg Gynecol Obstet. 1944;79:352–355.

39. Holmes JH, Heimbach DM. Burns/inhalation injury. In: Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC, 

eds. The Trauma Manual: Trauma and Acute Care Surgery. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2007: 

387–492.

40. Devgan L, Bhat S, Aylward S, Spence RJ. Modalities for the assessment of burn wound depth. J Burns Wounds. 

2006;5;e2.

41. Richard R. Assessment and diagnosis of burn wounds. Adv Wound Care. 1999;12:468–471.

42. Grigsby deLinde L, Miles WK. Remodeling of scar tissue in the burned hand. In: Hunter JM, Mackin EJ, Callahan AD, 

eds. Rehabilitation of the Hand: Surgery and Therapy. 4th ed. Saint Louis, Mo: Mosby; 1995.

43. Hunt JL, Sato RM. Early excision of full-thickness hand and digit burns: factors affecting morbidity. J Trauma. 

1982;22(5):414–419.

44. Saffle JR and Schnebly WA. Burn wound care. In: Richard RL, Staley MJ, eds. Burn Care and Rehabilitation: Principles 

and Practice. Philadelphia, Pa: FA Davis; 1994.

45. Anzarut A, Chen M, Shankowsky H, Tredget EE. Quality-of-life and outcome predictors following massive burn injury. 

Plast Reconstr Surger. 2005;116(3):791–797.

46. Richard R, Steinlage R, Staley M, Keck T. Mathematic model to estimate change in burn scar length required for joint 

range of motion. J Burn Care Rehabil. 1996;17(5):436–43.

47. Hedman TL, Renz, EM, Richard RL, et al. Incidence and severity of combat hand burns after All Army Activity message. J Trauma. 2008;64(suppl 2):169–173.
364

Care of the Combat Amputee

48. Cioffi WG, Rue LW, Buescher TM, Pruitt BA. The management of burn injury. Mil Med. 1981:349–377.

49. Staley M, Richard R, Warden GD, Miller SF, Shuster DB. Functional outcomes for the patient with burn injuries. J Burn 

Care Rehabil. 1996;7(4):362–368.

50. Kraemer MD, Jones T, Deitch EA. Burn contractures: incidence, predisposing factors, and results of surgical therapy. 

J Burn Care Rehabil. 1988;9(3):261–265.

51. Leblebici B, Adam M, Bagis S, et al. Quality of life after burn injury: the impact of joint contracture. J Burn Care Res. 

2006;27:864–868.

52. Dobbs ER, Curreri PW. Burns: analysis of results of physical therapy in 681 patients. J Trauma. 1972;12:242–248.

53. Richard RL, Hedman TL, Chapman TT, et al. Atlas of burn scar contractures: a patient education tool. J Burn Care Res. 

2007;28:S152.

54. Chapman TT, Richard RL, Hedman TL, et al. Military return to duty and civilian return to work factors following 

burns with focus on the hand and literature review. J Burn Care Res. 2008;29(5):756–762.

55. Cope O, Moore F. The redistribution of body water and the fluid therapy of the burned patient. Ann Surg. 1947;126:1010–1045.

56. Demling RH, Mazess RB, Witt RM, Wolberg WH. The study of burn wound edema using dichromatic absorptiometry.

J Trauma. 1978;18:124–128.

57. Warden G. Fluid resuscitation and early management. In: Herndon DN, ed. Total Burn Care. Philadelphia, Pa: WB 

Saunders; 1996: 55.

58. Sheridan RL. Comprehensive treatment of burns. Curr Probl Surg. 2001;38(9):657–756.

59. Shwartz S. Consensus summary on fluid resuscitation. J Trauma. 1979;19:876–877.

60. Pruitt BA Jr. Fluid and electrolyte replacement in the burned patient. Surg Clin North Am. 1978;58:1291–1312.

61. Chung KK, Blackbourne LH, Wolf SE, et al. Evolution of burn resuscitation in Operation Iraqi Freedom. J Burn Care 

Res. 2006;27(5):606–611.

62. Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care. 2005;11:333–338.

63. Hobson KG, Young KM, Ciraulo A, Palmieri TL, Greenhalgh DG. Release of abdominal compartment syndrome 

improves survival in patients with burn injury. J Trauma. 2002;53:1129–1133.

64. Sheridan RL, Tompkins RG, McManus WF, Pruitt BA Jr. Intracompartmental sepsis in burn patients. J Trauma. 

1994;36:301–305.

65. Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med. 1999;340:627–634.

66. Bayley E. Care of the burn patient with inhalation injury. In: Trofino RB, ed. Nursing Care of the Burn-Injured Patient. 

Philadelphia, Pa: FA Davis; 1991: 325–348.

67. Ryan CM, Yarmush ML, Burke JF, Tompkins RG. Increased gut permeability early after burns correlates with the extent 

of burn injury. Crit Care Med. 1992;20:1508–1512.

68. Herndon DN, Barrow RE, Stein M, et al. Increased mortality with intravenous supplemental feeding in severely burned 

patients. J Burn Care Rehabil. 1989;10:309–313.

69. Wilmore DW, Long JM, Mason AD Jr, Skreen RW, Pruitt BA Jr. Catecholamines: mediator of the hypermetabolic response to thermal injury. Ann Surg. 1974;180:653–669.
365

Rehabilitation of Burn Casualties

70. Herndon DN, Hart DW, Wolf SE, Chinkes DL, Wolfe RR. Reversal of catabolism by beta-blockade after severe burns. 

N Engl J Med. 2001;345:1223–1229.

71. Wolf SE, Edelman LS, Kemalyan N, et al. Effects of oxandrolone on outcome measures in the severely burned: a multicenter prospective randomized double-blind trial. J Burn Care Res. 2006;27:131–139.

72. Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med. 1996;334:1448–1460.

73. John S, Eckardt KU. Renal replacement strategies in the ICU. Chest. 2007;132:1379–1388.

74. Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. 

Lancet. 2006;368:379–385.

75. Suzuki K, Nishina M, Ogino R, Kohama A. Left ventricular contractility and diastolic properties in anesthetized dogs 

after severe burns. Am J Physiol. 1991;260:H1433–H1442.

76. Cioffi WG, DeMeules JE, Gamelli RL. The effects of burn injury and fluid resuscitation on cardiac function in vitro. J 

Trauma. 1986;26:638–642.

77. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. 

N Engl J Med. 1999;340:409–417.

78. Harrington DT, Mozingo DW, Cancio L, Bird P, Jordan B, Goodwin CW. Thermally injured patients are at significant 

risk for thromboembolic complications. J Trauma. 2001;50(3):495–499.

79. Lee JO, Benjamin D, Herndon DN. Nutrition support strategies for severely burned patients. Nutr Clin Pract. 

2005;20(3):325–330.

80. Mahan LK, Krause MV, Escott-Stump S. Krause’s Food, Nutrition & Diet Therapy. 9th ed. Philadelphia, Pa: WB Saunders 

Company; 1996.

81. Long CL, Schaffel N, Geiger JW, Schiller WR, Blakemore WS. Metabolic response to injury and illness: estimation of 

energy and protein needs from indirect calorimetry and nitrogen balance. JPEN J Parenter Enteral Nutr. 1979;3(6):452–

456.

82. Pereira CP, Muphy KD, Herdon DN. Altering metabolism. J Burn Care Rehabil. 2005;26(3):194–199.

83. McDonald WS, Sharp CW Jr, Deitch EA. Immediate enteral feeding in burn patients is safe and effective. Ann Surg. 

1991;213(2):177–183.

84. Gottschlich MM, Jenkins ME, Mayes T, Khoury J, Kagan RJ, Warden GD. The 2002 Clinical Research Award. An evaluation of the safety of early vs delayed enteral support and effects on clinical, nutritional, and endocrine outcomes after 

severe burns. J Burn Care Rehabil. 2002;23(6):401–415.

85. Hansbrough WB, Hansbrough JF. Success of immediate intragastric feeding of patients with burns. J Burn Care Rehabil. 

1993;14:512–516.

86. Cunningham JJ, Hegarty MT, Meara PA, Burke JF. Measured and predicted calorie requirements of adults during 

recovery from severe burn trauma. Am J Clin Nutr. 1989;49(3):404–408.

87. Kelemen JJ 3rd, Cioffi WG Jr, Mason AD Jr, Mozingo DW, McManus WF, Pruitt BA Jr. Effect of ambient temperature 

on metabolic rate after thermal injury. Ann Surg. 1996;223(4):406–412.

88. Barton RG, Craft WB, Mone MC, Saffle JR. Chemical paralysis reduces energy expenditure in patients with burns and 

severe respiratory failure treated with mechanical ventilation. J Burn Care Rehabil. 1997;18(5):461–468.
366

Care of the Combat Amputee

89. Hart DW, Wolf SE, Herndon DN, et al. Energy expenditure and caloric balance after burn: increased feeding leads to 

fat rather than lean mass accretion. Ann Surg. 2002;235(1):152–161.

90. Curreri PW, Richmond D, Marvin J, Baxter CR. Dietary requirements of patients with major burns. J Am Diet Assoc. 

1974;65(4):415–417.

91. Saffle JR, Medina E, Raymond J, Westenskow D, Kravitz M, Warden GD. Use of indirect calorimetry in the nutritional 

management of burn patients. J Trauma. 1985;25(1):32–39.

92. Turner WW Jr, Ireton CS, Hunt JL, Baxter CR. Predicting energy expenditures in burned patients. J Trauma. 1985;25(1):11–16.

93. Carlson DE, Cioffi WG Jr, Mason AD Jr, McManus WF, Pruitt BA Jr. Resting energy expenditure in patients with thermal 

injuries. Surg Gynecol Obstet. 1991;174(4):270–276.

94. Milner EA, Cioffi WG, Mason AD, McManus WF, Pruitt BA Jr. A longitudinal study of resting energy expenditure in 

thermally injured patients. J Trauma. 1994;37(2):167–70.

95. Wall-Alonso E, Schoeller DA, Schechter L, and Gottlieb LJ. Measured total energy requirements of adult patients with 

burns. J Burn Care Rehabil. 1999;20(4):329–337.

96. Gottschlich MM. Nutrition support in burns. In: Shronts EP, ed. Nutrition Support Dietetics: Core Curriculum. Silver 

Spring, Md: American Society of Parenteral and Enteral Nutrition; 1989: 213–219.

97. Matsuda T, Kagan RJ, Hanumadass M, Jonasson O. The importance of burn wound size in determining the optimal 

calorie:nitrogen ratio. Surgery. 1983;94(4):562–568.

98. Alexander JW, MacMillan BG, Stinnett JD, et al. Beneficial effects of aggressive protein feeding in severely burned 

children. Ann Surg. 1980;192(4):505–517.

99. Waxman K, Rebello T, Pinderski L, et al. Protein loss across burn wounds. J Trauma. 1987;27(2):136–40.

100. Saito H, Trocki O, Wang S, Gonce SJ, Joffe SN, Alexander JW. Metabolic and immune effects of dietary arginine supplementation after burn. Arch Surg. 1987;122(7):784–789.

101. Daly JM, Reynolds J, Thom A, et al. Immune and metabolic effects of arginine in the surgical patient. Ann Surg. 

1988;208(4):512–523.

102. Gottschlich MM, Jenkins M, Warden GD, et al. Differential effects of three enteral dietary regimens on selected outcome 

variables in burn patients. JPEN J Parenteral Enteral Nutr. 1990;14(3):225–236.

103. Hammarqvist F, Wernerman J, Ali R, von der Decken A, Vinnars E. Addition of glutamine to total parenteral nutrition 

after elective abdominal surgery spares free glutamine in muscle, counteracts the fall in muscle protein synthesis, and 

improves nitrogen balance. Ann Surg. 1989;209(4):455–461.

104. Yu YM, Wagner DA, Walesreswski JC, Burke JF, Young VR. A kinetic study of leucine metabolism in severely burned 

patients. Comparison between a conventional and branched-chain amino acid-enriched nutritional therapy. Ann Surg. 

1988;207(4):421–429.

105. Cerra FB, Mazuski JE, Chute E, et al. Branched chain metabolic support: a prospective, randomized, double-blind trial 

in surgical stress. Ann Surg. 1984;199(3):286–291.

106. Cerra F, Blackburn G, Hirsch J, Mullen K, Luther W. The effect of stress level, amino acid formula, and nitrogen dose 

on nitrogen retention in traumatic and septic stress. Ann Surg. 1987;205(3):282–287.

107. Mochizuki H, Trocki O, Dominioni L, Alexander JW. Effect of a diet rich in branched chain amino acids on severely 

burned guinea pigs. J Trauma. 1986;26(12):1077–1085.
367

Rehabilitation of Burn Casualties

108. Yu YM, Wagner DA, Walesreswski J, Burke JF, Young VR. A kinetic study of leucine metabolism in severely burned 

patients. Comparison between a conventional and branched-chain amino acid-enriched nutritional therapy. Ann Surg. 

1988;207(4):421–490.

109. Hart DW, Wolf SE, Zhang XJ, et al. Efficacy of a high-carbohydrate diet in catabolic illness. Crit Care Med. 2001;29(7):1318–1324.

110. Gottschlich MM, Warden GD, Michel M, et al. Diarrhea in tube-fed burn patients: incidence, etiology, nutritional 

impact, and prevention. JPEN J Parenteral Enteral Nutr. 1988;12(4):338–345.

111. Gottschlich MM, Alexander JW. Fat kinetics and recommended dietary intake in burns. JPEN J Parenteral Enteral Nutr. 

1987;11(1):80–85.

112. Williamson J. Actual burn nutrition care practices. A national survey (Part II). J Burn Care Rehabil. 1989;10(2):185–194.

113. Gottschlich MM, Warden GD. Vitamin supplementation in the patient with burns. J Burn Care Rehabil. 1990;11(3):275–279.

114. Boosalis MG, Solem LD, McCall JT, Ahrenholz DH, McClain CJ. Serum zinc response in thermal injury. J Am Coll Nutr. 

1988;7(1):69–76.

115. Berger MM, Cavadini C, Chiolero R, Guinchard S, Krupp S, Dirren H. Influence of large intakes of trace elements on 

recovery after major burns. Nutrition. 1994;10(4):327–334.

116. American Society for Parenteral and Enteral Nutrition. The A.S.P.E.N. Nutrition Support Core Curriculum: a Case-Based 

Approach—the Adult Patient. Silver Spring, Md: ASPEN; 2007: 145.

117. Voruganti VS, Klein GL, Lu HX, Thomas S, Freeland-Graves JH, Herndon DN. Impaired zinc and copper status in 

children with burn injuries: need to reassess nutritional requirements. Burns. 2005;31(6):711–716.

118. McCord JM. Free radicals and inflammation: protection of synovial fluid by superoxide dismutase. Science. 

1974;185(150):529–531.

	119. 	 Selmanpakoğlu AN, Cetin C, Sayal A, Işimer A. Trace element (Al, Se, Zn, Cu) levels in serum, urine and tissues of

burn patients. Burns. 1994;20:99–103.

120. Gropper SAS, Groff JL, Smith JL. Advanced Nutrition and Human Metabolism. Belmont, Calif: Thomson Wadsworth; 2005.

121. Berger MM, Cavadini C, Bart A, et al. Cutaneous copper and zinc losses in burns. Burns. 1992;18(5):373–380.

122. Allen JI, Kay NE, McClain CJ. Severe zinc deficiency in humans: association with reversible T-lymphocyte dysfunction. Ann Intern Med. 1981;95(2):154–157.

123. Levander OA. Considerations in the design of selenium bioavailability studies. Fed Proc. 1983;42(6):1721–1725.

124. Dimitrov NV, Ullrey DE, Primack S, Meyer C, Ku PK, Miller ER. Selenium as a metabolic modulator of phagocytosis. 

In: Combs GR Jr, Spallholz JE, Levander OA, Oldfield JE, eds. Selenium in Biology and Medicine: Proceedings of the Third 

International Symposium on Selenium in Biology and Medicine, Held May 27–June 1, 1984, Xiangshan (Fragrance Hills) Hotel, 

Beijing, People’s Republic of China. New York, NY: Van Nostrand Reinhold; 1987: 254–262.

125. Johnson RA, Baker SS, Fallon JT, et al. An occidental case of cardiomyopathy and selenium deficiency. N Engl J Med. 

1981;304(20):1210–1212.

126. Fleming CR, Lie JT, McCall JT, O’Brien JF, Baillie EE, Thistle JL. Selenium deficiency and fatal cardiomyopathy in a 

patient on home parenteral nutrition. Gastroenterology. 1982;83(3):689–693.

127. Duhr A, Galan P, Hercberg S. Relationship between selenium, immunity and resistance against infection. Comp Biochem 

Physiol C. 1990;96(2):271–280.
368

Care of the Combat Amputee

128. Porter EK, Karle JA, Shrift A. Uptake of selenium-75 by human lymphocytes in vitro. J Nutr. 1979;109(11):1901–1908.

129. Karle JA, Kull FJ, Shrift A. Uptake of selenium-75 by PHA-stimulated lymphocytes: effect on glutathione peroxidase. 

Biol Trace Elem Res. 1983;5:17–24.

130. Gamliel Z, DeBiasse MA, Demling RH. Essential microminerals and their response to burn injury. J Burn Care Rehabil. 

1996;17(3):264–272.

131. Chiarelli A, Enzi G, Casadei A, et al. Very early nutrition supplementation in burned patients. Am J Clin Nutr. 

1990;51(6):1035–1039.

132. Walsh EN, Dumitru D, King J C, Ramamurthy S. Management of acute and chronic pain. In: Kottke FJ, Amate EA, 

eds. Clinical Advances in Physical Medicine and Rehabilitation. Washington, DC: Pan American Health Organization, Pan 

American Sanitary Bureau, Regional Office of the World Health Organization; 1991: 373–401.

133. DeJong RH. Defining pain terms. JAMA. 1980;244(2):143–147.

134. Choinière M, Melzack R, Rondeau J, Girard N, Paquin MJ. The pain of burns: characteristics and correlates. J Trauma. 

1989;29(11):1531–1539.

135. Andreasen NJ, Noyes R Jr, Hartford CE, Brodland G, Proctor S. Management of emotional reactions in seriously burned 

adults. N Engl J Med. 1972;286(2):65–69.

136. Taal LA, Faber AW. Burn injuries, pain and distress: exploring the role of stress symptomatology. Burns. 1997;23(4):288–290.

137. Choinière M. The pain of burns In: Wall PD, Melzack R, Bonica JJ, eds. Textbook of Pain. 3rd ed. Edinburgh, Scotland: 

Churchill Livingstone; 1994.

138. Meyer WJ, Marvin JA, Patterson DR, et al. Management of pain and other discomforts in burned patients In: Herndon 

DN, ed. Total Burn Care. Philadelphia, Pa: WB Saunders; 1996.

139. Ulmer JF. Burn pain management: a guideline-based approach. J Burn Care Rehabil. 1998;19(2):151–159.

140. Williams PI, Sarginson RE, Ratcliffe JM. Use of methadone in the morphine-tolerant burned paediatric patient. Br J 

Anaesth. 1998;80(1):92–95.

141. Loeser JD, Bonica JJ, Bulter SH, Chapman CR, Turk DC, eds. Bonica’s Management of Pain. Philadelphia, Pa: Lippincott 

Williams & Wilkins; 2001.

142. Pal SK, Cortiella J, Herndon D. Adjunctive methods of pain control in burns. Burns. 1997;23(5):404–412.

143. Slogoff S, Allen GW, Wessels JV, Cheney DH. Clinical experience with subanesthetic ketamine. Anesth Analg.

1974;53(3):354–358.

144. Dickenson AH, Sullivan AF. Evidence for a role of the NMDA receptor in the frequency dependant potentiation of 

deep rat dorsal horn nociceptive neurones following C fibre stimulation. Neuropharmacology. 1987;26:1235–1238.

145. Cuignet O, Pirson J, Soudon O, Zizi M. Effects of gabapentin on morphine consumption and pain in severely burned 

patients. Burns. 2007;33(1):81–86.

146. Wasiak J, Cleland H. Lidocaine for pain relief in burn injured patients. Cochrane Database Syst Rev. 2007;3:CD005622. 

147. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual reality for adjunctive treatment of adult burn pain during 

physical therapy: a controlled study. Clin J Pain. 2000;16(3):244–250.

148. Rainville P, Hofbauer RK, Paus T, Duncan GH, Bushnell MC, Price DD. Cerebral mechanisms of hypnotic induction 

and suggestion. J Cogn Neurosci. 1999;11(1):110–125.
369

Rehabilitation of Burn Casualties

149. de Jong AE, Gamel C. Use of a simple relaxation technique in burn care: literature review. J Adv Nurs. 2006;54(6):710–721.

150. Choinière M. Burn pain: a unique challenge. Pain Clin Updates. 2001;9:1–4.

151. Foertsch CE, O’Hara MW, Stoddard FJ, Kealey GP. Treatment-resistant pain and distress during pediatric burn-dressing 

changes. J Burn Care Rehabil. 1998;19(3):219–224.

152. Schreiber S, Galai-Gat T. Uncontrolled pain following physical injury as the core-trauma in post-traumatic stress 

disorder. Pain. 1993;54(1):107–110.

153. Singer AJ, Brebbia J, Soroff HH. Management of local burn wounds in the ED. Am J Emerg Med. 2007;25(6):666–671.

154. MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology. 1998;89(3):749–770

155. Summer GJ, Puntillo KA, Miaskowski C, Green PG, Levine JD. Burn injury pain: the continuing challenge. J Pain. 

2007;8(7):533–548.

156. Latarjet J, Choinière M. Pain in burn patients. Burns. 1995;21(5):344–348.

157. Barash P, Liu S, Joseph R, et al. Peripheral nerve blocks. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical Anesthesia. 

5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2006: 453–471.

158. Viscusi E, Jan R, Schechter L, et al. Organization of an Acute Pain Management Service Incorporating Regional Anesthesia 

Techniques. Available at: http://nysora.com/regional_anesthesia/index.1.html. Accessed 2007.

159. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary 

aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologists Task Force on Preoperative Fasting. Anesthesiology. 1999;90(3):896–905.

160. Horlocker T, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risk (the second 

ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med. 2003;28(3):172–197.

161. Choinière M. Prescribing practices for analgesia in adults and children with minor burns. Paper presented at: 10th 

Congress of the International Society for Burn Injuries; November 1998; Jerusalem, Israel.

162. Edgar D, Brereton M. Rehabilitation after burn injury. BMJ. 2004;329(7461):343–345.

163. Ferguson SL, Voll KV. Burn pain and anxiety: the use of music relaxation during rehabilitation. J Burn Care Rehabil. 

2004;25(1):8–14.

164. Baxter CR. Fluid volume and electrolyte changes in the early postburn period. Clin Plast Surg. 1974;1(4):693–703. 

165. Kramer G, Lund T, Herndon D. Pathophysiology of burn shock and burn edema. In: Herndon DN, ed. Total Burn Care. 

2nd ed. New York, NY: WB Saunders; 2002.

166. Fess EE. The need for reliability and validity in hand assessment instruments. J Hand Surg [Am]. 1986;11(5):621–623.

167. Dewey WS, Hedman TL, Chapman TT, Wolf SE, Holcomb JB. The reliability and concurrent validity of the figure-ofeight method of measuring hand edema in patients with burns. J Burn Care Res. 2007;28(1):157–162.

168. Villeco J, Mackin E, Hunter J. Edema: therapist’s management. In: Hunter JM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand. 5th ed. Saint Louis, MO: Mosby; 2002: 186–188.

169. Schultz-Johnson K. Volumetrics: a Literature Review. Glenwood Springs, CO: Upper Extremity Technology; 1988: 16–23.

170. Waylett-Rendall J, Seibly D. A study of accuracy of a commercially available volumeter. J Hand Ther. 1991;4:10–13.
370

Care of the Combat Amputee

171. DeVore GL, Hamilton GF. Volume measuring of the severely injured hand. Am J Occup Ther. 1968;22(1):16–18.

172. King TI. The effect of water temperature on hand volume during volumetric measurement using the water displacement method. J Hand Ther. 1993;6(3):202–204.

173. Leard J, Breglio L, Fraga L, et al. Reliability and concurrent validity of the figure-of-eight method of measuring hand 

size with hand pathology. J Orthop Sports Phys Ther. 2004;24(6):335–340.

174. Pellecchia GL. Figure-of-eight method of measuring hand size: reliability and concurrent validity. J Hand Ther. 

2003;16(4):300–304.

175. Maihafer GC, Llewellyn MA, Pillar WJ Jr, Scott KL, Marino DM, Bond RM. A comparison of the figure-of-eight method 

and water volumetry in the measurement of hand and wrist size. J Hand Ther. 2003;16(4):305–310.

176. Richard RL, Miller SF, Finley RK Jr, Jones LM. Comparison of the effect of passive exercise v static wrapping on finger 

range of motion in the burned hand. J Burn Care Rehabil. 1987;8(6):576–578.

177. Humphrey C, Richard RL, Staley MJ. Soft tissue management and exercise. In: Richard R, Staley MJ, eds. Burn Care 

and Rehabilitation: Principles and Practice. Philadelphia, Pa: FA Davis; 1994: 334.

178. Feller I, Jones CA. Nursing the Burned Patient. Ann Arbor, Mich: Institute for Burn Medicine; 1973: 73, 151.

179. Adkins P. Postoperative care. In: Kasdan ML, ed. Occupational Hand and Upper Extremity Injuries and Diseases. 2nd ed. 

Philadelphia, PA: Hanley & Belfus, Inc; 1998: 441.

180. Gordon M, Goodwin CW. Burn management: initial assessment, management, and stabilization. Nurs Clin North Am. 

1997;32(2):237–249.

181. Beasly RW. Secondary repair of burned hands. Clin Plast Surg. 1981;8(1):141–162.

182. Chapman TT. Burn scar and contracture management. J Trauma. 2007;62(suppl 6):S8.

183. Brush KA. Abdominal compartment syndrome: the pressure is on. Nursing. 2007;37(7):36-41.

184. Gordon MD, Gottschlich MM, Hevlig EI, Marvin JA, Richard RL. Review of evidence-based practice for the prevention 

of pressure sores in burn patients. J Burn Care Rehabil. 2004;25(5):388–410.

185. Tymec AC, Pieper B, Vollman K. A comparison of two pressure-relieving devices on the prevention of heel pressure 

ulcers. Adv Wound Care. 1997;10(1):39–44.

186. Banwell PE. Topical negative pressure therapy in wound care. J Wound Care. 1999;8(2):79–84.

187. Atiyeh BS, Gunn SW, Hayek SN. State of the art in burn treatment. World J Surg. 2005;29(2):131–48.

188. Wolf S, Herndon DN, eds. Burn Care. Austin, Tes: Landes Bioscience; 1999: 9.

189. Blackbourne LH. Surgical Recall. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005: 562.

190. Bull JP, Fisher AJ. A study of mortality in a burns unit: a revised estimate. Ann Surg. 1954;139(3):269–274.

191. Muller MJ, Herndon DN. The challenge of burns. Lancet. 1994;343:216–220

192. Burke JF, Bondoc CC, Quinby WC. Primary burn excision and immediate grafting: a method shortening illness. J 

Trauma. 1974;14(5):389–395.

193. Pietsch JB, Netscher DT, Nagaraj HS, Groff DB. Early excision of major burns in children: effect on morbidity and 

mortality. J Pediatr Surg. 1985;20(6):754–757.
371

Rehabilitation of Burn Casualties

194. Munster AM, Smith-Meek M, Sharkey P. The effect of early surgical intervention on mortality and cost-effectiveness 

in burn care, 1978–1991. Burns. 1994;20(1):61–64.

195. Jurkiewicz MJ, Krizek TJ, Mathes SJ, Ariyan S. Wound closure. In: Jurkiewicz MJ, ed. Plastic Surgery: Principles and 

Practice. Vol 1. Saint Louis, Mo: Mosby; 1990: 22.

196. Venturi ML, Attinger CE, Mesbahi AN, Hess CL, Graw KS. Mechanisms and clinical applications of the vacuumassisted closure (VAC) device: a review. Am J Clin Dermatol. 2005;6(3):185–194.

197. Hartford CE. Surgical management. In: Fisher SV, Helm PA, eds. Comprehensive Rehabilitation of Burns. Baltimore, Md: 

Williams & Wilkins; 1984.

198. McCarthy JG. Facial burns. In: McCarthy JG, May JW, Littler JW, eds. Plastic Surgery. Vol 3. Philadelphia, Pa: Saunders; 

1990: 2200.

199. Rheinwald JG, Green H. Serial cultivation of strains of human epidermal keratinocytes: the formation of keratinizing 

colonies from single cells. Cell. 1975;6(3):331–344.

200. Pittelkow MR, Scott RE. New techniques for the in vitro culture of human skin keratinocytes and perspectives on their 

use for grafting of patients with extensive burns. Mayo Clin Proc. 1986;61(10):771–777.

201. Heimbach D, Luterman A, Burke J, et al. Artificial dermis for major burns: a multi-center randomized clinical trial. 

Ann Surg. 1988;208(3):313–320.

202. Clarke JA. HIV transmission and skin grafts. Lancet. 1987;1:983.

203. Lawrence JC. Allografts as vectors of infection. Lancet. 1987;1:1318.

204. Haberal M, Oner Z, Bayraktar U, Bilgin N. The use of silver nitrate-incorporated amniotic membrane as a temporary 

dressing. Burns Incl Therm Inj. 1987;13(2):159–163.

205. Sawhney CP. Amniotic membrane as a biological dressing in the management of burns. Burns. 1989;15(5):339–342.

206. Hunt JL, Purdue GF, Zbar RIS. Burns: acute burns, burn surgery, and postburn reconstruction. Selected Readings in 

Plast Surg. 2000;9(12):7.

207. McHugh TP, Robson MC, Heggers JP, Phillips LG, Smith DJ Jr, McCollum MC. Therapeutic efficacy of Biobrane in 

partial- and full-thickness thermal injury. Surgery. 1986;100(4):661–664.

208. Grabb WC, Smith JW, Aston SJ, Beasley RW, Thorne C. Grabb and Smith’s Plastic Surgery. 5th ed. Philadelphia, PA: 

Lippincott-Raven Publishers; 1997: 19.

209. Wood RJ, Peltier GL, Twomey JA. Management of the difficult split-thickness donor site. Ann Plast Surg. 1989;22(1):80–81.

210. Sood R, Achauer BM. Achauer and Sood’s Burn Surgery: Reconstruction and Rehabilitation. Philadelphia, Pa: Saunders 

Elsevier; 2006.

211. Barillo D, Paulsen S. Management of burns to the hand. Wounds. 2003;15(1):4–9.

212. Giuliani CA, Perry GA. Factors to consider in the rehabilitation aspect of burn care. Phys Ther. 1985;65(5):619–623.

213. Firoz EF, Firoz BF, Williams J, Henning JS. Allergic contact dermatitis to mafenide acetate: a case series and review of 

the literature. J Drugs Dematol. Aug 2007;6(8):825–828.

214. Whitmore JJ, Burt MM, Fowler RS, Halar E, Bernie R. Bandaging the lower extremity to control swelling: figure-8 

versus spiral technique. Arch Phys Med Rehabil. 1972;53(10):487–490.
372

Care of the Combat Amputee

215. Vitale M, Fields-Blache C, Luterman A. Severe itching in the patient with burns. J Burn Care Rehabil. 1991;12(4):330–333.

216. Field T, Peck M, et al. Postburn itching, pain, and psychological symptoms are reduced with massage therapy. J Burn 

Care Rehabil. 2000;21(3):189–193.

217. Van Zuijlen PP, Kreis RW, Vloemans AF, Groenevelt F, Mackie DP. The prognostic factors regarding long-term functional outcome of full-thickness hand burns. Burns. 1999;25(8):709–714.

218. Gibson T, Kenedi RM. Biomechanical properties of skin. Surg Clin North Am. 1967;47(2):279–294.

219. Lanir Y. The fibrous structure of the skin and its relation to mechanical behavior. In: Marks R, Payne PA, eds. Bioengineering and the Skin: Based on the Proceedings of the European Society for Dermatological Research Symposium, Held at the 

Welsh National School of Medicine, Cardiff, 19–21 July 1979. Boston, Mass: MTP Press; 1981: 93–96.

220. Oxlund H, Manschot J, Viidik A. The role of elastin in the mechanical properties of skin. J Biomech. 1988;21(3):213–218.

221. Gibson T, Kenedi RM. The structural components of the dermis and their mechanical characteristics. In: Bently JP, 

Dobson RL, Montagna W, eds. The Dermis; Proceedings of a Symposium on the Biology of Skin held at Salishan Lodge, Gleneden 

Beach, Oregon, 1968. New York, NY: Appleton-Century-Crofts; 1970.

222. Bartell TH, Monafo WW, Mustoe TA. A new instrument for serial measurements of elasticity in hypertrophic scar. J 

Burn Care Rehabil. 1988;9(6):657–660.

223. Clark JA, Cheng JCY, Leung KS, Leung PC. Mechanical characteristics of human postburn hypertrophic skin during 

pressure therapy. J Biomech. 1987;20:397–406.

224. Richard RL, Staley MJ. Biophysical aspects of normal skin and burn scar. In: Richard R, Staley MJ, eds. Burn Care and 

Rehabilitation: Principles and Practice. Philadelphia, Pa: FA Davis; 1994:49–69.

225. Koepke GH. The role of physical medicine in the treatment of burns. Surg Clin North Am. 1970;50(6):1385–1399.

226. Arem AJ, Madden JW. Effects of stress on healing wounds: I. Intermittent noncyclical tension. J Surg Res. 1976;20(2):93–102.

227. Viidik A. On the rheology and morphology of soft collagenous tissue. J Anat. 1969;105:184.

228. Escoffier C, de Rigal J, Rochefort A, Vasselet R, Lévêque JL, Agache PG. Age-related mechanical properties of human 

skin: an in vivo study. J Invest Dermatol. 1989;93(3):353–357.

229. Wilhelmi BJ, Blackwell SJ, Mancoll JS, Phillips LG. Creep vs. stretch: a review of the viscoelastic properties of skin. 

Ann Plast Surg. 1998;41(2):215–219.

230. Minns RJ, Soden PD, Jackson DS. The role of the fibrous components and ground substance in the mechanical properties of biological tissue: a preliminary investigation. J Biomech. 1973;6(2):153–165.

231. Richard R, Miller S, Staley M, Johnson RM. Multimodal versus progressive treatment techniques to correct burn scar 

contractures. J Burn Care Rehabil. 2000;21(6):506–512.

232. Andersen KN, ed. Mosby’s Medical, Nursing, and Allied Health Dictionary. 4th ed. Saint Louis, Mo: Mosby; 1994: 1469.

233. Coppard BM, Lohman H, eds. Introduction to Splinting. Saint Louis, Mo: Mosby; 2001.

234. Richard R, Chapman T, Dougherty M, Franzen B, Serghiou M. An Atlas and Compendium of Burn Splints. San Antonio, 

Tex: Reg Richard, Inc; 2006.

235. Boscheinen-Morrin J, Conolly WB, eds. The Hand: Fundamentals of Therapy. Boston, MA: Butterworth-Heinemann; 2001.

236. Madden JW, Enna CD. The management of acute thermal injuries to the upper extremity. J Hand Surg [Am]. 1983;8:785–788.
373

Rehabilitation of Burn Casualties

237. Peacock EE Jr. Wound repair. 3rd ed. Philadelphia, Pa: WB Saunders; 1984.

238. Hartford CE, Kealey GP, Lavelle WE, Buckner H. An appliance to prevent and treat microstomia from burns. J Trauma. 

1975;15(4):356–360.

239. Yeakel M. Occupational therapy. In: Artz CP, Moncrief JA, Pruitt Jr BA, eds. Burns: a Team Approach. Philadelphia, Pa: 

Saunders; 1979: 507.

240. Willis B. A follow-up. The use of orthoplast isoprene splints in the treatment of the acutely burned child. Am J Occup 

Ther. 1970;24;187–191.

241. Malick MH, Carr JA. Halo neck splint. In: Malick MH, Carr JA, eds. Manual on Management of the Burn Patient: Including Splinting, Mold and Pressure Techniques. Pittsburgh, Pa: Harmarville Rehabilitation Center; 1982: 55–56.

242. Perkins K, Davey RB, Wallis KA. Silicone gel: a new treatment for burn scars and contractures. Burns Incl Them Inj. 

1983;9(3):201–204.

243. Braddon RL, Boe L, Flowers L, Johnson-Vann T. The physical treatment and rehabilitation of burn patients. In: Hummel RP, ed. Clinical Burn Therapy: a Management and Prevention Guide. Boston, Mass: Wright/PSG; 1982: 287.

244. Lavore JS, Marshall JH. Expedient splinting of the burned patient. Phys Ther. 1972;52(10):1036–1042.

245. Palm L, Reming RL, Moylan JA. A method for splinting the upper extremity of thermally injured patients. Proc Am 

Burn Assoc. 1972;4:91.

246. Daugherty M, Carr-Collins J. Splinting techniques for the burn patient. In: Richard RL, Staley MJ, eds. Burn Care and 

Rehabilitation: Principles and Practice. Philadelphia, Pa: FA Davis; 1994: 287–291.

247. Hogan L, Uditsky T. Pediatric Splinting: Selection, Fabrication, and Clinical Application of Upper Extremity Splints. San 

Antonio, TX: Therapy Skill Builders; 1998: 18.

248. Brand P. The forces of dynamic splinting: ten questions before applying a dynamic splint to the hand. In: Mackin E, 

Callahan A, Skirven T, Schneider L, Osterman A, eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. Saint Louis, 

MO: Mosby; 2002.

249. Fess EE, Philips CA. Hand Splinting: Principles and Methods. 2nd ed. Saint Louis, Mo: Mosby; 1987.

250. Shah M, Lopez JK, Escalante AS, Green DP. Dynamic splinting of forearm rotational contracture after distal radius 

fracture. J Hand Surg [Am]. 2002;27(3):456–463.

251. Quick CD. Dorsal Wrist Extension Fulcrum Splint. Available at: http://www.burntherapist.com/images/SplintQuarter1-07/1stQuarter07Submission.pdf. Accessed January 14, 2009.

252. Colditz JC. Splinting peripheral nerve injuries. In: Hunter JM, Schneider LH, Mackin EJ, Callaghan AD, eds. Rehabilitation of the Hand: Surgery and Therapy. 3rd ed. Saint Louis, Mo: Mosby; 1990: 647–657.

253. Colditz JC. Splinting for radial nerve palsy. J Hand Ther. 1987;1:18–23.

254. Schultz-Johnson KS. Splinting: a problem-solving approach. In: Stanley BG, Tribuzi SM, eds. Concepts in Hand Rehabilitation. Philadelphia, Pa: FA Davis; 1992: 238–271. 

255. Schultz-Johnson K. Static progressive splinting. J Hand Ther. 2002;15(2):163–178.

256. Flowers KR. A proposed decision hierarchy for splinting the stiff joint, with an emphasis on force application parameters. J Hand Ther. 2002;15(2):158–162.

257. Griffin A. Therapist’s management of the stiff elbow. In: Mackin E, Callahan A, Skirven T, Schneider L, Osterman A, 

eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. Saint Louis, Mo: Mosby; 2002.
374

Care of the Combat Amputee

258. Bennett GB, Helm P, Purdue GF, Hunt JL. Serial casting: a method for treating burn contractures. J Burn Care Rehabil. 

1989;10(6):543–545.

259. Johnson J, Silverberg R. Serial casting of the lower extremity to correct contractures during the acute phase of burn 

care. Phys Ther. 1995;75(4):262–266.

260. Colditz JC. Plaster of Paris: the forgotten hand splinting material. J Hand Ther. 2002;15(2):144–157.

261. Ridgway CL, Daugherty MB, Warden GD. Serial casting as a technique to correct burn scar contractures. A case report. 

J Burn Care Rehabil. 1991;12(1):67–72.

262. Staley M, Serghiou M. Casting guidelines, tips, and techniques: proceedings from the 1997 American Burn Association 

PT/OT Casting Workshop. J Burn Care Rehabil. 1998;19(3):254–260.

263. Heimbach DM, Engrav LH. Surgical Management of the Burn Wound. New York, NY: Raven Press; 1984: 83–98.

264. Johnson CL, O’Shaughnessy EJ, Ostergren G. Burn Management. New York, NY: Raven Press; 1981: 79.

265. Nothdurft D, Smith PS, LeMaster J. Exercise and treatment modalities. In: Fisher SV, Helm PA, eds. Comprehensive 

Rehabilitation of Burns. Baltimore, Md: Williams & Wilkins; 1984: 6–147.

266. Covey MH. Application of CPM devices with burn patients. J Burn Care Rehabil. 1988;9(5):496–497.

267. Salter RB. The biologic concept of continuous passive motion of synovial joints. The first 18 years of basic research 

and its clinical application. Clin Orthop Relat Res. 1989;242:12–25.

268. Peters WJ. Heterotopic ossification: can early surgery be performed, with a positive bone scan? J Burn Care Rehabil. 

1990;11(4):318–321.

269. Edlich RF, Horowitz JH, Rheuban KS, Nichter LS, Morgan RF. Heterotopic calcification and ossification in the burn 

patient. J Burn Care Rehabil. 1985;6(4):363–368.

270. Roberts ML, Pruitt BA. Nursing care and psychological considerations. In: Artz CP, Moncrief JA, Pruitt Jr BA, eds. 

Burns: a Team Approach. Philadelphia, Pa: Saunders; 1979: 370–389.

271. Harnar T, Engrav LH, Marvin J, Heimbach D, Cain V, Johnson C. Dr. Paul Unna’s boot and early ambulation after skin 

grafting the leg: a survey of burn centers and a report of 20 cases. Plast Reconstr Surg. 1982;69(2):359–360.

272. Duncan CE. Use of a ramp surface for lower extremity exercise with burn-injured patients. J Burn Care Rehabil. 

1989;10(4):346–349.

273. Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 3rd ed. Philadelphia, Pa: FA Davis; 1996.

274. Richard RL, Staley MJ. Burn patient evaluation and treatment planning. In: Richard RL, Staley MJ, eds. Burn Care and 

Rehabilitation: Principles and Practice. Philadelphia, Pa: FA Davis; 1994.

275. Light KE, Nuzik S, Personius W, Barstrom A. Low-load prolonged stretch vs. high-load brief stretch in treating knee 

contractures. Phys Ther. 1984;64(3):330–333.

276. Helm P, Herndon DN, DeLateur B. Restoration of function. J Burn Care Res. 2007;28(4):611–614.

277. Trees D, Ketelsen C, Hobbs JA. Use of modified tilt table for preambulation strength training as an adjunct to burn 

rehabilitation: a case series. J Burn Care Rehabil. 2003;24(2):97–103.

278. Schmitt MA, French L, Kalil ET. How soon is safe? Ambulation of the patient with burns after lower-extremity skin 

grafting. J Burn Care Rehabil. 1991;12:33–37.
375

Rehabilitation of Burn Casualties

279. Burnsworth B, Krob MJ, Langer-Schnepp M. Immediate ambulation of patients with lower-extremity grafts. J Burn 

Care Rehabil. 1992;13:89–92.

280. Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications for the Physical Therapist. 2nd ed. Philadelphia, Pa: 

Saunders; 2003.

281. Davis C. Complementary Therapies in Rehabilitation: Evidence for Efficacy in Therapy, Prevention, and Wellness. Thorofare, 

NJ: SLACK; 2004.

282. ACSM’s Guidelines for Exercise Testing and Prescription. 5th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1995. 

283. Cronan T, Hammond J, Ward CG. The value of isokinetic exercise and testing in burn rehabilitation and determination 

of back-to-work status. J Burn Care Rehabil. 1990;11(3):224–227.

284. Austin KG, Hansbrough JF, Dore JF, Noordenbos J, Buono MJ. Thermoregulation in burn patients during exercise. J 

Burn Care Rehabil. 2003;24(1):9–14.

285. Wetzel JL, Giuffrida C, Petrazzi A, et al. Comparison of measures of physiologic stress during treadmill exercise in a 

patient with 20% lower extremity burn injuries and healthy matched and nonmatched individuals. J Burn Care Rehabil. 

2000;21(4):359–366.

286. Pedretti LW. Activities of daily living. In: Pedretti LW, Zoltan B, eds. Occupational Therapy: Practice Skills for Physical 

Dysfunction. 3rd ed. Baltimore, Md: Mosby; 1990: 230–271.

287. Cheng S, Rogers JC. Changes in occupational role performance after a severe burn: a retrospective study. Am J Occup 

Ther. 1989;43(1):17–24.

288. Rivers EA, Fisher SV. Rehabilitation for burn patients. In: Krusen FH, Kottke FJ, Lehmann JF, eds. Krusen’s Handbook 

of Physical Medicine and Rehabilitation. Philadelphia, Pa: Saunders; 1990: 1070–1101.

289. Wagner MM. Care of the Burn-Injured Patient: a Multidisciplinary Involvement. Littleton, Mass: PSG Publishing; 1981: 

151–153.

290. Hales RE, Travis TW. Exercise as a treatment option for anxiety and depressive disorders. Mil Med. 1987;152(6):299–302.

291. Friedmann J, Shapiro J, Plon L. Psychosocial treatment and pain control. In: Achauer BM, ed. Management of the Burned 

Patient. Norwalk, Conn: Appleton & Lange; 1987: 244–262.

292. Tobiasen JM, Hiebert JM. Burns and adjustment to injury: do psychological coping strategies help? J Trauma. 

1985;25(12):1151–1155.

293. Cromes FG Jr. Psychosocial aspects. In: Fisher SV, Helm PA, eds. Comprehensive Rehabilitation of Burns. Baltimore, Md: 

Williams & Wilkins; 1984: 330–352.

294. Watkins PN, Cook EL, May SR, Ehleben CM. Psychological stages in adaptation following burn injury: a method for 

facilitating psychological recovery of burn victims. J Burn Care Rehabil. 1988;9(4):376.

295. Summers TM. Psychosocial support of the burned patient. Crit Care Nurs Clin North Am. 1991;3(2):237–344.

296. Benson H. Beyond the Relaxation Response: How to Harness the Healing Power of Your Personal Beliefs. New York, NY: Times 

Books; 1984: 150.

297. Rivers EA. Rehabilitation management of the burn patient. In: Eisenberg MG, Grzesiak RC, eds. Advances in Clinical 

Rehabilitation. New York, NY: Springer; 1987: 177–214.

298. Krach LE, Fisher SV, Butzer SC, et al. Electrical injury: longterm outcome [abstract]. Arch Phys Med Rehabil. 

1979;60:533. 
376

Care of the Combat Amputee

299. Resick PA, Monson CM, Chard KM. Cognitive Processing Therapy: Veteran/Military version. Washington DC: US Department of Veterans Affairs; June 2007.

300. Blumenfield M, Schoeps M. Reintegrating the healed burned adult into society: psychological problems and solutions. 

Clin Plas Surg. 1992;19(3):599–605.

301. Adams RB, Tribble GC, Tafel AC, Edlich RF. Cardiovascular rehabilitation of patients with burns. J Burn Care Rehabil. 

1990;11(3):246–255.

302. Thompson TL, Steele BF. The psychological aspects of pain. In: Simons RC, ed. Understanding Human Behavior in Health 

and Illness. 3rd ed. Baltimore, Md: Williams & Wilkins; 1985: 60–67.

303. American Medical Association. Guides to the Evaluation of Permanent Impairment. Chicago, Ill: AMA; 1984.

304. Sheridan R. Burn Rehabilitation. eMedicine from WebMD. Available at: http://emedicine.medscape.com/

article/318436-overview. Accessed January 13, 2009.

305. Blakeney P, Partridge J, Rumsey N. Community integration. J Burn Care Res. 2007:28(4):598–601.

306. Haley J. Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D. New York, NY: WW Norton; 1973.

307. Bogaerts F, Boeckx W. Burns and sexuality. J Burn Care Rehabil. 1992;13(1):39–43.

308. Varghese G. Musculoskeletal considerations. In: Fisher SV, Helm PA, eds. Comprehensive Rehabilitation of Burns. Baltimore, MD: Williams & Wilkins; 1984: 242–248.

309. DeLisa JA. Rehabilitation of the patient with burns. In: Rehabilitation Medicine: Principles and Practice. Phildelphia, Pa: 

Lippincott; 1988: 821–839.

310. Artz CP, Moncrief JA, Pruitt BA. Burns: a team approach. Philadelphia, Pa: Saunders; 1979.

311. Young A. Rehabilitation of burn injuries. Phys Med Rehabil Clin N Am. 2002;13(1):85–108.

312. Banovac K, Gonzalez F, Renfree KJ. Treatment of heterotopic ossification after spinal cord injury. J Spinal Cord Med. 

1997;20(1):60–65.

313. Shafer DM, Bay C, Caruso DM, Foster KN. The use of eidronate disodium in the prevention of heterotopic ossification 

in burn patients. Burns. 2008;34(3):355–360.

314. Yang SC, Chen AC, Chao EK, Yuan LJ, Lee MS, Ueng SW. Early surgical management for heterotopic ossification about 

the elbow presenting as limited range of motion associated with ulnar neuropathy. Chang Gung Med J. 2002;25(4):245–252.

315. Crawford CM, Varghese G, Mani MM, Neff JR. Heterotopic ossification: are range of motion exercises contraindicated? 

J Burn Care Rehabil. 1986;7(4):323–327.

316. Stover SL, Hataway CJ, Zeiger HE. Heterotopic ossification in spinal cord-injured patients. Arch Phys Med Rehabil. 

1975;56(5):199–204.

317. Yowler CJ, Mozingo DW, Ryan JB, Pruitt BA Jr. Factors contributing to delayed extremity amputation in burn patients. 

J Trauma. 1998;45(3):522–526.

318. Viscardi PJ, Polk HC Jr. Outcome of amputations in patients with major burns. Burns. 1995;21:526–529.

319. García-Sánchez V, Gomez Morell P. Electric burns: high- and low-tension injuries. Burns. 1999;25(4):357–360.

320. Hussman J, Kucan JO, Russell RC, Bradley T, Zamboni WA. Electrical injuries—morbidity, outcome and treatment 

rationale. Burns. 1995;21(7):530–535.
377

Rehabilitation of Burn Casualties

321. Mann R, Gibran N, Engrav L, Heimbach D. Is immediate decompression of high voltage electrical injuries to the upper 

extremity always necessary? J Trauma. 1996;40(4):584–589.

322. Rai J, Jeschke MG, Barrow RE, Herndon DN. Electrical injuries: a 30-year review. J Trauma. 1999;46(5):933–936.

323. Tredget EE, Shankowsky HA, Tilley WA. Electrical injuries in Canadian burn care: identification of unsolved problems. 

Ann N Y Acad Sci. 1999;888:75–87.

324. Vadalouca A, Siafaka I, Argyra E, Vrachnou E, Moka E. Therapeutic management of chronic neuropathic pain: an 

examination of pharmacologic treatment. Ann N Y Acad Sci. 2006;1088:164–186.

325. Braddom RL. Rehabilitation of patients with burns. In: Braddom RL, Buschbacher RM, eds. Physical Medicine and 

Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders; 2000: 1321–1342.

326. Helm PA. Neuromuscular considerations. In: Fisher SV, Helm PA, eds. Comprehensive Rehabilitation of Burns. Baltimore, 

Md: Williams & Wilkins; 1984: 235–241.

327. Hettrick HH, O’Brien K, Laznick H, et al. Effect of transcutaneous electrical nerve stimulation for the management of 

burn pruritus: a pilot study. J Burn Care Rehabil. 2004;25(3):236–240.

328. Prigerson HG, Maciejewski PK, Rosenheck RA. Combat trauma: trauma with highest risk of delayed onset and 

unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis. 

2001;189(2):99–108.

329. Fauerbach JA, McKibben J, Bienvenu OJ, et al. Psychological distress after major burn injury. Psychosom Med. 

2005;69(5):473–482.

330. Vasterling JJ, Proctor SP, Amoroso P, Kane R, Heeren T, White R. Neuropsychological outcomes of Army personnel 

following deployment to the Iraqi war. JAMA. 2006;296(5):519–529.

331. Faber AW, Klasen HJ, Sauër EW, Vuister F. Psychological and social problems in burn patients after discharge. A 

follow-up study. Scand J Plast Reconstr Surg. 1987;21(3):307–309.

332. Smith M, Doctor M, Boulter T. Unique considerations in caring for a pediatric burn patient: a developmental approach. 

Crit Care Nurs Clin North Am. 2004;16(1):99–108.

333. Howard SK, Rosekind MR, Katz JD, Berry AJ. Fatigue in anesthesia: implications and strategies for patient and provider safety. Anesthesiology. 2002;97(5):1281–1294.

334. Lydic R, Baghdoyan HA. Sleep, anesthesiology, and the neurobiology of arousal state control. Anesthesiology. 

2005;103(6):1268–1295.

335. Zadra A, Pilon M, Donderi DC. Variety and intensity of emotions in nightmares and bad dreams. J Nerv Ment Dis. 

2006;194(4):249–254.

336. Grace JB, Holmes J. The management of behavioural and psychiatric symptoms in delirium. Expert Opin Pharmacother.

2006;7(5):555–561.

337. Tuunainen A, Wahlbeck K, Gilbody S. Newer atypical antipsychotic medication in comparison to clozapine: a systematic review of randomized trials. Schizophr Res. 2002;56(1-2):1–10.

338. Hollander AC, Ekblad S, Mukhamadiev D, Muminova R. The validity of screening instruments for posttraumatic 

stress disorder, depression, and other anxiety symptoms in Tajikistan. J Nerv Ment Dis. 2007;195(11):955–958.

339. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity 

Survey. Arch Gen Psychiatry. 1995;52(12):1048–1060.
378

Care of the Combat Amputee

340. Browne G, Byrne C, Brown B, et al. Psychosocial adjustment of burn survivors. Burns Incl Therm Inj. 1985;12(1):28–35.

341. Pivar IL, Field NP. Unresolved grief in combat veterans with PTSD. J Anxiety Disord. 2004;18(6):745–755.

342. Cahners SS, Bernstein NR. Rehabilitating families with burned children. Scand J Plast Reconstr Surg. 1979;13(1):173–175.

343. Shelby J, Sullivan J, Groussman M, Gray R, Saffle J. Severe burn injury: effects on psychologic and immunologic function in noninjured close relatives. J Burn Care Rehabil. 1992;13(1):58–63.

344. Langeland W, Hartgers C. Child sexual and physical abuse and alcoholism: a review. J Stud Alcohol. 1998;59(3):336–348.

345. Burd A, Huang L. Hypertrophic response and keloid diathesis: two very different forms of scar. Plast Reconstr Surg. 

2005;116(7):150e–157e.

346. Cummings GS, Crutchfield CA, Barnes MR. Soft Tissue Changes in Contractures. In: Orthopedic physical therapy series. 

Atlanta, Ga: Stokesville Publishing; 1983.

347. Greenhalgh DG, Staley MJ. Burn wound healing. In: Richard RL, Staley MJ, eds. Burn Care and Rehabilitation: Principles 

and Practice. Philadelphia, Pa: FA Davis; 1994: 70–102.

348. Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic burn scars: analysis of variables. J Trauma. 

1983;23(10):895–898.

349. Rudolph R. The effect of skin graft preparation on wound contraction. Surg Gynecol Obstet. 1976;142(1):49–56.

350. Staley MJ, Richard RL. Scar management. In: Richard RL, Staley MJ, eds. Burn Care and Rehabilitation: Principles and 

Practice. Philadelphia, Pa: FA Davis; 1994: 381.

351. Linares HA. Hypertrophic healing: controversies and etiopathogenic review. In: Carvajal HF, Parks DH, eds. Burns in 

Children: Pediatric Burn Management. Chicago, Ill: Year Book Medical Publishers; 1988: 305–323.

352. Shakespeare PG, van Renterghem L. Some observations on the surface structure of collagen in hypertrophic scars. 

Burns Incl Therm Inj. 1985;11(3):175–180.

353. Berman B, Zell D, Perez O. Keloid and Hypertrophic Scar. eMedicine from WebMD. Available at: http://emedicine.

medscape.com/article/1057599-overview. Accessed January 12, 2009.

354. Yamaguchi Y, Brenner M, Hearing VJ. The regulation of skin pigmentation. J Biol Chem. 2007;282(38):27557–27561.

355. Rauschuber E. Scar Management, Therapy Skills Builders Course. San Antonio, Tex: The Psychological Corporation; 1998.

356. Jewell L, Guerrero R, Quesada AR, Chan LS, Garner WL. Rate of healing in skin-grafted burn wounds. Plast ReconstrSurg. 2007;120(2):451–456.

357. Costa AM, Peyrol S, Pôrto LC, Comparin JP, Foyatier JL, Desmoulière A. Mechanical forces induce scar remodeling. 

Study in non-pressure-treated versus pressure-treated hypertrophic scars. Am J Pathol. 1999;155(5):1671–1679.

358. Davey RB. The place of “contact media” in a burn scar management programme. Eur J Plast Surg. 1998;21(1):24–27.

359. Ahn ST, Monafo WW, Mustoe TA. Topical silicone gel: a new treatment for hypertrophic scars. Surgery. 1989;106(4):781–787.

360. Mustoe TA. Evolution of silicone therapy and mechanism of action in scar management. Aesthetic Plast Surg. 

2008;32(1):495–500.

361. Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. New York, NY: Demos; 2004.

362. Wust KJ. A modified dynamic mouth splint for burn patients. J Burn Care Res. 2006;27(1):86–92.
379

Rehabilitation of Burn Casualties

363. Robertson CF, Zuker R, Dabrowski B, Levison H. Obstructive sleep apnea: a complication of burns to the head and 

neck in children. J Burn Care Rehabil. 1985;(6):353–357.

364. Leung KS, Cheng JC, Ma GF, Clark JA, Leung PC. Complications of pressure therapy for post-burn hypertrophic scars. 

Biochemical analysis based on 5 patients. Burns Incl Therm Inj. 1984;10(6):434–438.

365. Bruster JM, Pullium G. Gradient pressure. Am J Occup Ther. 1983;37(7):485–488.

366. Kealey GP, Jensen KL, Laubenthal KN, Lewis RW. Prospective randomized comparison of two types of pressure 

therapy garments. J Burn Care Rehabil. 1990;11(4):334–336.

367. Allely R, Van-Buendia LB, Jeng JC, et al. Laser Doppler imaging of cutaneous blood flow through transparent face 

masks: a necessary preamble to computer-controlled rapid prototyping fabrication with submillimeter precision. J 

Burn Care Res. 2008;29(1):42–48.

368. Smith K, Owens K. Physical and occupational therapy burn unit protocol–benefits and uses. J Burn Care Rehabil. 

1985;6(6):506–508.

369. Malick MH, Carr JA. Manual on Management of the Burn Patient: Including Splinting, Mold and Pressure Techniques. Pittsburgh, Pa: Harmarville Rehabilitation Center, Educational Resource Division; 1982.

370. Van den Kerchhove E, Boeckx W, Kochuyt A. Silicone patches as a supplement for pressure therapy to control hypertrophic scarring. J Burn Care Rehabil. 1991;12(4):361–369.

371. Quinn KJ. Silicone gel in scar treatment. Burns Incl Therm Inj. 1987;13(suppl):S33–S40.

372. American Society of Plastic Surgeons. Reconstructive surgery: procedures at a glance. Available at: http://www.

plasticsurgery.org/patients_consumers/procedures/ReconstructiveSurgery.cfm. Accessed August 23, 2007.

373. Achauer BM. Burn Reconstruction. New York, NY: Thieme Medical Publishers; 1991.

374. Salisbury RE, Bevin AG. Atlas of Reconstructive Burn Surgery. Philadelphia, Pa: Saunders; 1981: 164.

375. Monafo WW, Creekmore H. Electrical injuries of the scalp. In: Wachtel TL, Frank DH, eds. Burns of the Head and Neck. 

Philadelphia, PA: Saunders; 1984; 29: 94–111.

376. Achauer BM. Reconstructing the burned face. Clin Plast Surg. 1992;19(3):623–636.

377. Ben-Simchon C, Tsur H, Keren G, Epstein Y, Shapiro Y. Heat intolerance in patients with extensive healed burns. Plast 

Reconstr Surg. 1981;67(4):499–504. 

378. Roskind JL, Petrofsky J, Lind AR, Paletta FX. Quantitation of thermoregulatory impairment in patients with healed 

burns. Ann Plast Surg. 1978;1(2):172–176.

379. Shapiro Y, Epstein Y, Ben-Simchon C, Tsur H. Thermoregulatory responses of patients with extensive healed burns. J 

Appl Physiol. 1982;53(4):1019–1022.

380. US Army Human Resources Command. Army Physical Disability Evaluation System Web site. Available at: https://

www.hrc.army.mil/site/active/tagd/pda/pdesystem.htm. Accessed January 14, 2009.

381. US Department of the Army. Physical Evaluation for Retention, Retirement, or Separation. Washington, DC: DA; 2006. 

Army Regulation 635-40, Para 1-1.

382. US Office of the Surgeon General, Medical Command, Patient Administration Division. Medical Evaluation Board 

Overview Brief. Available at: http://www.cs.amedd.army.mil/APDES/docs/CommandTeamInformation/MEB_

OVERVIEW_BRIEF_(2).ppt. Accessed January 14, 2009.

383. Blakeney PE, Rosenberg L, Rosenberg M, Faber AW. Psychosocial care of persons with severe burns. Burns. 

2008;34(4):433–440.
380

Care of the Combat Amputee