INTRODUCTIONThe rehabilitation for patients with burn injuries starts from the day of injury, lastingfor several years and requires multidisciplinary eforts. A comprehensive rehabilitation programme is essential to decrease patients post-traumatic efects and improve functional independence.!" #owever, while optimal treatment provision involves a multidisciplinary team approach, when this is not possible or when availability of therapists and support services are limited, all members of the burns team can ta$e responsibility for their part in rehabilitation to ma%imise the bene&t to the patient. 'hile diferent professionals possess e%pertise in their own specialities, there are some simple and efective methods that can be utilised to help the patient reach their ma%imum functional outcome. (t is the dedication of theindividuals within the burn team and the commitment to caring for the patient and encouraging them to participate and engage fully in their rehabilitation, which can ma$e such a diference to their long-term quality of life.(n this article, an efort is being made to share the basic aspects of burn rehabilitation and provide practical information, which can be followed by diferent professionals wor$ing within the speciality of burns )and can be taught to family members* to best help their patients.+o to,STAGES OF REHABILITATION-ehabilitation of burns patients is a continuum of active therapy starting from admission. There should be no delineation between an .acute phase and a .rehabilitation phase/" as this idea can promote the inequality of a secondary disjointed scar management and0or functional rehabilitation team.1" #owever, for the ease of following a pathway of patient care, the stages of rehabilitation have been divided into early stages and later stages of rehabilitation2 although, it must be understood that there may be signi&cant crossover between these two stages depending on the individual patient.+o to,EARLY STAGES OF REHABILITATION3epending on the si4e and severity of the injury, the patients age and other pre-morbid factors, this stage can last from a few days to several months. The patient may be an inpatient or may be treated as an outpatient and is li$ely to be undergoing regular dressing changes, which are often painful and may also be a very frightening e%perience for the patient.-egular pain relief is essential, in particular prior to all interventions such as changeof dressing and e%ercise2 this needs to be given in adequate time to ta$e efect before commencing the procedure. The aim of analgesic drugs should be to developa good baseline pain control to allow functional movement and activities of daily living to occur at any time during the day./" (nadequate pain relief in the early stages can result in a complete reluctance of the patient to participate in their rehabilitation in both the short and long term.5arly commencement of rehabilitation is the $ey to compliance with treatment and ma%imising long-term outcome. 'hen the various aspects of rehabilitation are introduced as an integral part of care from day one, whether the patient is an in-patient or out-patient, they are easier for the patient to accept and follow rather than as an additional element to their care at a later date when contractures are already developing.+o to,REMEMBER TOMORROW MIGHT BE TOO LATE!6atients may want to delay their rehabilitation until they feel better2 however, everyday without burn therapy intervention will ma$e the eventual rehabilitation process more di7cult and painful and may result in a poorer outcome. (f windows are missed, they cannot be regained easily, since the inevitable sequelae of ever-increasing joint stifness and tethered soft-tissue glide become more and more devastating with the passage of time.8" 6atients may try to refuse treatment as they are in pain and may not understand fully the impact of not participating in theirrehabilitation2 they therefore need the support and encouragement of the burn care professionals to help them through this di7cult e%perience with the $nowledge of how diferent their quality of life can be.+o to,CRITICAL CARE(t is essential that physical rehabilitation is commenced at day ! of admission whether the patient is ambulant and well or on bed rest and immobile.'hen a patient is admitted with severe burns, it is essential to reduce the ris$s, as far as possible, of further complications arising. 6ostural management of the patientby elevating the head and chest helps with chest clearance and reduces swelling of the head, nec$ and upper airway. (n the early stages, signi&cant oedema may be present particularly in the peripheries2 poor positioning can lead to unnecessary additional morbidity which can be avoided. 5levation of all limbs afected is necessary in order to quic$ly reduce oedema2 hands should be splinted or positioned and feet $ept at 9: degrees, care and attention must also be given to theheel area which can quic$ly develop pressure. ;egs should be positioned in a neutral position ensuring that patient is not e%ternally rotating at the hips +raph !".6atients who are unable to move should have passive movements completed to maintain range of movement )-ashbac$s of the event. 'hile professionals may treat many people in one day, the e%perience for each individual patient is personal and their e%perience can impact on their mental wellbeing and readiness to participate in their treatment. (t is important that the patient is given comfort and reassurance that they are safe. Ta$ing the time to listen to the patients concerns, demonstrating genuine empathy and compassion, providing adequate information and answering their questions canoften go a long way to alleviating fears, which in turn can ease the treatment process for both patient and professional.+o to,ANTI-CONTRACTURE POSITIONINGAnti-contracture positioning and splinting must start from day one and may continue for many months post-injury. (t applies to all patients whether they have been s$in grafted or not. 6ositioning is important to in>uence tissue length by limiting or inhibiting loss of -e%or aspect of a joint or limb the ris$ of contracture is greater. This is due to the position of comfort being a >e%ed position2 also the >e%or muscles are generally stronger than the e%tensors so should a burn occur to the e%tensor aspect, patients can use the strength of the >e%ors to stretch the particular area. The >e%ed position is the position of function for e%ample clasping the hand, forward >e%ion of the shoulder and >e%ing the nec$. The aims of anti-contracture positioning are to counteract this natural tendency towards >e%ion as demonstrated in the table below.Table !Bommon post burn contractures and the respective anti contracture position of nursing@igure /The >e%ion contracture of the nec$ can be avoided by having a pillow under the shoulder and nursing with nec$ in e%tension. There should be no pillow under the head@igure 1This e%tension contracture of the nec$ can be avoided by sitting with head in >e%ionane lying with pillows behind the head@igure 8This a%illary contracture can be prevented by lying and sitting with arms abducted at 9: degrees supported by pillows or foam bloc$s between chest and arms and &gure of eight bandaging or strapping to provide stretch across chest@igure ?@le%ion contracture at the elbow can be avoided by $eeping the elbow in e%tension by an e%tension splint@igure CBlawing of &ngers can be avoided by $eeping the =6 joints in >e%ion, (6 joints in e%tension, thumb mid palmar radial abduction@igure DThe thumb in palm deformity is avoided by $eeping the wrist e%tended with minimal=B6 >e%ion and $eeping the &ngers e%tended and thumb abducted@igure E@le%ion contracture of the hips can be prevented by lying prone with legs e%tended. ;imit sitting and side lying. Fupine lying with legs e%tended, no pillow under $nees. Gursing in this position will cause >e%ion contractures in the hip and $nee joints ...@igure 9@le%ion contracture of the $nee can be avoided by $eeping the legs e%tended in lying and sitting and by using $nee e%tension splints@igure !:3orsal contracture at the an$le can be prevented by $eeping the an$les at 9: degrees - use pillows to maintain position and encourage sitting with feet >at on >oor as long as no oedema is present6ositioning a patient may ta$e some lateral thin$ing in order to achieve the requiredposition and prevent the patient from gradually rela%ing bac$ into a position of contracture.Hse of materials readily available in the ward such as pillows and drip stands )for elevation* can be used as efective positioning tools.Fimple but consistent positioning from 3ay ! can have a signi&cant efect in ma$ingcontractures avoidable. =any burn contractures can be minimised or avoided completely by early intervention @igures @igures!!!! and and!/!/".@igure !!Bomple% bilateral lower limb contractures which can be avoided by proper anti deformity splintage@igure !/This gross mandibular deformity, malocclusion and nec$ contracture can be prevented by proper nursing and splintage. A well padded tube can be inserted into the mouth to combat mouth contracture+o to,SPLINTINGFplints are a highly efective method of helping prevent and manage burn contractures and are an integral part of a comprehensive rehabilitation programme.C" Fplinting helps maintain anti-contracture positioning particularly for those patients e%periencing a great deal of pain, di7culty with compliance or with burns in an area where positioning alone is insu7cient. (f the injured site is over joint surfaces, special precautions should be ta$en to identify all possible joint contractures. A well-designed splintage programme incorporated with active and passive mobilisation is essential to prevent and convert joint contractures and deformities.!"Fplinting can provide a stretched position, which also provides an easier starting point for e%ercise and stretching regimes. As scars not only contract but also ta$e the shortest route possible, they often cause webbing across natural concavities and joints for e%ample to the nec$, $nee and a%illa2 splints appear to help remodel scar tissue as it forms and maintains the anatomical contours. Fplinting is the only available therapeutic modality that applies controlled gentle forces to soft tissues for su7cient lengths of time to induce tissue remodelling.8" 6revention is always better than cure. 5arly application of splints to prevent the development of post-burn scar contracture in the acute stage is essential.!"Fplints can be made of various diferent materials. The ideal material is low temperature thermoplastic as it is lightweight, easily mouldable and remouldable and conforms e%tremely well to contours. #owever, this is not the only material which splints can be made from and is not always readily available, in which case alternatives need to be used and improvisation may be necessary.+o to,MATERIALS FOR SPLINTING=aterials that are readily available are used to ma$e splints @igure !1"@igure !1=aterials used for ma$ing splints6laster of 6aris - This material is e%cellent in the early stages while a patient is immobile and has heavy dressings applied2 however, it tends to absorb e%udate, is heavy and brea$s easily. (t is often applied following surgery to immobilise and position a limb2 however, once it is discarded it must be replaced by something else.Bardboard - This material also ma$es an e%cellent early splint material and is particularly good for positioning and stretching burns to childrens hands. Hse of discarded dressing bo%es to fabricate easy, lightweight, disposable splints also minimises cost. A dorsal bloc$ can be applied over the digits to enhance stretch anda &rm )but not too tight* bandage maintains the required position of the hand. uence the collagen remodelling phase of wound healing.D" (t appears to soften, >atten and blanch the scar, ma$ing it comfortable and improving its appearance.E"Ac%!,!%!(s o- )"!ly l!,!&(ndividuals should be encouraged to return to their normal daily routines as soon as possible and should re-establish themselves in their roles in life prior to their burn injury as much as they can.Soc!"l '(h".!l!%"%!o&@ollowing a burn injury some individuals can feel isolated and alone. They may &nd it di7cult to integrate bac$ into society and ta$e up life as they $new it prior to theirinjury. They may feel li$e they are the only one who has sufered such an injury and they may not $now how to re-enter society, particularly if they have visible burns scars. These individuals should be encouraged in order to re-establish themselves intheir social and vocational lives as soon as they are able to, and their family members should be encouraged to promote this behaviour. @or children this will mean re-entering school as soon as they are ready to do so, meeting up with friendsand participating in activities and sports which they enjoy. Fometimes relatives can become very protective of the individual, fearing that something may happen again2in their desire to care for and protect the individual to $eep them safe, they can sometimes impede the reintegration process. ;ife after a burn injury, particularly a major injury can ta$e some signi&cant adjusting to however with the right support and rehabilitation, burn injured patients can lead a full life.+o to,CONCLUSION-ehabilitation from a burn injury is a lengthy process, which starts on day one and involves a continuum of care through to scar maturation and beyond. (t involves a dedicated multidisciplinary team of professionals and the full participation of the patient. Fustaining a burn injury, however big or small can have a dramatic afect on the individuals physical and psychological well-being and requires teamwor$ andcommitment to help each individual overcome the di7culties they may encounter. 'hile the path is not always easy, with the right support and therapeutic intervention, the commitment of the team to not accept even one contracture,1" and provide understanding of the psychological and social challenges, the patient can reach their ma%imum physical, psychological and functional outcome.