Chapter 21: Rehabilitation of the Burned Individual

Introduction

There have been major advances in the medical, surgical, and rehabilitative treatment of burn injuries over the past several decades.¹ Burns over more than 30% of a patient's total body surface area (TBSA) were uniformly fatal approximately 25 to 30 years ago. Today, about 12% of those who sustain burns of this magnitude die. With current methods of burn care, patients are increasingly surviving larger and more debilitating burns. The main objective and primary measure of success in the quality of burn care has shifted from survival per se to restoration of the patient's preinjury level of function, with the best possible cosmesis. Achieving this objective requires involvement of an entire burn care team, including highly trained and knowledgeable physical and occupational therapists. Of all the different and challenging processes that a burn patient undergoes, rehabilitation lasts the longest because it begins on the day of injury and never truly ends.²

The rehabilitation program's objectives change over time. In the acute care stages, rehabilitation focuses on restoring baseline cardiopulmonary status and preventing musculoskeletal dysfunction. In the later stages, rehabilitation focuses on regaining and restoring baseline function, returning to employment or school, and adjusting to possible aesthetic and psychological changes. This ever-changing focus ultimately underscores the need for an integrated burn care team approach.²

Each year an estimated 1 million people sustain burn injuries, and there are several at-risk populations in the United States that include a number of underserved groups. These include children under the age of 4 (for whom burn injury represents one of the leading causes of disability), adults over 65 years of age, African Americans and Native Americans, the poor, and people living in rural areas and substandard housing. In addition, national disasters represent a significant source of burn injuries. Approximately one third of the people injured in recent terrorist attacks sustained major burn injuries. Military personnel also sustained injuries from explosions, fires, and accidents.²

An estimated 500,000 people with burn injuries receive medical treatment per year. Treatment is received in hospital emergency departments and outpatient clinics, free-standing urgent care centers, and private physician's offices. There are approximately 4000 fire and burn deaths per year. This total includes an estimated 3500 deaths secondary to residential fires and 500 from motor vehicle and aircraft crashes, electricity, chemicals or hot liquids and substances, and other sources of burn injury. About 75% of these deaths occur at the scene or during the initial transport.³ A total of 40,000 people with burn injuries are hospitalized per year, with 25,000 admissions to the 125 hospitals with specialized burn centers. Burn centers average 200 admissions a year, while the other 5000 U.S. hospitals average less than 3 burn admissions per year.³

Selected statistics on admissions to burn centers for 1995 to 2005 include a 94.4% survival rate. Over one third of admissions (38%) exceeded 10% TBSA, ...