Burns

A hypertrophic burn scar remains metabolically active for months. It contracts, and across a joint that contraction removes range progressively. A shoulder, elbow, knee or neck can lose function long after the patient was discharged as healed.

This is why burn rehabilitation is measured in months and why stopping when the wound closes is the most common reason a patient ends up needing scar release surgery.

Positioning against the direction the scar wants to pull. Custom splinting, often worn at night for months. Daily sustained stretching. Pressure garments and silicone for scar management. And strengthening and conditioning, because a long acute admission leaves substantial muscle loss.

Hydrotherapy is useful once the skin is fully closed and intact — warm water allows movement that is painful on land — but it is not used over open areas or unhealed grafts.

Itch is one of the most distressing long-term symptoms and is frequently dismissed. Neuropathic pain from damaged nerve endings is common. Both are treated actively rather than tolerated, because they determine whether a patient can complete the stretching programme at all.

Psychological support belongs in this programme. Visible scarring, altered body image and traumatic memory affect participation directly, and rehabilitation that ignores them progresses badly.

Scars keep changing for a year or more: in a study of 326 children whose burns healed without grafting, raised scars were present in 56% at three to six months and still present in 16% at twelve to eighteen months 1. A joint that looks fine at three months can lose range at nine if the programme stops.

This is why splinting, positioning and pressure therapy continue long after the wound has closed, and why discharge at wound healing is the commonest reason burns patients lose function.

The evidence is weaker than their routine use suggests. A 2024 Cochrane review of 15 trials with 1,179 people found the evidence very uncertain on whether pressure garments prevent raised scarring, alone or combined with silicone, and suggested that patient preference could guide the choice until better trials exist 2.

For silicone gel sheeting, a Cochrane review found weak evidence of benefit in preventing raised scars in people at high risk, and improvements in scar thickness and colour, but in trials of poor quality 3. Static splinting to prevent contractures also rests more on clinical reasoning than on trials; a review found no strong evidence that it works 5.

Contractures themselves are common: in a systematic review they were present in 38–54% of patients at hospital discharge, more often after severe or flame burns, in children, and at the neck and arms 4. That is why positioning and stretching start early, with garments, silicone and splints used where they help an individual patient.