Vita TU, Occupational Therapist and Project Manager
Sunshine Social Welfare Foundation
Therapeutic exercises play an essential role in recovery from burn injuries, each type serving a unique purpose and effect. When used together, they maximize the benefits of burn rehabilitation, helping patients regain function and independence. Drawing from our clinical experience, this article highlights commonly used burn therapeutic exercises and key considerations for each, with a focus on Active Range of Motion (AROM) and stretching exercises.
1. Types of exercises and stretching
2. Why choose AROM exercises and stretching exercises for burn patients
3. Appropriate timing for active exercise and stretching exercises
4. How to combine active exercises and stretching
Burn therapeutic exercises and stretching
Exercises vary in type and intensity, each supporting different aspects of healing and movement.
Exercises
Active Range of Motion (AROM) refers to the movement of a body segment within its full range of motion (ROM) that is initiated by the active contraction of the muscles around that joint.
Active-Assisted Range of Motion (A-AROM) is a specific form of AROM where an external force, either manual or mechanical, aids the movement because the primary muscles require help to complete the action.
Passive Range of Motion (PROM) involves movement of a segment within its unrestricted ROM, entirely driven by an external force, with minimal to no voluntary muscle contraction. This external force can come from gravity, a machine, another person, or even another part of the individual’s body. It’s important to note that PROM is not the same as passive stretching.
Stretching
Manual or Mechanical/Passive or Assisted
A stretching force can lengthen shortened muscle-tendon units and surrounding connective tissues when a restricted joint is moved just beyond its available ROM. Force may be applied manually or mechanically with the aid of a device, in a sustained or intermittent manner. Passive stretching is when the patient is as relaxed as possible during the stretching process. If the patient contributes to the movement, it’s called assisted stretching.
Self-Stretching
Self-stretching refers to stretching done independently by the patient after guidance from the therapist. The patient applies force at the end of their available ROM to help lengthen tight soft tissues.
Why choose AROM exercise and stretching exercises for burn patients
There are many types of therapeutic exercises, but based on our clinical experience, we most often choose AROM and stretching exercises for burn patients during the rehabilitation period.
The goal of every rehabilitation intervention is to ultimately allow the patient to perform AROM well, therefore including AROM exercises in the rehabilitation plan is inevitable. AROM exercises not only help maintain joint and connective tissue mobility and mechanical elasticity of muscles, but more importantly, they can provide sensory feedback from the contracting muscles. They are also important for developing coordination and motor skills for functional activities. Therefore, in addition to massaging scars, using splints, and performing passive stretching, AROM exercises or activities must be added to improve the functional performance of the limbs.
For burn patients, the most common problem is scar contracture, so stretching exercises are a commonly used intervention. As scar tissue forms, it can become rigid. Also, the traction force of myofibroblasts contribute to wound closure but also to contraction of the wound towards the center, which leads to scar tissue contracture. Scar contracture, especially over joints, can restrict movement. Stretching exercises help reduce the stiffness of these scars and maintain or increase flexibility around joints, preventing contractures from worsening and aiding recovery of movement.
Post-burn immobility and inactivity can lead to muscle atrophy and shortening. Stretching maintains muscle length, which supports mobility and functional use of affected limbs. Improved flexibility and range of motion from stretching allow for more comfortable and functional movement. This can make everyday tasks like dressing, walking, or reaching easier and less painful, leading to increased independence.
Appropriate timing for active exercise and stretching exercises
Active joint mobilization exercises are safer exercises and can usually be used throughout the burn recovery process, except for certain situations that require immobilization, such as the initial stage of skin grafting or exposure of the dorsal tendon of the proximal interphalangeal joint.
Performing active joint ROM exercises can produce muscle contraction, help increase venous and lymphatic return and reduce edema. Immediately after the wound has healed and the skin graft has stabilized, performing active joint mobilization exercises can avoid applying excessive tension that may cause damage to the wound and the skin graft recipient site. Therefore, when starting exercises after surgery, active joint mobilization exercises are usually performed first. If a burn patient is unable to actively achieve full range of motion due to weakness, fear, and pain, active-assistive exercise can be used to achieve full range of motion.
Stretching exercises are used in burn rehabilitation to stretch scar tissue and increase joint mobility to improve movement and function. The method of stretching is to stretch the scar or joint in the opposite direction of the contracture. The appropriate intensity of stretching is the degree that allows the scar to blanch.
Stretching exercises that stretch tissues without damaging them are achieved through prolonged, low-intensity continuous stretching. Therefore, the intensity of stretching must be an intensity that the patient can endure for a period of time in order to achieve the real effect of tissue stretching. Stretching exercises can be performed actively or passively and can also be performed with equipment or bare hands. They are the most important exercise method during the burn rehabilitation period and when scars proliferate and contract rapidly.
Stretching is indicated in burn rehabilitation when range of motion (ROM) is limited due to the loss of soft tissue extensibility caused by adhesions, contractures, or scar tissue formation. These limitations often result in ADL restrictions. Addressing these issues early on through stretching is essential, as restricted motion can eventually lead to deformities.
Stretching is contraindicated in several situations. It should be avoided if a bony block restricts joint movement or if there is an incomplete bony union following a recent fracture. Additionally, stretching should not be performed if there are signs of inflammation or infection, such as heat and swelling, as it could exacerbate the condition. Stretching may also disrupt wound healing, so it must be carefully evaluated. Other contraindications include sharp, acute pain during joint movement or muscle elongation and the presence of a hematoma or other indicators of tissue trauma.
How to combine active exercises and stretching
Is it better to perform active exercises first and then stretching exercises, or to perform stretching exercises first and then active exercises? The order in which active exercises and stretching are performed has different considerations and effects.
Performing AROM exercises before stretching
After a burn injury, the most intense stage of hypertrophic scar growth will be during the rehabilitation phase. After waking up from a night’s sleep, patients will feel like their joint movements have returned to a stiff state, as if they never did any exercises.
If active exercises are performed first to warm up, the pain felt by patients from rehabilitation will be milder. Then, performing stretching exercises will further enhance the joint mobility effect achieved by active movements. For example, the patient can first use the shoulder wheel to perform active shoulder joint movement and then use the weight of a sandbag to passively extend shoulder joint range of motion. Performing active movements first and then following with stretching focuses on a continued increase in joint range of motion.
Perform stretching exercises before active movements
Starting with stretching exercises can increase the range of joint mobility. When this is followed by active exercises, because the joints are stretched more easily, muscle contraction and the control of coordination between nerves and muscles are strengthened, which leads to improved movement performance. For example, manual therapeutic stretching can be first used to increase MP flexion, and then the patient can perform palmar pinch to pick up blocks. Performing stretching exercises first and then performing active movements is expected to result in better functional performance.
The sequence of burn rehabilitation exercises should align with the patient’s priority goals. If the focus is on reducing stiffness, AROM exercises done first can ease pain before stretching. For patients aiming to enhance functional movement, starting with stretching primes joints for improved active performance.
References:
John Kisner, Carolyn, ColbyAllenLynn, & Borstad. (2022). Therapeutic Exercise Foundations and Techniques (8th edition). Philadelphia: F A Davis Co.
蕭鳳儀, & 宋有礪. (2018). 燒傷復健期的處理-理論與實務. 新北市: 合記圖書出版社.