Long-Term Outcomes in Patients Surviving Large

Burns: The Musculoskeletal System

Radha K. Holavanahalli, PhD, Phala A. Helm, MD, Karen J. Kowalske, MD

The authors have previously described long-term outcomes related to the skin in

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patients surviving large burns. The objective of this study was to describe the long-term
musculoskeletal complications following major burn injury. This is a cross-sectional
descriptive study that includes a one-time evaluation of 98 burn survivors (mean age =
47 years; mean TBSA = 57%; and mean time from injury = 17 years), who consented to
participate in the study. A comprehensive history and physical examination was conducted
by a senior and experienced Physical Medicine and Rehabilitation physician. In addition
to completing a Medical Problem Checklist, subjects also completed the Burn-Specific
Health Scale (Abbreviated 80 item), a self-report measure used to review the level of
functional adaptation. Joint pain, joint stiffness, problems walking or running, fatigue,
and weak arms and hands are conditions that continue to be reported at an average of 17
years from the time of burn injury. Seventy-three percent (68 of 93) of the study sample
were found to have a limitation of motion and areas most affected were the neck (47%),
hands (45%), and axilla (38%). The global (Burn-Specific Health Scale-total) score for
the overall sample was 0.78. Subjects with limitation of motion had significant difficulty
in areas of mobility, self-care, hand function, and role activities. This study underscores
the importance of long-term follow-up care and therapeutic interventions for survivors
of major burn injury, as they continue to have significant and persistent burn-related
impairments even several years following injury. (J Burn Care Res 2016;37:243–254)

Musculoskeletal complications are common following
burn injuries.1,2 Such complications including con-
tractures, bone loss, heterotopic ossification (HO),
scoliosis and kyphosis, septic arthritis, subluxations
and dislocations occur either as a direct or indirect
sequelae from the burn injury itself or its effects on
the bones, joints, and tendons.1,2 An evidence-based
review of the scientific literature on rehabilitation of
individuals with burns found that impairment due to
loss of muscle mass, contractures, HO, amputations,
From The Department of Physical Medicine and Rehabilitation,
University of Texas Southwestern Medical Center, Dallas.
The contents of this work were developed under a grant from
the Department of Education, NIDRR Grant Numbers
H133A020104 and H133A120090. However, these contents
do not necessarily represent the policy of the Department of
Education, and you should not assume endorsement by the
Federal Government.
Address correspondence to Radha K. Holavanahalli, PhD,
University of Texas Southwestern Medical Center, 5323 Harry
Hines Blvd., Dallas, 75390-9136. Email:radha.holavanahalli@
utsouthwestern.edu.
Copyright © 2015 by the American Burn Association
1559-047X/2016
DOI: 10.1097/BCR.0000000000000257
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
nervous system injury, and psychological problems
are all complications that have a significant impact
on recovery after burn injuries.3 Contractures are a
common occurrence that result in long-term func-
tional impairments and disabilities.3 HO may also
lead to decreased range of motion or joint fusion,
and like amputations and other musculoskeletal com-
plications, it can result in impairments in functional
activities and activities of daily living.3 Prevention,
early identification, and treatment of such complica-
tions are considered continuing goals of treatment
in acute and outpatient settings.1,2 During the post-
acute rehabilitative phase of treatment a multitude of
physical and emotional changes occur.4 This phase
can be five to 10 times longer than the acute phase
of treatment.4 Despite aggressive treatment during
the acute management of burn injuries, there are
residual defects that may last a life-time.3,4 There has
been a strong commitment to shift the goal of burn
care from patient survival to a state of restored liv-
ing through focused research and rehabilitation.5 Yet,
there is no substantial information on long-term out-
comes of a major burn injury. It is not known which
243

244  Holavanahalli, Helm, and Kowalske July/August 2016
problems resolve, which problems are permanent,
which problems recur, and which new problems may
emerge over time as a result of the burn injury.6 The
objective of this study was to evaluate persons who
survived a major burn injury and to document and
describe the long-term physical and psychosocial
residual problems. We previously reported on long-
term outcomes related to the skin.6 This report is the
second in the series of the long-term outcomes stud-
ies and focuses on the musculoskeletal complications
after major burn injury. In addition, a description of
the functional adaptation as reported by long-term
survivors of major burn injury is presented.
METHODS
Study Population and Setting
Criteria to participate in the study included 1) ≥30%
TBSA burn, 2) ≥3 years from the time of injury,
and 3) ≥18 years of age at the time of study evalua-
tion. Subjects meeting study criteria were recruited
at a Regional Burn Center. The World Burn Con-
gress (WBC) organized by the Phoenix Society for
Burn Survivors was included as an additional site for
recruiting subjects to the study.
Measurement Procedures
A Health Insurance Portability and Accountabil-
ity Act waiver was obtained from the institutional
review board for recruitment at the burn center.
The waiver allowed for a review of two large data-
bases, the surgical database maintained by the burn
surgeon at the center and the Burn Model Systems
database that was established at the center in 1994.
Subjects meeting the study inclusion criteria were
selected from these two databases. Letters were sent
and calls were made to contact the eligible subjects.
As reported in the previous publication,6 the surgi-
cal database (1974–1992) consisted of 1660 subjects
who met the study inclusion criteria. However, only
670 of the 1660 medical records were retrievable to
obtain contact information. Of the 670 mailings,
300 mails were returned undeliverable, 78 were
deceased, and from the remaining 292 subjects, 30
(10%) subjects consented to participate. The Burn
Model Systems database (1994–2002) consisted of
181 subjects and who met the study inclusion crite-
ria and 22 (12%) subjects consented to participate.
A total of 52 subjects were recruited to the study
at the burn center. For recruitment at the WBC, at
the request of the study investigators, the organiz-
ers of the WBC included a flier describing the study
and inclusion criteria in the registration packet given
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Journal of Burn Care & Research
to the burn survivor attendees. The investigators set
up a study booth at the WBC where interested par-
ticipants (n = 46) voluntarily presented themselves to
the study investigators. A total of 98 subjects (burn
center = 52; WBC = 46) consented to participate in
the study. Study participants signed an institutional
review board-approved informed written consent
and Health Insurance Portability and Accountabil-
ity Act authorization form. Consenting subjects
were scheduled for a comprehensive history and
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physical examination conducted by a senior Physical
Medicine and Rehabilitation physician. The physical
exams conducted at the burn center were more com-
prehensive than those conducted at the WBC, due
to privacy constraints at the latter location. Subjects
were monetarily compensated for their time.
Measurement Tools
The measures used in this study include the
­following: 1) The Patient Information Form—The
patient information form is a self-report designed
for the specific purpose of this study to obtain infor-
mation regarding subject and injury demographics,
pre- and postburn sociodemographics (family, liv-
ing situation, work, education, and recreation); 2)
The Medical Problem Checklist (MPC)—The MPC
is also a self-report designed for the specific pur-
pose of this study. It is a 50-item list of problems
with a Yes/No choice to respond at three points of
time—“before burn” (to exclude nonburn-related
problems), “since burn” (to include postburn prob-
lems that may have resolved by the time of study
participation), and “now or current” (to include
long-term problems reported at time of study par-
ticipation). The three points of time were chosen
to isolate burn-specific problems, to document
the most prevalent problems that occur following
a burn injury, and to document which problems
continue to persist long-term; 3) The History and
Physical Exam Form—The History and Physical
Exam Form was designed for the purpose of docu-
menting findings from a detailed History and Physi-
cal Exam. During the history and physical exam, a
review of the MPC was undertaken by the physician
as a good additional step to clarify and confirm that
the subject had understood the questions and had
responded accurately. As mentioned earlier, only
findings related to the musculoskeletal conditions
are presented in this article; and 4) Burn-Specific
Health Scale (BSHS), a self-report measure was used
to review the level of functional adaptation follow-
ing burn injury.7 It is a 80-item self-report question-
naire in which each item is rated on a zero (extreme
 Journal of Burn Care & Research
Volume 37, Number 4 Holavanahalli, Helm, and Kowalske  245
difficulty) to four (no difficulty) scale and a score
is derived by dividing the total score by the total
possible score. The scores range from 0.00 to 1.00
with higher scores indicating better functional adap-
tation. Scores in the range of 0.80 or greater seem
to indicate that a person is functioning well.8 The
BSHS includes a global domain score (an overall
score) and four domain scores each with further sub-
domains. The physical domain (subdomains include
mobility, self-care, hand, and role activities), psy-
chological domain (subdomains include body image
and affective), social domain (subdomains include
family/friends and sexuality), and a general domain
(subdomains include items related to specific burn
impairments, such as pain, health, appearance, and
social sensitivity). The BSHS has been shown to
have acceptable validity when compared with other
preburn health and psychological scales.9
Statistical Analyses
This is a cross-sectional descriptive study that includes
a one-time evaluation of burn survivors who are
3 years or more (range 3–30 years) from the time of
their injury. Descriptive statistics include burn-related
musculoskeletal conditions reported by study subjects,
physician findings from a clinical examination of burn-
related musculoskeletal conditions, and level of func-
tional adaptation in each domain of the BSHS. Two
independent-samples t-tests were conducted as part of
exploratory analyses to evaluate differences in BSHS
domain scores between 1) subjects with limitation of
motion (LOM) and without LOM; and 2) subjects
recruited at the burn center and subjects recruited at
WBC. To allow for multiple testing, the Bonferroni
Correction was used to adjust P value (P < .025).
Table 1. Age at time of injury and time from injury for participants recruited to the study at the burn center and the WBC
Burn Center
N = 52
Mean age (in years) at time of injury 32.6
SD = 12.49
Range = 8–71 years
Participants <18 years of age at time 6 (12%)
of injury
Time From Injury (Years) N (%)
3–5 10 (53)
6–10 12 (60)
11–15 8 (53)
16–20 12 (80)
21–30 6 (46)
>30 4 (25)
WBC, World Burn Congress.
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
RESULTS
The database used in this study was reported in
our previously published study6 and therefore, data
regarding the subject demographics and injury char-
acteristics reported in this study remain unchanged.
Study subjects were predominantly male (63%)
and Caucasian (69%). The primary burn etiology
was flame (75%) with a mean TBSA burn of 57%
(SD = 17.73), and a mean of 17 (SD = 12.91)
years after burn injury. The mean age at the time
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of study participation was 47 years (range = 22–79
years; SD = 10.81). The mean age of subjects at
the time of injury was 29.34 (range = 1–71 years;
SD = 13.92), with 22.4%, who were burned as chil-
dren. As reported previously,6 the study sample across
the two recruitment sites did not differ significantly
in terms of gender, ethnicity, age at time study partic-
ipation, and size of burn. The two recruitment sites
differed in terms of participant’s age at time of injury
and time from injury as shown in Table 1. Thirty-five
percent of the subjects recruited at the WBC were
less than 18 years of age at the time of their injury
compared with only 12% at the burn center who were
less than 18 years of age at time of their injury. Of the
16 subjects who were 30 years or more from the time
of their injury, 12 (75%) were recruited at the WBC
and four (25%) at the burn center.
Subject responses to burn-related musculoskeletal
conditions on the MPC are summarized in Table 2.
The top five conditions subjects reported experi-
encing “since burn” include weak arms and hands,
problems walking or running, joint pain, joint stiff-
ness, and fatigue. On comparing with the conditions
they reported experiencing “now/current” at the
WBC Total
N = 46 N = 98
25.6 29.34
SD = 14.65 SD = 13.92
Range = 1–53 years Range = 1–71 years
16 (35%) 22
N (%) Total
9 (47) 19
8 (40) 20
7 (47) 15
3 (20) 15
7 (54) 13
12 (75) 16

246  Holavanahalli, Helm, and Kowalske July/August 2016
Table 2. Burn-related musculoskeletal conditions reported by study participants (N = 98) “since burn” (time period
between injury and study participation) and “now” (at time of study participation)
Musculoskeletal Conditions “Since Burn” N (%)
Weak arms and hands 68 (69)
Problems walking or running 63 (64)
Joint pain 62 (63)
Joint stiffness 62 (63)
Fatigue 58 (59)
Weight gain 56 (57)
Weak legs and feet 53 (54)
Painful feet 45 (46)
Shortness of breath 42 (43)
Joint swelling 37 (38)
Weight loss 25 (25)
Heterotopic bone 12 (12)
time of study participation, the top five conditions
remained the same. Joint pain, joint stiffness, prob-
lems walking or running, fatigue, and weak arms and
hands are conditions that continue to be reported at
an average of 17 years from the time of burn injury.
As shown in Table 2, the percentage of participants
reporting joint pain increased from 63 to 70%, and
similar increase from 63 to 65% was found for joint
stiffness. Despite a decrease in the percentage of sub-
jects reporting all other conditions listed in Table 2,
it can be seen that musculoskeletal conditions persist
over time. About 23% reported use of assistive device
“since burn” and that number dropped to 13% at
the time of study participation. Only 5% of the par-
ticipants reported the use of an artificial limb since
the burn injury and continued to be using it even
at time of study participation. At an average of 17
years postinjury, subjects continue to report painful
feet (42%), weak legs and feet (38%), and experienc-
ing shortness of breath (39%). Heterotopic bone was
reported by 8% of the subjects in this study. About
6 to 8% reported having diabetes, and 28% reported
high blood pressure since burn.
A detailed description of the percentage of sub-
jects reporting musculoskeletal conditions is pre-
sented in Table 3. The data in this table is presented
in two ways: 1) the overall sample (average 17 years
post injury; n = 93) and 2) the overall sample clas-
sified into six categories based on time from injury
(3–5, 6–10, 11–15, 16–20, 21–30, and >30 years
postburn). Joint pain and joint stiffness were the two
most common problems reported by study partici-
pants irrespective of their time from injury. Those
who are 11 to 30 years from the time of their injury
report the problem more than those who are either
less than 10 years or more than 30 years. More
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Journal of Burn Care & Research
Musculoskeletal Conditions
“Now/Current” N (%)
Joint pain 69 (70)
Joint stiffness 64 (65)
Problems walking or running 55 (56)
Fatigue 53 (54)
Weak arms and hands 50 (51)
Weight gain 50 (51)
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Painful feet 41 (42)
Shortness of breath 38 (39)
Weak legs and feet 37 (38)
Joint swelling 34 (35)
Weight loss 15 (15)
Heterotopic bone 8 (8)
than half of the overall sample report fatigue which
is found to be more prevalent among those who
are 6 to 15 years from their injury. Nearly 40% of
the overall sample report shortness of breath. This
number stays relatively the same across all groups,
with the exception of the 11 to 15 years postinjury
group (67%). Report of weak arms and hands, weak
legs and feet, painful feet, and problems walking or
running is higher among subjects who are 3 to 5
years from the time of their injury when compared
with subjects who are farther out from their injury.
Forty-four percent of the subjects reported exercis-
ing regularly at an average of 17 years from the time
of their injury. The percentage of subjects report-
ing exercising regularly was the highest in the 3 to 5
years postinjury group followed by >30 years postin-
jury group (58 and 50%, respectively). It is also of
interest to note that the percentage of participants
reporting problems with burn-related musculoskele-
tal conditions is lower among those who are 20 years
or more from the time of their injury.
History and Physical Examination
Ninety-three of 98 subjects (five participants failed
to keep their appointment) participated in the physi-
cal exam conducted by a physical medicine and reha-
bilitation physician which lasted an average of 60 to
90 minutes. The findings from the examination of
burn-related musculoskeletal conditions are shown
in Table 4 for the overall sample (n = 93) at an aver-
age of 17 years postinjury, and for each of the six
categories based on time from injury.
In the physical examination, the term limitation of
motion (LOM) is used instead of contracture. Active
and passive range of motion was observed by the
physician during the examination. A goniometer was
 Journal of Burn Care & Research
Volume 37, Number 4 Holavanahalli, Helm, and Kowalske  247

Table 3. Burn-related musculoskeletal conditions reported by subjects (N = 98) at an average of 17 years after burn injury
at the time of study participation and with a breakdown of the overall sample based on time from injury
Breakdown of Overall Sample
Overall Sample 17
Years Postburn Yr (Avg) 3–5 Yrs 6–10 Yrs 11–15 Yrs 16–20 Yrs 21–30 Yrs >30 Yrs

Subjects (N) 98 19 20 15 15 13 16
Mean %TBSA burn 51 (30–97) 59 (35–97) 61 (31–95) 52 (30–78) 62 (38–87) 58 (45–80) 51 (30–86)
(range)
Sex (% male) 63 74 65 80 67 46 44
Ethnicity (% 68 84 50 53 67 77 81
Caucasian)

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Age (yrs) 47 46 42 45 50 47 53
Age at time of burn 29 41 32 31 33 22 11
(yrs)
% Subjects reporting
 Joint pain 70 63 60 80 93 69 63
 Joint stiffness 65 63 55 67 80 69 63
 Joint swelling 35 11 30 53 47 31 44
 Fatigue 54 58 65 60 53 46 38
 Shortness of 39 42 30 67 27 39 31
breath
 Weak arms and 51 63 58 47 60 39 38
hands
 Weak legs and feet 38 53 45 40 47 23 13
 Painful feet 42 63 55 40 40 39 6
 Weight gain 51 37 50 47 67 62 50
 Weight loss 15 21 20 13 7 23 6
 Problems walking 56 74 60 67 60 46 25
  or running
 Problems sleeping 59 58 80 67 47 62 38
 Heterotopic bone 8 11 5 20 7 8 6
 Exercise regularly 44 58 37 29 47 39 50
 (yes)

not used to measure the range of motion. Even at
an average of 17 years from the time of their injury,
73% (68 of 93) of the study sample were found to
have a LOM. The areas that were seen to be affected
the most were the neck (47%), hands (45%), and the
axilla (38%). Among those with an axillary LOM,
limitation in shoulder abduction was seen in over
85% of the subjects. The clinical exam of the hand
resulted in an enormous magnitude of data relating
to the LOM, deformities, ankylosis, subluxations,
dislocations, and amputations. The findings of the
musculoskeletal outcomes of the hand secondary
to a severe burn injury will be presented in detail
and separately as part of the continuing series of
presentations on long-term outcomes. While the
elbow (23%) and the feet (20%) were the other
areas affected by LOM, the hip (4%) and knee (2%)
seemed to be less problematic. LOM was seen as a
predominant problem among subjects in all six cat-
egories of time from injury. Eighty-five percent of
the participants who were 21 to 30 years postburn
and 71% of those more than 30 years postburn injury
were found to have LOM.
About 29% of the overall sample had problems
with gait upon clinical examination. Gait problems
resulted from a drop foot, antalgia, plantar abnor-
malities, and tight heel cords. Deconditioning was
observed in 12% of those examined in the overall
sample. With the exception of a single individual,
deconditioning was not seen in subjects who were
20 years or more form the time of their injury.
HO was seen in 16% of the subjects in the overall
sample during the physical exam and this number is
higher than subject self-report as shown in Table 2.
HO in the elbow (80%) was the most common. Only
one case of HO for each of the other locations, such
as the shoulder, hip, and knee were seen. Twelve of
15 instances of HO were seen among participants
who were 3 to 15 years from the time of their injury.
About 37% of the overall sample had amputa-
tions, and a majority of these included the hand,
lower extremity, including knee, foot/toe, and

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
248  Holavanahalli, Helm, and Kowalske July/August 2016

Table 4. Physician findings from a clinical examination of burn-related musculoskeletal conditions in subjects (N = 93) at
an average of 17 years after burn injury
Overall Sample Breakdown of Overall Sample by Postburn Year
17 Yrs (Avg)
Postburn 3–5 Yrs 6–10 Yrs 11–15 Yrs 16–20 Yrs 21–30 Yrs >30 Yrs

Subjects (N) 93 19 20 15 15 13 16

%TBSA burn, mean 51 (30–97) 59 (35–97) 61 (31–95) 52 (30–78) 62 (38–87) 58 (45–80) 51 (30–86)
(range)
Sex (% male) 63 74 65 80 67 46 44
Ethnicity (% 68 84 50 53 67 77 81

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Caucasian)
Age (yrs) 47 46 42 45 50 47 53
Age at time of burn (yrs) 29 41 32 31 33 22 11

Physician Findings N (%) N (%) N (%) N (%) N (%) N (%) N (%)

LOM 68 (73) 15 (88) 14 (74) 12 (80) 6 (40) 11 (85) 10 (71)

Axilla 35 (38) 8 (47) 8 (42) 3 (20) 5 (33) 6 (46) 5 (36)
Neck 44 (47) 9 (53) 10 (53) 6 (40) 1 (27) 7 (54) 8 (57)
Elbow 21 (23) 5 (29) 6 (32) 2 (13) 2 (13) 5 (38) 1 (7)
Hand 42 (45) 9 (53) 9 (47) 9 (60) 4 (27) 6 (46) 5 (36)
Hip 4 (4) 1 (6) 1 (5) 1 (7) 1 (7) – –
Knee 2 (2) 1 (6) 1 (5) – – – –
Feet 19 (20) 4 (23) 5 (26) 4 (27) 2 (13) 3 (23) 1 (7)
Microstomia 21 (23) 3 (18) 5 (26) 2 (13) – 6 (46) 5 (36)
Facial deformity 41 (44) 11 (65) 8 (42) 6 (40) 4 (27) 6 (46) 6 (43)
HO 15 (16) 3 (18) 6 (32) 3 (20) 1 (7) 1 (8) 1 (7)
Gait 27 (29) 4 (23) 7 (37) 4 (27) 6 (40) 4 (31) 2 (14)
Amputation 34 (37) 10 (59) 7 (37) 6 (40) 4 (27) 3 (23) 4 (29)
Obesity 8 (9) – 2 (10) 1 (7) 2 (13) 2 (15) 1 (7)
Deconditioned 11 (12) 2 (12) 3 (16) 2 (13) 3 (20) – 1 (7)
Callus feet 8 (9) 1 (6) – 1 (7) 3 (20) 2 (15) 1 (7)
Pain 22 (24) 5 (29) 6 (32) 4 (27) 2 (13) 3 (23) 2 (14)

HO, heterotopic ossification.

Dashed cells indicate that there were no cases with the condition found during the physical examination.

upper extremity, including lower elbow and upper
elbow. Sixty-eight percent of the subjects enrolled
at the WBC had an amputation of some kind when
compared with 32% of subjects enrolled at the burn
center, who had an amputation. Over 40% of the
participants in the overall study sample had a facial
deformity. These included deformities of the ear
(32%), nose (27%), eyebrows and eyelashes (26%),
mouth (23%), and eyelids (12%). About 11% of those
examined in the overall sample had facial amputa-
tions that mostly involved the ears.
Level of Functional Adaptation as Measured
by the BSHS
The results of the BSHS-B domain scores for the
overall sample (n = 98) and with a breakdown of the
sample into six groups based on time from injury are
presented in Table 5. The BSHS scores range from
0.00 to 1.00 with higher scores indicating greater
functional adaptation. The maximum possible score
were not reported on any of the BSHS items (global,
domain, or subdomains) at any time point. At an
average of 17 years from time of injury, scores for
the physical and social domains were 0.80 and 0.82,
respectively. Scores for the psychological and general
domains was below 0.80. The results indicate that cer-
tain subdomain items, such as mobility, self-care, hand
function, and family/friends have higher scores when
compared with subdomain items, such as role activi-
ties, body image, affective, and sexuality. The global
(BSHS total) score for the overall sample in this study
at 17 years postinjury was reported to be 0.78. When
observing the BSHS scores across the six groups of
time from injury, those subjects who are more than 20
years postburn have a BSHS total score above 0.80.
A review of the BSHS scores across the different
groups based on post-burn time showed that subjects
who were 3 to 5 years postburn injury scored <0.80

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 Journal of Burn Care & Research
Volume 37, Number 4 Holavanahalli, Helm, and Kowalske  249

Table 5. The BSHS-B scores (mean [SD]) in the overall sample (N = 98) at an average of 17 years after burn injury at the
time of study participation and with a breakdown of the overall sample based on time from injury

Overall Sample Breakdown of Overall Sample by Postburn Year

17 Yrs (Avg)
Postburn 3–5 Yrs 6–10 Yrs 11–15 Yrs 16–20 Yrs 21–31 Yrs >30 Yrs

N = 97 N = 19 N = 20 N = 15 N = 15 N = 12 N = 16
BSHS Domains Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD). Mean (SD) Mean (SD)

Mobility 0.86 (0.21) 0.77 (0.27) 0.89 (0.22) 0.84 (0.18) 0.86 (0.22) 0.87 (0.22) 0.96 (0.06)
Hand Function 0.80 (0.25) 0.61 (0.33) 0.83 (0.23) 0.72 (0.22) 0.87 (0.20) 0.85 (0.22) 0.93 (0.14)
Role 0.69 (0.26) 0.55 (0.27) 0.68 (0.31) 0.65 (0.20) 0.72 (0.24) 0.73 (0.29) 0.87 (0.13)

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Body 0.69 (0.23) 0.63 (0.23) 0.72 (0.24) 0.65 (0.25) 0.67 (0.20) 0.71 (0.19) 0.77 (0.24)
Affective 0.78 (0.21) 0.77 (0.20) 0.77 (0.24) 0.74 (0.23) 0.76 (0.21) 0.81 (0.18) 0.86 (0.16)
Family 0.84 (0.17) 0.83 (0.18) 0.85 (0.21) 0.78 (0.18) 0.82 (0.16) 0.87 (0.14) 0.88 (0.16)
Sex 0.79 (0.26) 0.68 (0.25) 0.81 (0.26) 0.75 (0.31) 0.77 (0.30) 0.86 (0.22) 0.89 (0.16)
Physical 0.80 (0.21) 0.67 (0.26) 0.82 (0.23) 0.75 (0.19) 0.82 (0.18) 0.83 (0.21) 0.93 (0.09)
Psychological 0.75 (0.22) 0.75 (0.20) 0.73 (0.27) 0.72 (0.23) 0.74 (0.20) 0.72 (0.27) 0.84 (0.17)
Social 0.82 (0.17) 0.79 (0.17) 0.82 (0.20) 0.77 (0.19) 0.81 (0.17) 0.86 (0.15) 0.88 (0.15)
General 0.75 (0.20) 0.72 (0.21) 0.76 (0.25) 0.74 (0.19) 0.69 (0.20) 0.78 (0.17) 0.84 (0.14)
Global 0.78 (0.17) 0.74 (0.17) 0.79 (0.22) 0.74 (0.16) 0.76 (0.17) 0.81 (0.16) 0.87 (0.12)

BSHS, burn-specific health scale.

on all domains of the BSHS and the global score.
Subjects who were 6 to 10 and 16 to 20 years post-
burn injury scored >0.80 on the physical and social
domains. Subjects who were 21 to 30 years post burn-
injury scored 0.80 or above on the physical and social
domains, and the BSHS global. Subjects in the >30
years postinjury scored 0.80 or above on all the BSHS
domains and the BSHS global score. It is interesting
to note that subjects who were 11 to 15 years postin-
jury scored <0.80 on all domains of the BSHS.
On examining the BSHS subdomain items, the
scores for “family/friends” is consistently high
(>0.80) across all postinjury groups, with an excep-
tion of the 11–15 years postburn group. The scores
on the BSHS subdomain “body image” is consis-
tently low (<0.80) across all groups. Even subjects
who are >30 years postburn and who have a score
>0.80 on all BSHS domains and BSHS global scored
below <0.80 on the body image subdomain.
Independent-samples t-tests evaluated the differ-
ence between the means of the BSHS domain scores
of 1) subjects with LOM (n = 67) and without LOM
(n = 25); and 2) subjects recruited at the burn cen-
ter (n = 52) with subjects recruited at the WBC
(n = 46). The results of the independent-samples
t-tests are shown in Tables 6 and 7, respectively. As
shown in Table 6, subjects with LOM had signifi-
cantly lower scores on the BSHS physical domain
than subjects without LOM, t (49.15) = −2.34;
P = .02. On average subjects with LOM reported
poor physical health, as compared with subjects with
no LOM. There were no significant differences on
any other BSHS domain scores or the BSHS global
scores between subjects with and without LOM. As
shown in Table 7, subjects recruited at the burn cen-
ter had significantly lower BSHS physical (P = .02),
and BSHS general (P = .01) scores when compared
with the subjects recruited at the WBC.
Return to Employment
At the time of injury, 62% of the subjects in this study
were employed and about 25% were in school. Of
those employed at the time of injury, 72% returned
to work, with little over 50% returning to the same
job. Forty-six percent reported having returned to
school after their injury. Of those with a limitation of
motion, 72% returned to work with 41% returning
to the same job.
DISCUSSION
This study is a detailed report of musculoskeletal
conditions after a major burn injury (30% TBSA or
greater). Subject self-reports and in-depth physical
examination highlight some of the problems burn
survivors face long term at an average of 17 years
(range 3–53 years) from the time of their injury.
Although these conditions and problems have been
documented in the burn literature, it is the long-
term persistent nature of some of these conditions
that are underscored in this study.
Patients with severe burns (TBSA of >30%) have
been found to have weaker muscles even years after
the trauma, suggesting either an inability to fully

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
250  Holavanahalli, Helm, and Kowalske July/August 2016

Table 6. Results of independent-samples t-test evaluating the difference in BSHS-B scores between subjects with and with-
out LOM
LOM

BSHS Domains Yes (N = 67) No (N = 25) t P

Physical 0.77 (0.22) 0.88 (0.19) −2.34 .023*

Psychological 0.75 (0.21) 0.72 (0.26) −0.73 NS
Social 0.83 (0.16) 0.80 (0.20) −0.61 NS
General 0.75 (0.19) 0.74 (0.24) 0.18 NS
Global 0.78 (0.16) 0.78 (0.21) 0.10 NS

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BSHS, burn-specific health scale; LOM, limitation of motion; NS, not significant.
*P < .025.

recover or insufficient rehabilitation.10 This may be
related to injury to the nervous system with incom-
plete recovery. Another potential factor in burn-
induced skeletal changes is immobilization.11 There
is a need for long-term musculoskeletal assessments
in burn patients as loss of lean body mass contrib-
utes to morbidity during the acute phase of burn
care and slows rehabilitation and return to function
in society.11
Joint pain is a problem reported consistently by
a majority of burn injury survivors. The joint stiff-
ness and joint swelling reported by the participants
in this study did not match the findings in the physi-
cal exam. Due to burn-related contractures, the pull-
ing of the skin may be interpreted as joint stiffness.
The stiffness may be felt internally due to contrac-
tures. Some of the factors that contribute to joint
pain include contractures, joint ankylosis, and het-
erotopic bone. The highest incidences of contracture
formation are in the areas of the hand, head, neck,
and axilla.12–14 Restrictions in range of motion were
observed in about one-fifth of burn patients even 5
years after injury.15 In this study, the neck, hands,
and axilla have been found to be the most affected
areas with LOM at an average of 17 years after a
major burn injury. Twenty-three percent of the
study sample was found to have LOM in the elbow.
The elbow joint is critical to upper extremity func-
tion and a stiff elbow results in compensatory shoul-
der, wrist, and hand function frequently causing
other secondary ailments.16 Significant neck burns
may lead to deforming lateral flexion and rotation
contractures.17 Neck contractures can interfere with
basic activities of daily living, sports, and recreational
activities, and can be dangerous when driving, and
may limit job prospects. Inability to turn one’s palms
up (forearm pronation contractures), renders it dif-
ficult to perform certain activities, such as carrying a
tray or reaching for items with palms up. This type of
functional deficit interferes with many other activi-
ties of daily living. Axillary contractures often cause
cosmetic problems and functional deficiency.13 Most
axillary LOM in this study was found to be due to
tight anterior and posterior skin bands. If surgery
is delayed, full range of motion may be difficult to
achieve because of joint capsule tightness.
Over 40% of the subjects had some kind of facial
deformity and almost a quarter (23%) of the sub-
jects had microstomia which supports the literature
that maxillofacial disturbances after burns of the
head and neck are common.18 Oral commissures
are deforming, can interfere with activities of daily
living, prevent optimal dental care, result in many
dental problems, preclude easy access to the upper

Table 7. Results of independent-samples t-test evaluating the difference in BSHS-B scores between subjects recruited at
the burn center and the WBC
Recruitment Site

BSHS Domains Burn Center WBC t P

Physical 0.75 (0.24) 0.85 (0.17) −2.33 .022*

Psychological 0.73 (0.22) 0.77 (0.23) −0.78 NS
Social 0.80 (0.19) 0.85 (0.15) −1.36 NS
General 0.71 (0.22) 0.80 (0.16) −2.34 .021*
Global 0.75 (0.19) 0.82 (0.14) −2.07 NS

BSHS, burn-specific health scale; NS, not significant; WBC, World Burn Congress.
*P < .025.

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
Volume 37, Number 4 Holavanahalli, Helm, and Kowalske  251
airway, and can cause problems with swallowing
and eating.19,20
Patients with toe burn scar contractures routinely
report significant functional limitations, difficulty
with activities of daily living, inability to wear stan-
dard footwear, and challenges ambulating with a
normal gait.21–23 The greater the severity of toe con-
tracture, the greater the incidence of joint pain and
difficulties with prolonged walking.24 Burn contrac-
tures of the foot and ankle in pediatric patients have
a recurrence rate as high as 74%25 and this calls for
primary prevention.
Many reasons could be attributed to the problem
of painful feet which was reported by 46% of the
study subjects. If they were burned on the bottom of
their feet and toes, they could develop flexion con-
tracture of the toes, calluses, and fragile skin. Pain
can also be caused by deformities of the toes, such as
halux valgus, halux rigidus, tight heel cords, plantar
fasciitis, and partial foot amputations. Neurological
problems, such as peroneal nerve injury or periph-
eral neuropathy with clawing of the toes can be very
disabling and interfere with normal gait. Heel cord
tightness may cause an individual to walk on their
toes with increased pressure on and pain in the meta-
tarsal heads. Inserts may be required to provide pres-
sure relief. Diabetics with insensate feet who have
foot burns are even more complex due to additional
problems with poor wound healing, ulcerations,
neuropathic pain, and gait abnormalities.
HO is an infrequently encountered but well-
recognized complication that can result in signifi-
cantly compromised limb function,26–30 cause joint
immobilization and permanent physical impair-
ment.28 The most common areas for HO include
the elbow followed by the shoulder, hip, knee, and
forearm.26,28,31 The high rate of HO in the study
sample may be attributed to the large TBSA burn.
HO occurs in areas of persistent edema and persis-
tent open wounds. HO can involve the ulnar nerve
and cause weakness, loss of sensation, and deformity.
Ongoing active range of motion in the early stages
postinjury is essential to avoid joint fusion. Other
secondary complications include joint subluxation,
joint ankylosis, scoliosis, and kyphosis. Although not
all of these conditions can be corrected, exercise and
orthotics may help some of these problems.
Problems with walking or running are related to
burns of the lower extremity, and can occur due to
contractures, amputations, weakness, nerve damage,
painful feet, shortness of breath due to pulmonary
problems, obesity, or lack of exercise. Other contrib-
uting factors include ankylosis of the joints and neu-
rological problems. Patients with altered step length,
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
velocity, and cadence after a burn injury may have
impairments in ROM and muscle activity that affect
their ability to walk compared with healthy subjects.32
A higher proportion of burn survivors engage in
exercise compared with their healthy counterparts,
but a substantial number are exercising just once per
week or less, below the recommended guidelines of
the American Heart Association of activity for 20
minutes three times per week to maintain physical
fitness.33 Walking was the most common type of
exercise, and subjects reported lower compliance
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with stretching and strengthening exercises.33 Adult
burn survivors were also found to have a lower aero-
bic capacity compared with nonburned adults when
evaluated about 1 month postinjury.34 Adult burn
survivors are disproportionately unfit relative to the
general US population, and this puts them at an
increased risk of all-cause mortality.35 About 44% of
the subjects in this study reported exercising regu-
larly, and over 50% reported fatigue. It was not clear
if the fatigue was related to the exercise. The rea-
sons for fatigue may include deconditioning, weak-
ness, neurological problems, shortness of breath,
amputations of lower extremities, effect of extreme
hot or cold temperatures, lack of sleep, high blood
pressure, joint stiffness and pain, and painful feet.
Joint pain and stiffness could be factors affecting the
ability to exercise. When joints get stiffer, it could
increase the level of pain. Shortness of breath affects
walking and running and causes fatigue. Weakness in
arms and hands or legs and feet can cause shortness
of breath by increasing the work of exercise. Both
peripheral and mononeuropathies can improve by
remyelination and nerve regrowth over the first 2 to
3 years. If it has not resolved by 3 years, the changes
are likely permanent. Contractures can make arms
and hands weak, unable to grip. Obesity is a con-
tributing factor to fatigue, and pain in the hip, legs,
and feet.
Staying in bed for extended periods of time
can cause back pain. Low back pain is related to
increased bed rest. Although it is unlikely that back
pain 3 years postburn is due to the initial injury. It is
more likely that bone loss or postural concerns along
with degenerative changes associated with aging
are contributing factors. Normal ageing can result
in decreased shoulder ROM as it affects the mus-
culoskeletal components of the shoulder complex.36
Other causes of decreasing shoulder ROM with age-
ing include loss of tissue elasticity and a reduction
in muscle mass,36 shortening of joint capsules, liga-
ments, muscles and tendons,37 and stiffness.38 Gill et
al39 found a consensus among a number of studies
that in older adults (aged 50 years and older) both

252  Holavanahalli, Helm, and Kowalske July/August 2016
active and passive shoulder ROM are significantly
lower than the American Academy of Orthopedic
Surgery norms and that increasing age is statisti-
cally related to decreased active flexion,40,41 abduc-
tion,40 and external rotation.37 A downward trend
for shoulder flexion and abduction with increasing
age, particularly from the fifth decade has also been
noted.39
At 17 years postinjury, burn survivors report bet-
ter functional adaptation in the physical and social
domains than in the psychological, general, or global
domains. About 72% of the study subjects employed
at the time of injury returned to work, similar to the
findings of a systematic review by Mason et al42. In
addition, 61% of those employed at the time of their
burn injury reported being employed at the time of
study participation (average of 17 years postinjury).
Burn survivors, however, continue to report diffi-
culties with body image and role activities including
doing regular chores around the house, carrying on
ordinary leisure activities, and participating in physi-
cally active pastimes. It was not surprising to find
that subjects with LOM had significant difficulty in
areas of mobility, self-care, hand function, and role
activities.
Despite no significant difference in the size of
burn, subjects at WBC reported better functional
adaptation in the BSHS general domain that includes
items, such as social sensitivity. These subjects were
younger at the time of injury, more years postinjury
and younger at the time of study evaluation. Being
around individuals who have been through a similar
trauma may seem to aid in the coping and adjust-
ment process or perhaps those who chose to attend
WBC are already more socially comfortable.
Previous long-term studies of burn-specific health
have found that patients suffered from substantial
heath losses at short term, but after 18 months the
majority reached a health-related quality of life com-
parable with the norm population with the excep-
tion of patients requiring two or more surgeries
postdischarge.43 Most problems were reported in
the subscales heat sensitivity, body image, and work,
but burn-specific health was found to improve over
time, including up to 7 years postburn.44 However,
a study45 examining patients 5 years postburn injury
showed that even slight functional limitations were
linked to severe depression, similar to the values
found with patients with serious functional impair-
ment. Patients with one or more contractures had
significantly lower scores for the SF-36 subscales of
physical functioning, physical role limitations, body
pain, and vitality.46 Patients surviving >70% TBSA
burns and who were more than 2 years from their
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Journal of Burn Care & Research
injury were found to have a poorer quality of life
compared with that of general population indicating
that physical and psychological problems persist for
a long period.47 A retrospective cross-sectional study
of subjects surviving over 70% TBSA burns showed
that while most had a satisfying quality of life, a few
patients had continuing serious physical disability
at an average of 14.7 years after injury.48 Individu-
als with burn injuries have significant difficulties
with community integration as no improvement was
found over time beyond 6-month postburn injury.49
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Burn patients as a group reported overall quality of
life similar to that of the norm population at about
47 months postinjury despite experiencing a signifi-
cant reduction of generic health and reporting limita-
tions poorer than expected for generation population
scores in both physical and psychosocial domains.50
CONCLUSION
This study underscores the importance of long-term
follow-up for patients with major burn injury. Reha-
bilitation from a burn injury is indeed a lifelong jour-
ney and the ultimate goal of burn rehabilitation is to
reintegrate the burn survivor into society with the
capacity to function and assume social responsibili-
ties.51 There are several limitations in the study that
need to be highlighted. The self-selection of sub-
jects introduces bias in the observed data. It remains
unknown what differences exist between subjects
we were able to contact and subjects we were not
able to contact. It is unknown whether the subjects
we were unable to locate are doing better or worse
when compared with those we were able to locate.
Limitation to recall information dating several years
back may affect the accuracy of subject self-reports.
The study is also limited by the absence of predic-
tive or intervening variables, and no control group
or statistical testing.6 Despite such limitations, the
findings of this study reinforce the persistent burn-
related impairments seen 3 to 30 years postinjury,
which are compounded by issues associated with
normal aging. Difficulty with basic and instrumental
activities of daily living, fine motor skills, and inabil-
ity to work, pursue hobbies or participate in recre-
ational activities or be functionally independent have
a significant effect on the quality of life. Difficulties
persist with role activities, body image, sexuality,
and specific-burn impairments, such as pain, health,
appearance, and social sensitivity. Outpatient reha-
bilitation programs should include exercise programs
tailored to contribute to the long-term rehabilitation
of injured.51 Long-term follow-up and therapeutic
 Journal of Burn Care & Research
Volume 37, Number 4 Holavanahalli, Helm, and Kowalske  253
interventions can lessen the burden on those who
have survived a major burn injury and therefore,
should be a standard of care.
ACKNOWLEDGMENTS
The authors would like to thank the Phoenix Society for
Burn Survivors, Grand Rapids, Michigan, for granting us
permission to collect parts of the data at the World Burn
Congress for two consecutive years. The authors would
like to also thank all burn survivors who consented to par-
ticipate in this study and provided valuable information.
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