Supporting community reintegration after burn injuries

More than 30% of burn survivors report experiencing long-term psychosocial challenges after their injury (Rosenberg et al., 2018; Shokre et al., 2024), including managing social relationships and participating in meaningful activities (Capell et al., 2025). During hospitalization, survivors report symptoms including nightmares and disrupted sleep, post-traumatic stress from their incident, anxiety, depression, hopelessness, and changes in self-identity (Fauerbach et al., 2011; Rosenburg et al., 2018). Burn centers, including the one at Regions Hospital (Regions) in Minnesota, provide comprehensive support systems to address patients’ psychosocial needs throughout their hospitalization. However, patients enter a new phase of recovery as they leave the hospital, and this community reintegration process brings new challenges. As burn survivors return to the community, they must manage their recovery process while adjusting to changes in their sense of self. Occupational therapy practitioners (OTPs) are well-equipped to support these transitions, as they focus holistically on occupational participation, routines, and relationships. Practitioners can support survivors by helping them build confidence, establish new routines, and reconnect with their sense of self outside of the hospital setting.

Social Adjustment

Occupational therapy supports the health and well-being of populations, enabling them to engage in their desired occupations. The Occupational Therapy Practice Framework: Domain and Process (OTPF-4; American Occupational Therapy Association [AOTA], 2020) defines health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (AOTA, 2020, p. 5). OTPs provide support for various occupations, including social participation, which includes any activity that involves interacting with other individuals, such as family members, friends, intimate partners, and community members (AOTA, 2020).

For burn survivors, both physical and psychological factors can affect social participation levels. Changes in body image and self-esteem can contribute to a fear of being judged by others, which may lead to increased isolation. Physical changes such as fatigue, pain, itch, sensitivity to touch, and skin tightness may exacerbate these concerns and affect how an individual pursues social opportunities. Symptoms of anxiety and depression are common in burn survivors, which may decrease motivation or desire to spend time with friends, family members, or romantic partners (Shokre et al., 2024).

In addition to personal factors, burn survivors may experience losses that create further barriers to social participation. These may include having to relocate after losing their home in a fire, or the injury or death of friends or family members involved in the burn event. Job loss or increased financial strain after hospitalization may affect access to social events or activities. Additionally, an inability to drive, whether due to pain medications or physical limitations, can affect an individual’s independence and ability to connect with loved ones after they leave the hospital.

OTPs can help address barriers to social engagement by identifying the underlying reasons for one’s social isolation. This may include self-perception, fear of judgment or rejection from others, mental health challenges, or concerns about having little or no social support (Rosenburg et al., 2018). As practitioners gain insight into these contributing factors, they can tailor their interventions to their patients’ specific needs. Practitioners can refer individuals struggling to cope with their experiences to peer support groups, which provide opportunities for survivors to process emotions and connect with others who have lived through similar experiences. OTPs also support individuals with appearance-related anxiety through the development of coping skills, cognitive reframing practices, and gradual exposure to their changed physical appearance.

As burn survivors begin to cope with their new reality, OTPs may gradually expose them to social experiences, using strategies to build confidence in discussing their injuries, coping with anxiety during social interactions, setting boundaries, and advocating for their needs by creating social scripts or role-playing through different scenarios. Practitioners at Regions Hospital, a Level 1 Trauma Center in St. Paul, Minnesota, begin addressing social participation during hospitalization to prepare for discharge. They educate patients on scripts to use for managing stares or comments from strangers. They also scaffold exposure to social environments with trips to the hospital gift shop or cafeteria to practice these strategies in relatively safe environments (those with controls and support) before leaving the hospital. Additionally, OTPs encourage survivors to initiate and plan activities to support their engagement with peers, such as going to the movies or cooking a meal for others. Participating in these meaningful activities can help survivors reconnect with their sense of self, supporting their overall engagement in social relationships. These practices can help survivors reduce social avoidance tendencies, which often lead to higher rates of depression and lower body image (Rosenburg et al., 2018).

Burn survivors may also face barriers within intimate partner relationships following hospitalization. OTPs support patients with their sexual and romantic relationships by addressing areas of concern, including training on positioning techniques to reduce discomfort in areas of increased sensitivity and to avoid shearing recently healed skin. OTPs also educate on fatigue management and desensitization strategies to support participation in physical activities, such as energy conservation techniques and exposure to different textures or clothing materials. Additionally, practitioners collaborate with survivors and their partners to explore activities to promote the intimacy and emotional connection associated with sexual activity but scaffolded in a manner that is comfortable for each individual.

Establishing New Routines

Another domain of occupational therapy practice involves supporting performance patterns to help shape and reinforce a person’s occupational identity. Routines are a specific type of performance pattern, and these are often disrupted as burn survivors discharge from the hospital and navigate transitions to the community. Routines are described as the “established sequences of occupations or activities that provide structure for daily life; they can also promote or damage health” (AOTA, 2020, p. 12). Patients discharging from the hospital must establish routines that align with new roles and responsibilities to optimize recovery. These responsibilities may include caring for their wounds, managing scars, engaging in home exercise programs (HEP), attending follow-up appointments, and returning to work and leisure activities. Survivors often have to navigate these new routines while still fulfilling the responsibilities of their previous roles. For example, a single parent who was injured may now have to return to caring for their child(ren) and managing household tasks without any support, while continuing to manage their recovery process. Throughout hospitalization, OTPs at Regions educate patients on how they can best manage their recoveries, emphasizing HEP routines to support their reintegration process. See Figure 1 for additional intervention approaches used by OTPs in burn rehabilitation settings. However, some individuals may not be able to return to previous roles as quickly as desired. Some may face difficulties returning to work or school, or they may require additional support to complete self-care activities. Challenges during reintegration may result in feelings of grief due to the loss of previous abilities or roles. This grief may be especially present when an individual loses the ability to participate in something that at one time defined them, affecting their sense of occupational identity.

Figure 1. Interventions to Address Social Participation and Routine Building

Case Example

Mateo is a 28-year-old Mexican-American male who sustained 27% total body surface area full and deep partial thickness burns affecting his bilateral upper extremities (circumferential), chest, anterior neck, and face. He is married, a father of one, and works as a barber. Throughout hospitalization, Mateo experienced serial surgical procedures, eventually resulting in split-thickness autografting to all affected sites. Mateo transitioned home after 55 days in the hospital. He presented for outpatient occupational therapy sessions at Regions with high levels of fatigue and hypertrophic scar formation. He also reported feeling anxious about how others would respond when they see him. Throughout his transition to the community, Mateo has faced challenges with returning to caregiver activities, work tasks, and social interaction.

During outpatient therapy, practitioners trained Mateo on ADLs and home management skills to reduce his wife’s caregiver burden and help protect their marital relationship. With training on HEP throughout hospitalization, OTPs also discussed how stretching and exercises have been implemented into daily routines. Additionally, OTPs facilitated strength and endurance programs, as well as fine motor coordination activities, to support Mateo with work and child-rearing tasks. OTPs also educated him on skin precautions so he could perform his roles without causing pain or injury to his fragile and sensitive new skin.

To prepare Mateo for work and social engagement outside of the hospital and home environments, practitioners exposed Mateo to his new skin through touch and mirror use. Throughout this gradual exposure, OTPs provided education and reassurance regarding the skin healing process and changes in pigmentation and sensitivity over time. OTPs also supported his emotional processing of these physical changes. They provided scripts and educated him on cognitive reframing techniques to use when discussing his burn event with strangers and loved ones, with a goal of improving stress management within social contexts.

Conclusion

Returning to everyday habits and routines can be difficult for burn survivors, especially reintegration to social participation, such as work, family engagement, and sexual intimacy. Social participation is a key occupation that occupational therapy can address throughout each phase of burn recovery. As survivors adjust to life outside of the hospital, OTPs can help re-establish meaningful roles and routines, fostering a sense of occupational identity and supporting long-term recovery.

References

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Capell, E. L., Kazis, L. E., Gabbe, B. J., Tracy, L. M., Ryan, C. M., Slavin, M. D., … Edgar, D. (2025). Measuring the social impact of burn injuries in Australia: An adaptation of the life impact burn recovery evaluation—The Aus-LIBRE Profile. Journal of Burn Care & Research, 46(1), 107–112. https://doi.org/10.1093/jbcr/irae134

Fauerbach, J., Wiechman, S., Mason, S., & the Model Systems Knowledge Translation Center. (2011). Psychological distress after burn injury [Fact sheet]. MSKTC. https://msktc.org/burn/factsheets/psychological-distress-after-burn-injury

Rosenberg, L., Rosenberg, M., Rimmer, R. B., & Fauerbach, J. A. (2018). Psychosocial recovery and reintegration of patients with burn injuries. In Total burn care (5th ed., pp. 709–720). Elsevier.

Shokre, E. S., Mohammed, S. E. M., Elhapashy, H. M. M., Elsharkawy, N. B., Ramadan, O. M. E., & Abdelaziz, E. M. (2024). The effectiveness of the psychosocial empowerment program in early adjustment among adult burn survivors. BMC Nursing, 23(1), 45. https://doi.org/10.1186/s12912-024-01700-x

Ellie Bute, OTD, OTR/L, is a recent graduate from the University of Minnesota’s Occupational Therapy Program. She completed her doctoral capstone experience at Regions Hospital Burn Center in St. Paul, supporting patients’ physical and psychosocial well-being throughout burn recovery.

Lisa Kittleson, MS, OTR/L, is the Lead Burn Therapist at Regions Hospital Burn Center in St. Paul, MN, a regional verified burn center that serves a five-state area in the Midwest. She has spent her career in the specialty area of burn rehabilitation, treating patients across the lifespan in the acute, rehabilitation, and outpatient phases of burn recovery.

Hannah Oldenburg, EdD, OTR/L, BCPR, is an Associate Professor at the University of Minnesota. She teaches adult rehabilitation course content and is a Supplemental Practitioner in Acute Care at the Mayo Clinic-Rochester.