a burn injury is one of the most traumatic injuries that a child or adult can 
 experience1 .
advances in acute burn care 
 have improved survival rates after burns , and this highlights the importance of physical 
 therapy rehabilitation programs after recovery from a burn injury in overcoming long - term 
 burn - related complications and extensive physical and functional limitations2 , 3 . 

pulmonary function ( pf ) can be compromised as a result of complications caused by smoke 
 inhalation , direct thermal damage to the respiratory tract , pulmonary edema , and respiratory 
 tract infection4 .
thermal injuries result 
 in a reduction of pulmonary function , which is typified by an initial obstructive pattern of 
 disease lasting up to 2  years and then the restrictive pattern of pulmonary function , which 
 lasts into convalescence , and patients who survive thermal injury might not regain normal 
 cardiopulmonary functions5 .
the evidence pertaining to the effect of impaired pulmonary function on exercise capacity 
 in burn injury patients is equivocal .
mlcak et al.6 reported that burn injury patients with inhalation injuries 
 displayed a ventilatory rather than a cardiac limitation to exercise .
furthermore , bourbeau 
 et al.7 found that long - term pulmonary 
 function was impaired but not below normal limits , and that exercise tolerance was unchanged 
 in adults following inhalation injury .
conversely , willis et al.8 demonstrated that adults with burn injuries , with and 
 without inhalation injury , had a signicantly lower aerobic capacity and greater oxygen 
 desaturation during a maximal oxygen exercise test compared with healthy controls .
this 
 decit in burn injury patients persisted for up to ve years following injury , although it 
 was not correlated with pf .
the decreased aerobic capacity demonstrated in the burn injury 
 population may be due to periods of prolonged bed rest , as well as to the associated 
 hypermetabolic state that occurs as a result of major burns .
the hypermetabolism that 
 follows burn , impacts the cardiovascular system , is characterized by increased oxygen 
 consumption , cardiac output , minute ventilation , and core temperature9 .
the resultant increased energy expenditure can lead to 
 exhaustion , which can have deleterious consequences for aerobic capacity10 .
periods of prolonged bed rest and 
 inactivity experienced during recovery from major burns may further decrease aerobic 
 capacity11 .
balance is a function of multiple factors , including 
 tactile sensation , muscle strength , proprioception , joint mobility , and cognition .
the scale is used in a wide 
 range of populations , including the elderly , stroke patients , and parkinson s patients and 
 has excellent correlation with gait speed12,13,14,15 .
burn rehabilitation strategies aim to achieve optimal function and independence in 
 individuals with a burn injury , with the ultimate goal being community reintegration16 .
aerobic exercise is any activity that uses large muscle groups that overload the heart and 
 lungs and causes them to work harder than at rest for a period of 15 to 20 minutes or 
 longer17 .
it provides an objective and 
 reproducible assessment of a patient s functional capacity or exercise capacity18 .
aerobic exercises are considered an important component of rehabilitation programs , as they 
 improve the patient s functional status , and if the intensity of training is adequate , they 
 result in a physiological training effect19,20,21 .
therefore , the current study aimed to assess whether a 12-week exercise program consisting 
 of a traditional rehabilitation program and/or aerobic exercise would improve aerobic 
 capacity and balance in adults after a burn injury .
they were 
 recruited from the outpatient clinic of the faculty of physical therapy , cairo university , 
 which is where the study was conducted .
the inclusion criteria included age 2040 years , 
 thermal burns covering 2040% of the total body surface area ( tbsa ) as assessed by the rule 
 of nines method22 , second degree burns , 
 and at least 3 months after burn injury .
the exclusion criteria included the presence of 
 diabetes , neuropathy , psychiatric disorders , cardiopulmonary diseases , quadriplegia , certain 
 behavior or cognitive disorders ( e.g. , aggressive behavior , impulsivity , and dementia ) , leg 
 amputation , any limitation in the rom of joints of the lower limbs , and participation in any 
 rehabilitation program prior to the study that may prevent adequate participation in 
 exercise activities or affecting the results .
patients were randomized into two groups : a 
 study group ( group a ) , which included 15 patients who participated in an aerobic exercise 
 program in addition to a traditional rehabilitation program , and control group ( group b ) , 
 which included 15 patients who participated in a traditional rehabilitation program .
all variables were collected for all participants at baseline and after 3 months , which was 
 the length of the intervention period .
aerobic capacity assessment was used to determine maximum oxygen consumption ( vo2max ) , and 
 participants underwent a graded exercise test ( gxt ) performed on treadmill using the 
 modified bruce protocol .
this test has been well validated with respect to evaluation and 
 assessment of cardiovascular fitness and for testing maximal aerobic endurance on a 
 treadmill8 .
the protocol required 
 participants to walk at increasingly higher workloads , with the speed and the inclination of 
 the treadmill increased incrementally every three minutes until the participant could no 
 longer continue because of volitional exhaustion , despite strong verbal encouragement of the 
 investigators . during gxt , subjects breathed through a face mask ( hans rudolph inc , kansas 
 city , mo , usa ) connected to a calibrated expired gas analysis system ( zan-680 ergospiro 
 ergospirometry system ) , which is manufactured by zan me bgerate gmbh , germany .
expired gas 
 passed through a flowmeter , an oxygen analyzer , and a carbon dioxide analyzer .
the flow 
 meter and gas analyzers were connected to a computer , which calculated breath - by - breath 
 minute ventilation , oxygen uptake , carbon dioxide production , and the respiratory exchange 
 ratio ( rer ) from conventional equations . heart rate ( hr ) was monitored continuously during 
 the graded exercise test .
absolute maximum aerobic capacity ( vo2max ) was taken as the 
 average value over the last 30 seconds during the exercise test23 .
treadmill time measurement was done by calculating the maximum time that a patient could 
 walk on the treadmill .
balance assessment was done by using the berg balance scale ( bbs ) , which is a valid and 
 reliable clinical tool for assessing balance in individuals .
it is a 14-item battery of 
 tasks related to activities of daily living ( adls ) .
the tasks address the subject s ability 
 to maintain positions of increasing difficulty by progressively diminishing the base of 
 support .
there are three dimensions to the test : maintenance of a position , postural 
 adjustment to voluntary movements , and reaction to external perturbations .
each task is 
 scored from zero to four , with zero the lowest and four the highest functional level .
a 
 composite score of 020 is categorized as a high fall risk , 2140 is categorized as as a 
 medium fall risk , and 4156 is categorized as a low fall risk24,25,26,27 . subjects with missing or 
 incomplete berg balance scale assessments were excluded from the analysis .
the treatment procedures were started three months after the patients were discharged from 
 the hospital and lasted for 12 weeks in both groups .
burn patients in group a had also participated in an 
 aerobic exercise program at a rate of 3 sessions / week , with each session lasting from 2040 
 minutes .
a ram model 770 cf electronic treadmill was used for aerobic exercise . each 
 participant
treadmill running exercises began and 
 ended with warming - up and cooling down periods in the form of walking on the treadmill for 
 about 510 minutes at a speed of 11.5 kilometers / hour with zero inclination . in the cooling 
 down period , the speed was gradually decreased until reaching zero29 , 30 .
participants 
 were regularly monitored throughout the exercise program , and their heart rates were 
 recorded during the exercise sessions .
the traditional physical therapy program for both groups was in the form of stretching and 
 strengthening exercises for all areas involved , in addition to diaphragmatic breathing 
 exercises , 3 days / week , while activities of daily living were performed daily .
ethical considerations were taken into account by explaining the study protocol in detail 
 to each patient before the initial assessment , and signed informed consent was obtained from 
 each patient ( or his family ) before enrollment in the study .
this study was approved by the 
 institutional review board of the faculty of physical therapy , cairo university .
the quantitative variables were 
 expressed as the mean  standard deviation ( sd ) .
comparison of variables before and after 
 the intervention was done using the paired t - test .
nonparametric statistical analysis was used for the berg 
 balance scale including the wilcoxon signed rank test for variable comparison within groups 
 and the mann - whitney u test for comparison between groups .
all p - values in the analysis were 
 considered statistically significant when p  0.05 .
table 1table 1.statistical analysis of demographic characteristics of patients in both 
 groupsvariablesgroup ( a)group ( b)t - valueage ( years)27.97.329.56.60.6584weight ( kg)68.15.169.55.10.7555height ( cm)167.86.6170.16.70.9272tbsa ( % ) 32.96.629.55.11.6022data are presented as the mean  sd .
t - value : unpaired t value.*significant . shows demographic data for the patients , and it demonstrates that there were 
 no significant differences between the groups regarding patient age , weight , height tbsa , 
 and sex distribution .
table 2table 2.statistical analysis of aerobic capacity variables and berg balance scale scores 
 within each groupvariablegroupsprepostpercentage of improvementvo2max ( ml / m / kg)study ( n=15)21.8 ( 2.3)33.9 ( 3.8)55.6control ( n=15)22.4 ( 1.9)25.8 ( 2)14.9treadmill time ( minutes)study ( n=15)11.1 ( 1.8)18.7 ( 1.8)68.2control ( n=15)10.9 ( 1.7)13.8 ( 1.2)26.5berg balance scale study ( n=15)27 ( 2429)48 ( 4551)77.8control ( n=15)27 ( 2429)40 ( 3443)48.2data are presented as the mean ( sd ) for aerobic capacity variables and median 
 ( interquartile range ) for berg balance scale scores .
. shows the results for aerobic capacity , and it demonstrates that there were no 
 statistically significant differences in mean vo2 max and treadmill time values in the two 
 groups before the intervention ( p>0.05 ) .
after implementation of the intervention , 
 patients in the study and control groups exhibited significant differences in vo2 max and 
 treadmill time in the paired t - test between pre- and posttreatment values , as the mean 
 pretreatment values for vo2 max were 21.75  2.25 and 22.44 1.9  ml / m / kg , respectively , and 
 the mean posttreatment values for vo2 max were 33.85 3.76 and 25.78 2.03  ml / m / kg , 
 respectively ; the p - value was 0.001 in both groups .
regarding treadmill time , the mean 
 pretreatment values for the study and control groups were 11.11.82 and 10.891.72 minutes , 
 respectively , while the mean posttreatment mean values were 18.661.78 and 13.781.23 
 minutes , respectively ; the p - value was 0.001 in both groups . upon comparing the vo2 max and 
 treadmill time results between the 2 groups post intervention
, there was a significant 
 difference in the mean posttreatment values favoring the study group ( p = 0.0001 and 0.001 , 
 respectively ; table 3table 3.statistical analysis of post treatment values of aerobic capacity variables and 
 berg balance scale scores between groupsvariablestudy group ( n=15)control group ( n=15)vo2max ( ml / m / kg)33.9 ( 3.8)25.8 ( 2)treadmill time ( minutes)18.7 ( 1.8)13.8 ( 1.2)berg balance scale48 ( 4551 ) 40 ( 3443 ) data are presented as the mean ( sd ) for aerobic capacity variables and median 
 ( interquartile range ) for berg balance scale scores . * significant . ) .
data are presented as the mean ( sd ) for aerobic capacity variables and median 
 ( interquartile range ) for berg balance scale scores .
data are presented as the mean ( sd ) for aerobic capacity variables and median 
 ( interquartile range ) for berg balance scale scores . *
there were no statistically 
 significant differences in the median bbs values in the two groups before the intervention 
 ( p>0.05 ) .
there were significant differences between the median pre- and posttreatment 
 values of the bbs for the study and control groups ( p= 0.001 in both groups ) .
statistical 
 analysis of the median posttreatment values of both groups showed a significant difference 
 ( p<0.0001 ) favoring the study group ( tables 2 
 and 3 ) .
scientific evidence has dramatically changed our ideas about the relationships among 
 physical activity , rest , and fatigue .
several studies have reported that exercise can 
 prevent the manifestation of fatigue and reduce its intensity in burn patients during and 
 after treatment .
this approach may appear counterintuitive ; however , physical activity 
 produces adaptive changes such as gains in muscle mass and plasma volume , improved lung 
 ventilation and perfusion , increased cardiac reserve , and a higher concentration of 
 oxidative muscle enzymes .
furthermore , resistance exercises have been shown to reduce the 
 loss of muscle mass related to corticoid treatment31 , 
 32 . the current study aimed to evaluate the effect of addition of aerobic exercise to a 
 traditional rehabilitation program for burn patients on their aerobic capacity and 
 balance .
the results of the current study pointed out that there was a reduction in the exercise 
 capacity of burn patients represented by a reduction in the vo2max compared with the normal 
 values before application of the treatment procedure .
this finding is supported by the 
 results achieved by suman and his colleagues28 , who reported abnormal cardiopulmonary functions in a patient who 
 survived a thermal injury .
in addition , our results showed that there was improvement in the 
 exercise capacity , treadmill time , and balance of the burn patients after 12 weeks of 
 exercise training .
the study group , which performed training using aerobic exercise in 
 addition to the traditional program , showed more significant improvement in both vo2 max and 
 bbs compared with the control group .
improvement in the aerobic capacity variables may be 
 due to an increase in the blood flow to the active muscle mass because of an increase in 
 maximal cardiac output , and the changes within the muscle also contribute to this increase , 
 primarily the increases in capillarization , myoglobin , and oxidative enzyme activity33 .
in addition , it was suggested that the significant increase in aerobic capacity might be 
 related to the effect of aerobic exercise in improving respiratory function and to an 
 increase in the stroke volume of the heart by the effect of regular exercise .
these 
 respiratory adaptations facilitate oxygen supply to tissues and add further evidence to the 
 improvement of respiratory fitness34 .
similarly , a study was previously done to compare the efficacy and effects of an exercise 
 program versus traditional outpatient therapy in children with burn injuries , and it 
 concluded that an exercise program may be safely included in rehabilitation programs for 
 children with severe burns and that it can be effective in increasing muscular strength and 
 functional outcome31 .
suman et al.28 reported that a 12-week 
 exercise program , when implemented six months post injury , improved both aerobic exercise 
 capacity and pf in children with severe burns , which supports the current study results .
de - lateur et al.3 have also been 
 established that a 12-week aerobic treadmill exercise program improved aerobic capacity in 
 adult burn survivors , when implemented between 9 and 122 days post injury , which is 
 consistent with our results .
grisbrook et al.35 evaluated the effects 
 of exercise training on aerobic capacity and pf in adults with long - term burns ( at least two 
 years post burn ) .
the exercise training consisted of interval training ( combination of high- 
 and low / moderate - intensity exercise ) and resistance exercises for 12 weeks .
exercise 
 training did not result in pf improvements , but there were improvements in aerobic capacity 
 and clinically relevant achievement towards occupational performance goals , which is in 
 agreement with the results of the current study .
the effect of aerobic exercise on balance in burn patients and on the bbs have not been 
 widely studied in burn patients . in this study , patients demonstrated increases in both the 
 raw bbs score ( mean : 17 points ) and fall risk categories .
studies have found that a change 
 of eight points in the bbs score correlates with a meaningful clinical change36 . however ,
the results of a study by schneider et al.15 , which suggested an overall functional 
 improvement in balance with inpatient rehabilitation therapy for burn injury , are similar to 
 ours .
there are some limitations to this study like the small sample size and lack of follow - up 
 over the following months after the intervention period , which reflect the need for future 
 research with a larger sample of patients and follow - up measurements . in spite of that
, 
 statistically signicant improvements were observed across all outcome measures in both 
 groups , suggesting that these outcomes would be reected in a larger sample .
standardization of rehabilitation program is difficult , 
 as no two burn injuries are identical and physical therapy programs are tailored to each 
 patient s individualized lesions .
however , this study underscores the importance of addition 
 of aerobic exercises to burn rehabilitation programs as an approach to improve aerobic 
 capacity and balance in the burn population .
 [ purpose ] this study aimed to determine the impact of aerobic exercise on aerobic 
 capacity , balance , and treadmill time in patients with thermal burn injury . 
 [ subjects and 
 methods ] burned adult patients , aged 2040 years ( n=30 ) , from both sexes , with second 
 degree thermal burn injuries covering 2040% of the total body surface area ( tbsa ) , were 
 enrolled in this trial for 3 months . 
 patients were randomly divided into ; group a ( n=15 ) , 
 which performed an aerobic exercise program 3 days / week for 60  min and participated in a 
 traditional physical therapy program , and group b ( n=15 ) , which only participated in a 
 traditional exercise program 3 days / week . 
 maximal aerobic capacity , treadmill time , and 
 berg balance scale were measured before and after the study . 
 [ results ] in both groups , the 
 results revealed significant improvements after treatment in all measurements ; however , 
 the improvement in group a was superior to that in group b. [ conclusion ] the results 
 provide evidence that aerobic exercises for adults with healed burn injuries improve 
 aerobic physical fitness and balance . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION