burns 40 (2014) 1513–1520

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The effect of burn rehabilitation massage therapy

on hypertrophic scar after burn: A randomized
controlled trial

Yoon Soo Cho a, Jong Hyun Jeon a, Aram Hong b, Hyeong Tae Yang c,
Haejun Yim c, Yong Suk Cho c, Do-Hern Kim c, Jun Hur c, Jong Hyun Kim c,
Wook Chun b,c, Boung Chul Lee d, Cheong Hoon Seo a,b,*
a
Department of Rehabilitation Medicine, Burn Center, Hangang Sacred Heart Hospital, Hallym University Medical
Center, Seoul, Republic of Korea
b
Hallym University Burn Institute, Seoul, Republic of Korea
c
Department of Burn Surgery, Hallym Burn Center, Seoul, Republic of Korea
d
Department of Psychiatry, Hallym Burn Center, Seoul, Republic of Korea

article info abstract

Article history: Objective: To evaluate the effect of burn rehabilitation massage therapy on hypertrophic
Accepted 9 February 2014 scar after burn.
Method: One hundred and forty-six burn patients with hypertrophic scar(s) were randomly
Keywords: divided into an experimental group and a control group. All patients received standard
Burn rehabilitation therapy for hypertrophic scars and 76 patients (massage group) additionally
Hypertrophic scars received burn scar rehabilitation massage therapy. Both before and after the treatment, we
Rehabilitation determined the scores of visual analog scale (VAS) and itching scale and assessed the scar
Massage therapy characteristics of thickness, melanin, erythema, transepidermal water loss (TEWL), sebum,
and elasticity by using ultrasonography, Mexameter1, Tewameter1, Sebumeter1, and
Cutometer1, respectively.
Results: The scores of both VAS and itching scale decreased significantly in both groups,
indicating a significant intragroup difference. With regard to the scar characteristics, the
massage group showed a significant decrease after treatment in scar thickness, melanin,
erythema, TEWL and a significant intergroup difference. In terms of scar elasticity, a
significant intergroup difference was noted in immediate distension and gross skin elas-
ticity, while the massage group significant improvement in skin distensibility, immediate
distension, immediate retraction, and delayed distension.
Conclusion: Our results suggest that burn rehabilitation massage therapy is effective in
improving pain, pruritus, and scar characteristics in hypertrophic scars after burn.
# 2014 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: Department of Rehabilitation Medicine, Hangang Sacred Heart Hospital, Hallym University, 94-200 Yeong-
deungpo-Dong Yeongdeungpo-Ku, Seoul 150-030, Republic of Korea. Tel.: +82 2 2639 5730; fax: +82 2 2635 7820.
E-mail address: chseomd@gmail.com (C.H. Seo).
http://dx.doi.org/10.1016/j.burns.2014.02.005
0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
1514 burns 40 (2014) 1513–1520
1. Introduction
Hypertrophic scarring after surgical procedures and trauma,
especially, burns, is a great concern for patients and a
challenging problem for clinicians. Peacock defined hyper-
trophic scars as scars raised above the skin level but within the
confines of the original lesion [1]. Hypertrophic scars may
cause significant functional and cosmetic impairment, pain,
and pruritus, which compromise the patients’ quality of life
[2–4]. These scars are caused by a general failure in normal
wound-healing processes [5]. Post-burn hypertrophic scars
typically appear on the trunk and extremities.
Hypertrophic scars usually develop within 1–3 months of
injury, whereas keloid scars may appear up to 12 months after
the injury [6]. The nature of scarring appears to depend on
factors such as race, age, genetic predisposition, hormone
levels, atopy, and immunologic responses of the patient, type
of injury, wound size and depth, anatomic region affected, and
mechanical tension on the wound [7]. The presence of
complications, such as bacterial colonization and infection
of the wound, seems to promote hypertrophic scarring [6–11].
The development of hypertrophic scars in burn wounds is
mainly influenced by the time to heal and the depth and size of
the wound [12,13]. Unfortunately, most of the reports
published on post-burn scarring do not accurately define
these factors [14,15], and only a few authors have used
validated criteria or classification systems to define hyper-
trophic scarring [12,16–18].
Hypertrophic scars are currently managed by application of
silicone gel, pressure therapy, intralesional corticosteroid
injection, laser therapy, cryotherapy, radiation, surgery, etc.
According to Roh et al., massage therapy for post-burn
hypertrophic scar improved pruritus, Vancouver scar scale
(VSS), and depression [19].
Various tools are currently available for the assessment of
hypertrophic scars. The VSS is a validated subjective scale [20–
22], as is the patient and observer assessment scale (POSAS),
which encompasses both patient and observer evaluations
[23,24]. Tools for the objective assessment of hypertrophic
scars are scarce. Nevertheless, reports have been published on
the use of negative impressions of the scar, ultrasound
images, laser doppler flow, color measurements, and three-
dimensional systems for the analysis of hypertrophic scars
[20,25,26].
This study sought to determine the effects of burn
rehabilitation massage therapy for hypertrophic scar manage-
ment after burn by using objective evaluation tools.
2. Materials and methods
We enrolled patients who were admitted to our hospital for
the rehabilitation hypertrophic scars developing after the
acute management of burns, including skin grafts. The study
was designed as a prospective randomized experimental and
control group study; the subjects were randomized into 2
groups, namely, the massage group, which received both
standard therapy and burn rehabilitation massage therapy,
and the control group, which received only standard therapy.
Medical staff not involved in the study randomly assigned
patients to the 2 groups using a computer-generated allocation
random number table and prepared the procedure for each
patient. All participants were reviewed and approved by the
Institutional Review Board. The standard therapy comprised
range of motion (ROM) exercise for the prevention of burn scar
contracture, silicone gel application, pressure therapy, intra-
lesional corticosteroid injection, and application of whitening
cream, anti-redness cream, and moisturizing oil for hyper-
trophic scar management. Patients were administered burn
rehabilitation massage 3 times a week, at 30 min per session
for each area by specialized burn rehabilitation massage
therapists. Effleurage, friction, and petrissage massage were
performed after the application of Rosakalm1 cream (Plante
system, France), moisturizing Emu oil (Emu spirit, Australia)
oil and Physiogel1 lotion (Stiefel, United States). The effects of
the treatment were evaluated on the basis of the visual analog
scale (VAS; score, 0–10) and itching scale (score of 0–4) for
pruritis. Additionally, 5 of the following parameters were
applied to objectively investigate and measure burn scar
characteristics: (1) scar thickness, (2) scar melanin and
erythema, (3) scar transepidermal water loss (TEWL), (4) scar
sebum, and (5) scar elasticity. Patients were assessed both
before treatment and after treatment, before discharge from
the hospital, by rehabilitation doctor. And assessors blinded to
whether the patient had received standard care or burn
rehabilitation massage therapy.
A total of 160 subjects were divided into a massage group
(n = 80) and a control group (n = 80), but 4 subjects in the
massage group withdrew from the study and 10 from the
control group were excluded since they were lost to follow up.
The final analysis included 76 subjects in the massage group
and 70 in the control group, i.e., 146 subjects in all (Fig. 1).
2.1. Methods of measurement
2.1.1. Measurement of scar thickness
The thickness of the scar was measured by a high-resolution
ultrasonic wave equipment (128 BW1 Medison, Korea) by
using a 7.5-MHz probe. The ultrasound image enabled the
differentiation of the subcutaneous fat layer and the muscle
layer from the scar. The measurements enabled the assess-
ment of the thickness of the scar in a unit centimeter (cm) [27–
29].
2.1.2. Measurement of level of scar melanin and erythema
The mexameter1 (MX18 Courage-Khazaka Electronics GmbH,
Germany), which uses the principle of ‘‘photo-spectrum
analysis,’’ was used to measure the melanin and severity of
erythema in the skin, in a relative unit of A.U., ranging from 0 to
999. A higher value indicates a higher level of melanin deposition
and erythema. The measurement is obtained immediately after
the skin comes in contact with the sensor [26,30].
2.1.3. Measurement of scar TEWL
TEWL was measured by a Tewameter1 (Courage-Khazaka
Electronic GmbH, Germany). The probe was positioned on the
affected area for 30 s, and an average value was obtained. The
Tewameter1 is a common equipment used for evaluating skin
barrier function, and TEWL is measured in g/h/m2[26,30].
 burns 40 (2014) 1513–1520 1515

Admission for
rehabilitation
(n = 160)
Initial assessment (n = 160)
• Pain(VAS), Pruritus(itching scale)
• Scar characteristics (thickness,
melanin, erythema, TEWL,
sebum, elasticity)
Randomized (n = 160)

Control Group (n = 80) Massage Group (n = 80)

♦ Range of motion exercise ♦ Range of motion exercise

♦ Standard therapy ♦ Standard therapy
: silicone gel, pressure therapy, : silicone gel, pressure therapy,
corticosteroid injection, corticosteroid injection,
moisturizing cream moisturizing cream
♦ Burn rehabilitation massage
therapy

Lost to follow-up (n = 10) Lost to follow up (n = 4)

Follow-up assessment (n = 70) Follow-up assessment (n = 76)

• Pain (VAS), Pruritus (itching scale) • Pain(VAS), Pruritus (itching scale)
• Scar characteristics (thickness, • Scar characteristics (thickness,
melanin, erythema, TEWL, melanin, erythema, TEWL,
sebum, elasticity) sebum, elasticity)

Fig. 1 – Diagram for subject enrollment, allocation, and follow-up. VAS, visual analog scale; TEWL, transepidermal water
loss.

2.1.4. Measurement of the level of sebum in the scar

Sebum in the scars was measured by Sebumeter1 (Courage-
Khazaka Electronic GmbH, Germany). The measurement is
based on the principle of grease-spot photometry. The
measuring head of the cassette with its special tape is placed
on the skin. It is then inserted into a slot in the device, where
the transparency is measured by a light source passing
through the tape. A photocell measures the transparency. A
microprocessor calculates the result, which is shown on the
display in mg sebum/cm2 of the skin [31].
2.1.5. Measurement of scar elasticity
Skin elasticity was measured using Cutometer SEM 5801
(Courage-Khazaka Electronic GmbH, Colongne, Germany).
This device pulls skin using negative pressure on an 8-mm
diameter probe and indicates the skin’s maximum level of
distortion by a numerical value. Two seconds of negative
pressure of 450 m bar is followed by 2 s of recess, and this
consists of a complete cycle. Three successions of cycles
were carried out, and the average value was obtained
[26,30].
3. Statistical analysis
Collected data were analyzed by using SPSS 21.0 program
(SPSS Inc., Chicago, USA). Fisher’s exact test and independent
samples t-test were used for homogeneity test. Independent
samples t-test was used to ensure homogeneity between the 2
groups at the initial assessment. Paired t-test was used to
compare the pre- and post-treatment status, and the analysis
of covariance (ANCOVA) was used. p Value below 0.05 was
considered statistically significant.
4. Results
4.1. Demographic and clinical characteristics of the
patients
A total of 146 patients comprised 111 men and 35 women. Of the
76 subjects in the massage group, 61 were men and 15 were
women, while the control group comprised 50 men and
1516 burns 40 (2014) 1513–1520

Table 1 – Demographic and clinical characteristics of patients.

Control group (n = 70) Massage group (n = 76) p
Gender (M:F) 50:20 61:15 0.247*
Age (years) 47.21 (8.22). 46.06 (8.63) 0.413y
TBSA (%) 35.64 (17.33) 37.25 (18.60) 0.591y
Interval between burn injury and rehabilitation therapy (days) 156.47 (56.48) 148.77 (56.85) 0.414y
Period of rehabilitation therapy (days) 35.85 (11.80) 34.69 (22.53) 0.701y
Times of burn rehabilitation massage therapy (times) 12.46 (7.17)
*
Fisher’s exact test.
y
Independent samples t-test, values are represented as mean (standard deviation).
TBSA, total body surface area.

Table 2 – Pre-homogeneity test of initial assessment.

Control group (n = 70) Massage group (n = 76) p
Pain(VAS) 5.65 (1.48) 5.63 (1.47) 0.917
Pruritus (itching scale) 2.78 (0.86) 2.73 (0.88) 0.737
Thickness (cm) 0.26 (0.15) 0.28 (0.14) 0.553
Melanin 177.78 (137.91) 188.96 (106.19) 0.582
Erythema 519.71 (106.31) 518.09 (93.32) 0.922
TEWL (g/h/m2) 33.74 (12.04) 37.60 (18.70) 0.144
Sebum (mg sebum/cm2) 40.32 (24.67) 34.36 (19.67) 0.136
Skin distensibility 0.1656 (0.1313) 0.2527 (0.1789) 0.140
Immediate distension 0.0942 (0.1168) 0.1470 (0.1045) 0.202
Biologic skin elasticity 0.4922 (0.0647) 0.4405 (0.0777) 0.058
Gross skin elasticity 0.6708 (0.1144) 0.7237 (0.1159) 0.220
Immediate retraction 0.0972 (0.0662) 0.1242 (0.0839) 0.337
Skin viscoelasticity 0.7752 (0.4732) 0.4880 (0.4745) 0.108
Delayed distension 0.0962 (0.0996) 0.0953 (0.0872) 0.980
Independent samples t-test, values are represented as mean (standard deviation).
VAS, visual analog scale; TEWL, transepidermal water loss.

20 women. The mean age was 46.06 (standard deviation 8.63)
years in the massage group. The mean total body surface area
(TBSA) was 37.25% (18.6) in the massage group. The mean interval
between burn and rehabilitation therapy was 148.77 (56.85) days
in the massage group. This study group is about the rehabilitation
patients who underwent skin grafts after burns. We had to start
the massage therapy started after the total burn wounds healed.
The mean period of rehabilitation therapy was 34.69 (22.53) days
in the massage group. In the massage group, the mean number of
times of burn rehabilitation massage therapy administration was
12.46 (7.17). There is no significant intergroup difference
( p > 0.05) (Table 1). No significant intergroup difference was
noted at the initial assessment ( p > 0.05) (Table 2).
4.2. The change in scar pain VAS and itching scale scores
The scar pain VAS score in the massage group decreased. A
significant intergroup difference was noted (CI, 0.69–2.02;
p < 0.001) (Table 3).
The itching scale score decreased. A significant intergroup
difference was noted (CI, 0.01–0.75; p = 0.04) (Table 3).
4.3. The change in scar thickness
The scar thickness decreased in the massage group. A
significant difference was noted in the decrease in scar
thickness (CI, 0.03–0.09; p = 0.02) (Fig. 2).

4.4. The change in scar melanin and erythema

Table 3 – The Change in scar pain (VAS) and pruritus
(itching scale). The scar melanin decreased in the massage group. A
Initial Follow up Adjusted difference p value significant difference was noted in the improvement in
(95% confidence melanin level (CI, 12.1–21.3; p = 0.02) (Fig. 3).
interval) The scar erythema decreased in the massage group. A
Pain (VAS) significant difference was noted in the improvement in
CG 5.65 (1.48) 4.47 (1.34) erythema (CI, 34.2–89.2; p = 0.04) (Fig. 4).
MG 5.63 (1.47) 3.02 (0.81) 1.36 (0.69–2.02) <0.001
Pruritus (itching scale)
4.5. The change in scar TEWL
CG 2.78 (0.86) 2.00 (0.70)
MG 2.73 (0.88) 1.56 (0.59) 0.38 (0.01–0.75) 0.04
The scar TEWL decreased significantly decreased in the
Values are represented mean (SD), VAS, visual analog scale; CG,
massage group. The difference showed a significant difference
control group; MG, massage group.
(CI, 2.3–6.2; p = 0.03) (Fig. 5).
 burns 40 (2014) 1513–1520
Fig. 2 – Comparison of scar thickness. yp < 0.05.
Fig. 3 – Comparison of scar melanin. *p < 0.05.
4.6. The change in scar sebum
The scar sebum increased in the massage group. No significant
difference was noted (CI, 1.2–7.1; p = 0.51) (Fig. 6).
4.7. The change in scar elasticity
The skin distensibility increased in the massage group. The
difference between initial and follow-up skin distensibility
*
Fig. 4 – Comparison of scar erythema. p < 0.05.
1517
Fig. 5 – Comparison of scar TEWL. *p < 0.05.
Fig. 6 – Comparison of scar sebum level.
showed no significant difference (CI, 0.003–0.368; p = 0.17). The
immediate distension increased in the massage group. The
difference between initial and follow-up immediate disten-
sion showed a significant difference (CI, 0.111–0.310; p = 0.01).
The biologic skin elasticity increased in the massage group.
The difference between the initial and follow-up biologic skin
elasticity showed no significant difference (CI, 0.084–0.206;
p = 0.13). The gross skin elasticity in the massage group. The
difference between the initial and follow-up gross skin
elasticity showed significant difference ( p = 0.01) (CI, 0.137–
0.539). The immediate retraction increased in the massage
group. The difference between initial and follow-up immedi-
ate retraction showed no significant difference (CI, 0.076 to
0.172; p > 0.69). The skin viscoelasticity increased in the
massage group. The difference between initial and follow-
up skin viscoelasticity showed no significant difference (CI,
0.307 to 0.245; p = 0.21). The delayed distension increased in
the massage group. The difference between initial and follow-
up delayed distension showed no significant intergroup
difference (CI, 0.111 to 0.083; p = 0.76) (Table 4).
5. Discussion
Hypertrophic scarring, a particularly difficult burn manage-
ment problem, has been extensively described in the literature.
Hypertrophic scars are morphologically characterized by an
1518 burns 40 (2014) 1513–1520

Table 4 – The change in scar elasticity.

Initial Follow up Adjusted difference (95% confidence interval) p value
Skin distensibility
CG 0.165 (0.131) 0.212 (0.221)
MG 0.252 (0.178) 0.395 (0.273) 0.183 (0.003 to 0.368) 0.17
Immediate distension
CG 0.094 (0.116) 0.044 (0.043)
MG 0.147 (0.104) 0.255 (0.183) 0.211 (0.111 to 0.310) 0.01
Biologic skin elasticity
CG 0.492 (0.064) 0.467 (0.203)
MG 0.440 (0.077) 0.528 (0.184) 0.061 (0.084 to 0.206) 0.13
Gross skin elasticity
CG 0.670 (0.114) 0.482 (0.332)
MG 0.723 (0.115) 0.821 (0.182) 0.282 (0.137 to 0.539) 0.01
Immediate retraction
CG 0.097 (0.066) 0.173 (0.178)
MG 0.124 (0.083) 0.221 (0.154) 0.048 (0.076 to 0.172) 0.69
Skin viscoelasticity
CG 0.775 (0.473) 0.584 (0.229)
MG 0.488 (0.474) 0.615 (0.468) 0.031 (0.307 to 0.245) 0.21
Delayed distension
CG 0.096 (0.099) 0.153 (0.153)
MG 0.095 (0.087) 0.139 (0.102) 0.014 (0.111 to 0.083) 0.76
Values are represented mean (SD), CG, control group; MG, massage group.

abnormal collagen pattern, with decreased numbers of elastin
fibers; persistent cellularity; alterations in the abundance and
composition of proteoglycans; and a prolonged, chronic
inflammatory reaction, which includes increased vascularity
and deposition of ground matrix [32].
Although the management of hypertrophic scars has
advanced in the past years, the lesions remain difficult to
prevent and treat. Hypertrophic scarring after burns requires a
specific therapeutic approach since the scars are often non-
linear and widespread [18]. Recurrences are common patient
satisfaction with the treatment is variable [18]. Extensive
research has increased the knowledge base regarding the
pathophysiologic processes of wound healing and scar
formation [5], but there is still no consensus regarding the
best treatment strategy for reducing and preventing hyper-
trophic scarring.
Physicians and therapists have used and reported a variety
of therapeutic modalities for the treatment of hypertrophic
scar. Techniques such as silicone gel application, pressure
therapy, intralesional corticosteroid injection, laser therapy,
cryotherapy, radiation, and others have been used but are yet
to demonstrate any objective, reproducible improvement in
the character of hypertrophic scars. One of the techniques
reported to soften restrictive fibrous bands and improve the
pliability of the scar tissue is massage therapy.
They are many types of massage, such as effleurage,
friction, and petrissage. Basically, the effects of massage are
reflex and mechanical. The reflex effects of massage therapy
are realized through the stimulation of the afferent peripheral
nerves to the central nervous system to produce muscle
relaxation, a decrease in painful sensations, and an overall
sense of well-being. The mechanical effects of massage are
related to an improvement in venous return and lymphatic
drainage. Further, massage therapy stimulates movement
between muscle fibers, which results in more fluid muscle
movement.
In this study, the massage group received an average of
12.46  7.17 burn rehabilitation massage therapies during
34.69  22.53 days in average. Each session of 30-min treat-
ment included effleurage, friction, and petrissage massage
after applying whitening cream, anti-redness cream, and
moisturizing oil, and this massage treatment improved pain,
pruritus, and scar characteristics (thickness, melanin,
erythema, TEWL, elasticity) to a significantly greater degree
than only standard therapy.
A study by Morien at al. reported that 8 children who were
treated with 20–25 minute-long daily massage therapy for 3–5
days improved the ROM in the knees, neck, and shoulders [33].
Roh et al. compared 18 subjects who received massage therapy
and 17 who received standard therapy for 3 months and
reported that the massage-therapy group showed greater
improvements in pruritus, VSS score, and depression [19].
Filed at al. reported greater immediate and long-term
improvements in pruritus, pain, anxiety, and mood in the
10 subjects who received massage therapy for 5 weeks than
the 10 subjects who only received standard therapy [34].
Previous studies on the effects of massage therapy lacked
objectivity in scar condition measurements. However, Ultra-
sound, Mexameter1, Tewameter1, Sebumeter1, and Cut-
ometer1 were used in this study to objectively measure scar
conditions, and the measurement revealed that the scar
thickness, melanin, erythema, TEWL, and elasticity of the scar
improved to a significantly greater extent with massage
therapy than with the standard therapy alone.
However, evidence to support the use of scar massage is
inconclusive, although its efficacy appears to be greater in
postsurgical scars. There is much variability and inconsis-
tency with regard to when treatment should be initiated, the
appropriate treatment protocol and duration, and evaluation
and measurement of outcomes. Because these results are
difficult to interpret, evidence-based recommendations can-
not be made. Potential positive effects of scar massage include
 burns 40 (2014) 1513–1520
involving patients in their treatment, hastening the release
and absorption of buried sutures, aiding the resolution of
swelling and induration, and economic value, especially
compared to silicone gel application. Possible negative aspects
of this therapy include wasting the patient’s time if massage is
not an efficacious treatment, irritation from friction, and
developing irritant or contact dermatitis from the lubricant
used for massage.
The natural history of acute wound healing progresses
through distinct but interconnected stages: inflammation,
proliferation, and remodeling [35,36]. The remodeling phase
can last from months to years, during which time the scar
matures and improves in appearance and pliability. This
process occurs in the absence of any intervention. Although
the effect of massage on this phase of wound healing is
unknown, it may shorten the time needed to form a mature
scar.
Notwithstanding the lack of evidence, massage should
theoretically be effective. One hypothesis supporting its use is
that mechanical disruption of fibrotic tissue increases the
pliability of scars. Mechanical forces induce changes in the
expression of extracellular matrix proteins and proteases, and
massage may alter the structural and signaling milieu [37,38].
A study of cultured human skin fibroblasts by Kanazawa
and colleagues revealed a decrease in messenger ribonucleic
acid (mRNA) and protein levels of connective tissue growth
factor and collagen type 1 alpha 2 (Col1a2) after 24 h of uniaxial
cyclical stretching [39]. Because connective tissue growth
factor has been implicated in maintaining fibrosis induced by
transforming growth factor-beta [40], its downregulation may
prevent abnormal scarring. In another in vitro model, human
hypertrophic scar samples responded to mechanical loading
by inducing apoptosis and decreasing levels of tumor necrosis
factor-alpha [41], although another study showed that biaxial
mechanical strain upregulates matrix metalloproteinase-1
and collagen type 1 and 3 mRNA expression and down-
regulates the proapoptotic protein Bax [42]. These results
suggest that massage may be exert its beneficial effects
through its ability to affect matrix remodeling and fibroblast
apoptosis, although the exact mechanism remains to be
determined.
In addition to physical modifications of the scar, massage
may have other benefits. Massage therapy is an effective
adjunct therapy in managing lower back pain, depression,
addiction, atopic dermatitis, etc. [43–45]. Connective tissue
massage produces a statistically significant elevation of beta-
endorphins levels in healthy volunteers [46], which suggests
that this therapy may have a beneficial effect on the pain relief
and the patients’ sense of well-being. Other studies have
shown reduction of urinary cortisol level and increase in
serotonin and dopamine levels after massage therapy [47,48],
which suggests that massage therapy may improve the
patients’ mood and decrease anxiety. In addition to the
release of endogenous opioid peptides and neurotransmitters,
the beneficial effect of massage therapy on pain be explained
by the gate theory of pain, described by Melzack and Wall in
1965 [49].
The limitations of this study are as follows. First, the
massage therapy was performed for an average of
34.69  22.53 days, and therefore, its long-term effects were
1519
not identified. Second, evolution of hypertrophic scar was not
considered. Typically, burn scars undergo hypertrophy
between 6 and 12 months and tend to regress between 18
and 24 months [30]. In addition, there may be a positive
correlation between pruritis and hypertrophy of the burn scar.
Thus, the effect of massage may differ depending on whether
the burn scar is in the early or late stages of maturation. Future
studies should focus on comparing the effect of massage on
‘‘new’’ and ‘‘old’’ burn scars.
6. Conclusion
Burn rehabilitation massage therapy can be one of the
modality for controlling post-burn hypertrophic scar pain,
pruritus and the scar characteristics (thickness, melanin
deposition, erythema, TEWL, and elasticity). However, further
studies are needed to establish a standard protocol for burn
scar massage therapy on the basis of the long-term ther-
apeutic effects and evolution of hypertrophic scars.
Conflict of interest
None declared.
Acknowledgment
This study was supported by a grant of the Korean Health
Technology R&D Project, Ministry of Health & Welfare,
Republic of Korea (A120942).
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