OT FORUM Editor Carole L. Johnson, PT, PhD Seatsle, Washington “Rating the Burn Scar” addresses a critical issue for many studies, The authors state that “a reliable, objective and universal method of assessing burn scars does not exist in today’s buen literature.” They chose four criteria (pigmen- tation, vascularity, plabilty) and scar height and devised ‘a number scale for each. Theit openness to pursue this dliffcule seudy is evident in the last statement: “Comments from the readers ofthis journal would be most welcome.” I strongly encourage you to read and respond to a very thoughtful seudy. Since minimal scarring is one measure of our success in ‘cating the patient with bums, the topic gencrates much interest. I just returned from the American Burn Associ- ation meeting in Las Vegas, and almost half of the Special Interest Group mecting was devoted to the topic of pres- sure garments. Competition between the manufacturing companies of these garments is obvious. Scott Ward, PT, University of Utah, has volunteered to do a review on the development and manufacture of the garments. Regardless of company preference, we need to make the best choice for the patient, which again emphasizes the need for critical analysis or rating of the buen scar. Rating the Burn Scar T. Sullivan, BSc, OT(C), J. Smith, BSc, OTR, OT(C),', J. Kermode, BSR, OT/PT(C)," E. McIver, DipCOT, OT(C),* and D. J. Courtemanche, MD* Vancouser, Britis Cabonbia, Canada A reliable, objective, and universal method of assessing burn scars does not exist in today’s ‘burn literature. Such a method is necessary to provide a descriptive terminology for the ‘comparison of burn scars and the results of treatment. The method should be applicable to patients both within an institution and between burn centers. A burn scar assessment has been devised based on physical parameters. These relate to the healing and maturation of ‘wounds, cosmetic appearance, and the function of the healed skin. Pigmentation, vascularity, pliability, and scar height are assessed independently, with increasing score being assigned to the greater pathologic condition. Normal skin has a score of 0. Seventy-three patients were assessed by three separate occupational therapists and the findings subjected to statistical analysis for interrater reliability. For each parameter a Cohen's x statistic of approximately 0.5 + 0.1 indicates a statistically significant agreement between observers. These values were found to improve with time. This appears to be a useful tool for the assessment of burn scars, allowing objective comparison of the same scar by different observers. (J BURN Care REHABIL 1990;11:256-60) Fran Vancouser General Hopital Burn Unit and the Department @f Plate Surgery, University of British Columbia, Vancouver, Brivis Columbia “Occupational therapice, Vancouver General Fes (ital Burn Unit; ‘Resident in Plate Surgery, Univesity of British Calnbin. Supported by w grant from the Britich Colunbia Profesional Fire: “fobter? Auaciation. Phseted in pare at the Twentieh Annual Meeting ofthe American Burn Assocation, Seattle, Wash, March 23-26, 1988 Reprint requests: Jonne Sith, Rebabiltation Services, Vancouver Goneral Hopital, 855 W. Tiel Ave, Vanconver, BC, Canada 52, 1M9. 30/1/11974 256 For the surviving patient the ultimate outcome of deep second: and third-degree burns is scarring. This occurs whether the wound heals spontaneously of is closed by skin graft. The prevention and treatment of burn scars through the use of compression and splinting is well documented in the literature. How- ever, the evaluation of bu scar maturation is highly subjective and it has thus been impossible to docu- ment objectively the efficacy of these devices, Scar ‘maturity has been related to transcutaneous oxygenVolume 11 Number 3 May/June 1990 ‘UaNCOWUER GENERAL HOSPITAL ‘OCCUPATIONAL THERAPY OCPAITMENT ‘BURN scan assESsMENT PATIENT NBME t Rating the burn war 287 2 Risen Figure 1. The Burn Scar Assessment form. tension, with increasing Po, correlating with clinical improvement over 60 weeks of therapy.' Scar thick- rncss has been measured by ultrasonography.? Clinical assessment of elasticity has been shown to equate closely with the measured in vivo mechanical prop- crties of hypertrophic scar. Accurate assessment should also allow the early diagnosis of problems or complications arising from pressure therapy.* Any method for assessing burn scars must consider wound healing, cosmetic appearance, and the func tional significance of the scar. The ideal result must be comparable to normal skin, All of the variables noted above must be taken into account. The as- sessment should be clinical, easy to apply in the outpatient clinic, and not rely on expensive equip- ment or invasive tests. A simple clinical scale hhas been developed previously by Garcia-Velasco etal In addition the assessment must be objective and reliable from one reporter to the next, giving essen- tially the same score for any given scar at a given point in time. This is particularly important when assessing scar maturation over time. Inan attempt to standardize this evaluation process an assessment scale for scoring burn scars has been developed. MATERIAL AND METHODS The Burn Scar Assessment ‘The Burn Scar Assessment scale was developed to reflect the easily recognized characteristics of the burn scar, Pathologic changes were assigned scores on an index scale based on their deviation from nor- ‘mal (rated 0). Four components were considered: pigmentation, vascularity, pliability, and height (Fig- ure 1).Journal of Burn Care 288 Sullivan era, ‘& Rehabilitation ‘Table 1. Observed Cohen’s « statistics and their estimated standard errors for the three different occupational therapist rater pairs for the four different time periods of the study* Rater pair A B c Assessment/ period 5 SE a « SE Pigmentation 1 0.4286 02614 0.3247 0.2887 o.sss6 0.2783 2 0.5082 0.2345 0.3333, 0.1689 0.724 0.1067 3 0.4900 0.2572 0.6667 o.gst 0.4270 0.2247 4 os4s 0.1597 0.6828 0.1301 0.6761 0.0934 All 0.5204 0.1031 0.5643 0.0897 0.5537 0.0935, Vasculavty 1 0.1261 0.1706 ose 0.1600 o2s7 osss 2 0.4043 0.1779 0.6610 0.1448 0.4239 0.1837 3 o7is2 0.1476 0.3770 0.1830 0.4516 0.1793 4 0.5430 0.1565 0.0974 0.1426 0.3907 011728 All 0.4699 osm 0.5584 0.0824 0.4000 0.0934 liability 1 0.3953 02107 0.4348 oases 0.2158 0.1398 2 0.4964 0.440 0.4982 0.1461 0.5586 0.1454 3 0.1626 01513, 0.3615 0.489 0.4887 o.14s3 4 0.6141 oa24 0.5106 o.400 0.5687 0.1490 All 0.4551 0.0802 0.4828 0.0782 0.4859 0.0784 Height 1 0.8761 0.1968 0.1250 0.1966 0.0545 oasis 2 0.4677 0.1503 0.5395 0.1381 osois 0.1459 3 0.1608 0.1839 0.5584 0.1758 0.3462 0.1961 4 0.6839 0.1610 0.7444 0.1707 0.4749 0.1929 All 0.4840 0.0884 os185 0.0886 0.4022 0.0894 ‘Period 1 extends fom Oct. 18 to Nov. 14, 1987; period 2 extends from Nov. 15 to Dec. 14, 1987; perio 3 extends from Dex. 15, 1987, co Jan. 14, 1986, and period exens rom Jan. 15 to Feb. 18, 198, These pecods contain 13, 20, 17, and 23 buen sens, respectively. Pigmentation Pigmentation changes frequently accompany burn scarring in healed wounds, donor sites, and skin grafts. Hyperpigmentation appears to be more sig- nificant in our patient population (mainly white per- sons) and particularly in the native Indian and Asian populations. ‘To climinate the effect of vascularity on skin color, the skin is blanched with a piece of clear plastic and ‘compared with an area of similarly blanched normal skin, Normal skin is rated 0, hypopigmented skin 1, and hyperpigmented skin 2. Scars with mixed pig- mentation changes are rated according to the most significant pigmentation change. Vascularity Vascularity is always altered in the early phases of ‘wound healing, with active scars being hyperemic as aresult of the increased blood supply. This decreases with scar maturation. Vascularity is assessed by de- ciding on the amount of redness in the scar. This assessed by looking at the scar at rest and also by blanching the scar and observing the rate and amount of blood return. A normal color and capillary refill rates 0. Skin with a slight increase in local blood supply is pink and scores 1. A significant increase in the local blood supply gives a red scar, scoring 2. Excessive local blood supply is purple, rating 3. Active scars refill quickly. Some scars are congested and refill slowly or cannot be completely blanched. We have grouped these into the purple category. Pliability liability relates to the functional mobility of the scar as related to contracture and the elastic textureVolume 11 Number 3 ‘May/June 1990, Of the scar. Functional impairment is a significant complication of a burn scar; therefore we have given this type of scar a high rating. Normal skin scores 0. Supple skin that yields with ‘minimal resistance scores 1. Yielding scars give way to pressure while offering 2 moderate resistance but do not behave as a solid mass of scar and rate 2. A firm scar moves as a solid, inflexible unit and rates 3. Banding producing “ropes” of scar tissue that blanch on stretching but do not limit range of motion rates 4. Contracture of any type of scar that limits range of motion rates 5. The severity of the con- tracture is not considered. Height Finally the height of the scar is evaluated. This is related to the overall collagen content of the scar, as well as the relative edema of the tissue. Flat scars, flush with normal skin rate 0, those <2 mm rate 1, those 2 to 5 mm rate 2, and those >S mm rate 3, This is a visual and palpable estimation of the max- imal vertical elevation of the scar above the normal skin, Method For the purposes of this study a scar was defined as an area of 4 cm? (I inch by 1 inch). Scars less than 1 year old were selected at the discretion of the ther- apists participating in the study and represent a wide variety of sites and quality. Scar location is indicated on the body diagram of the assessment form (Fig- ure 1). Patients ranged in age from 3 to 75 years. subjects were recruited from the Vancouver Genera: Hospital outpatient burn clinic with their informed consent under the approval of the Medical Ethics Committees of the University of British Columbia and the Vancouver General Hospital. At the time of rating all pressure garments had been removed for a minimum of 5 minutes and the patients had been acclimatized to the temperature of the clinic, The area to be assessed was in a nonde- pendent position. ‘The observers were three occupational therapists (1. S, J. S., and J. K.) who rated the same scars independently. Data were pooled and analyzed for agreement ac- cording to Cohen's x statistic, where 0 indicates agreement purely by chance. Values below zero in- dicate no agreement; values between O and 1 indicate agreement beyond chance. Significance is indicated by the relative size of the standard error in relation- Rating the burn sear 259 7 Voscularty Pliability Height 08 | 0.5] 0.4] 0] ° 0.2 ol KAPPA Rater Pairs Figure 2. Cohen's « statistics and estimated standard errors for all three rater pairs in the fourth time period. sti a | | 234 123 4 Period Figure 3. Cohen's x statistics and estimated standard errors for rater pair B for all four time periods. ship to the value of x. Data were analyzed for the three different possible rater pairs and for four dif- fecent time periods during the study. RESULTS ‘The observed Cohen’s « statistics and the estimated SEs for all of the different assessments are presented in Table 1. Graphic representation is shown for all rater pairs in the fourth time period (Figure 2) and for rater pair B for all four time periods (Figure 3). ‘The mean x values are approximately 0.5 in each260. Sullivan e al rater pair, with standard error of approximately 0.1. ‘These x values are generally 5 standard errors beyond chance agreement and are statistically significant. Te should be noted that the interrater reliability showed an improvement with time, DISCUSSION ‘The four-component burn assessment scale is pre- sented, although there is still no complete agreement among the investigators that this should be the final form. Two areas that have consistently been difficult to rate are the scar with mixed pigmentation and the dark, vascular scar. We also recognize that symptoms are important in the treatment of these scars and believe that pain and itching should also be rated. ‘A modified scale could include the following: pain: 0, none; 1, occasional; and 2, requiring medication; itching: 0, none; 1, occasional; and 2, requiring med- ication. ‘The scale has not been designed to indicate the absolute severity of the pathologic condition but rather the presence or absence and to a lesser extent the degree of the pathologic condition of the burn scar. The scope of each component has been kept relatively small. A two-point rating would likely al- low greater agreement but would be meaningless clinically (scar versus no scat). Conversely a very wide scale would allow greater subjective description of cach individual scar but would decrease the interrater reliability and therefore the objective nature of the assessment. Ttmay be that longitudinal assessment will confirm our bias that this will also serve as a longitudinal assessment tool with maturing scars gathering pro- gressively lower scores. The « statistic has shown that the rating is statis- tically reliable between raters even though there is Journal of Bum Care & Rehabilitation not perfect agreement. Interrater reliability showed an improvement with time, indicating an increasing familiarity with the scale and a refinement in the definitions and rating criteria that were ongoing throughout the study. Because the reliability of the scale improved with time, we are currently recom- mending a 3- to 4-month trial before implementing the clinical use of this scale. At present we believe this is a workable scale for the assessment of burn scars. It is undergoing further study in a longitudinal analysis of its use and a critical analysis of the rating scales. It is proposed that this scale or a modification of this scale could serve as a useful clinical and research tool in the evaluation of burn scars as a guide to their prognosis, progress, and therapy, always aiming for the ideal of reconstituting a mature, healed wound of normal or near-normal cosmesis and function. We thank C. F. T. Snelling, J.P. Stephens, M. Neiforth, and P. Ma for their assistance. REFERENCES 1. Bery RB, Tan OT, Cooke ED, et al. Tanscutancous oxygen tenson a an inde of macuiy in hyperophic scars wesed by compression. Be J Plast Surg 1985;38:163, 2, Leung KS, Cheung JOY, Ma GEY, Chik JA, Leung PC. Com- plications of presse therapy for post-bum hypectophic scars Erochemical analysis on five patients. Buens nl ‘Therm Inj 1984; 10:434. 3, Leung KS, Cheung JCY, Ma GRY, Clak JA, Leung PC. In vivo su ofthe mechanical propery of post-buma hyper” twophie sear tissue. J BUN Cane Renan 198435458, 4 Clak JA, Cheung JCY, Leung KS, Leung FC. Mechanical characterization of human postburn hypertrophic skin during pesure therapy. J Biomech 1987:20:397. 5. Ka SM, Frank DH, Leopold GR, Woche! TL. Objective measurement of hypertrophic burn seat: a preliminary stud) Sf eonomeny and lasso. Ann Pst Su 1988) aaa, 6. Garca-Velasco M, Ley R, Murch D, Sutkes N, Wiliams HB. Gompesion extn of ipetcophi se inbred ck dren. Can J Surg 1978;2149