burns 46 (2020) 1867 1874

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A comparison of two scar massage protocols in

pediatric burn survivors

Soccoro Valladares-Poveda a, Oneyda Avendaño-Leal a ,

Humberto Castillo-Hidalgo a , Evelyn Murillo a, Carmen Palma a ,
Ingrid Parry b, *
a
APROQUEN, Department of Physiotherapy and Occupational Therapy, Managua, Nicaragua
b
Shriners Hospital for Children, Northern California, Department of Physical and Occupational Therapy,
2425 Stockton Blvd., Sacramento, CA 95817, United States

article info abstract

Article history: The current evidence to support the use of massage for scar management is conflicting in
Accepted 14 May 2020 the literature. The purpose of this study was to compare two scar massage protocols
administered with pediatric burn survivors to determine if a more structured and
standardized approach to scar massage could improve outcome. A retrospective review
of the medical records of 100 children who received massage during the time period when
Keywords: two different protocols were implemented was conducted and data that was collected as part
Scar management of the clinical exam regarding scar height, vascularity, pliability, itch and pain were
Burn scar extracted. Comparisons were made within subject for scar changes from baseline to follow
Rehabilitation up and between subjects receiving Protocol A and those receiving Protocol B for the same scar
Massage characteristics. Versions of the Vancouver Scar Scale were used to assess scars, while visual
Scar massage analogue scale, Itch Man Scale and Wong-Baker Faces Pain Scale were used to assess itch and
Therapy pain. Results demonstrated improvements in itch and vascularity over time with both scar
massage protocols. However, when comparing patients who received Protocol A to those
who received Protocol B, there was no difference found in scar height, vascularity, pliability,
itch or pain. Using commonly applied subjective scar assessment tools, we did not find
clinically meaningful changes in scar characteristics with the implementation of a
structured scar massage program compared to a general approach to massage. Further
research is needed to better define the impact of massage on the recovery experience for burn
survivors.
© 2020 Elsevier Ltd and ISBI. All rights reserved.

internationally, massage is the most commonly reported scar

1. Introduction
Massage is a technique that has been used to manage scars
after burn injury. In survey research, 81% of clinicians reported
doing scar tissue massage with burn survivors [1] and
management modality [2]. Scar massage is used in both
low and high income countries and is not typically influenced
by economic or monetary constraints [2], likely due to the
fact that very few resources are needed to administer manual
massage. The fact that this modality is accessible and

* Corresponding author.
E-mail address: ingridparry@gmail.com (I. Parry).
https://doi.org/10.1016/j.burns.2020.05.013
0305-4179/© 2020 Elsevier Ltd and ISBI. All rights reserved.
1868 burns 46 (2020)
affordable to clinicians and patients throughout the world
makes it a priority for research to determine optimal methods
of investigating scar massage and if there are quantifiable
benefits of massage for the burn survivor.
Although, the clinical use of manual massage appears to be
quite common after burn injury, the current evidence to
support the efficacy of massage for scar management is
conflicting in the literature. There are three systematic
reviews on massage which demonstrate the spectrum of
conclusions. In 2011, Shin systematically reviewed 10 pub-
lications on the use of massage with post-surgical and burn
scars and concluded that the evidence for the use of scar
massage is weak [3]. Five years later, Anthonissen et al.
systematically evaluated five publications on massage to burn
scars and concluded massage therapy may have a positive
effect on scar pliability, pain and pruritus but that the
supporting evidence is minimal [4]. Most recently, Ault et al.
evaluated eight publications on the use of massage with
hypertrophic scars and concluded that preliminary evidence
exists for the efficacy of scar massage to decrease scar height,
vascularity, pliability, pain, pruritus and depression [5].
It may be that the sequence of these manuscripts reflects
that evidence for massage improved throughout the time
frame that these systematic reviews were conducted. Howev-
er, two recent randomized controlled trials using objective scar
assessment tools to evaluate massage with hypertrophic scars
report conflicting findings. In 2014, Cho et al. found that
patients who received massage had significant decreases in
scar thickness, melanin, erythema, trans-epidermal water loss
(TEWL) and showed less pain and itch compared to control
subjects [6]. In contrast, the most recent study on massage by
Nedelec et al., published in 2019, found no long-term differ-
ences in any scar parameters (elasticity, erythema, melanin, or
thickness) when comparing scar sites which received a 12
week course of massage compared to sites on the same
individuals which did not [7]. Pain and itch were not evaluated
in that study due to low baseline levels for both.
A critique of the current literature on scar massage is that
there is substantial variability in the massage techniques used,
the initiation, duration and frequency of massage treatment,
the clinical outcomes that massage targets and optimal tools
used to measure outcome. Efforts have been made to
standardize the techniques used for scar massage [8,9]
however, the majority of studies do not report the techniques
that were applied, making comparison and repetition of the
studies difficult. The timeframe after burn injury when
massage is initiated and the frequency and duration of
intervention also vary significantly in the literature and would
presumably affect the results [4]. A variety of outcomes are
Table 1 – Criteria for enrollment.
Inclusion criteria
Patient has two or more burn scar evaluations
Patient admitted to the outpatient physical therapy program from January 2014 to
April 2017
Patient with second degree and third degree burns with or with without skin grafts
Pediatric patient 15 years old
currently measured to determine the efficacy of massage with
burn survivors including: range of motion (ROM) [10,11], pain
and or anxiety [12 14], pruritus [6,14,15], scar characteristics
such as thickness, pliability, pigmentation and height, TEWL,
melanin [6,7], and depression [16].
Despite conflicting evidence as to the efficacy of scar
massage, clinicians continue to use massage with burn
survivors and believe it to be beneficial [1,2,17]. This may be
because there are some immediate effects of massage
observed such as reduced melanin and increased elasticity
[7] which lead the clinician to believe that there are long-term
benefits that have not been proven. It may be that the specific
clinical indications for scar massage with burn patients are not
well defined, something that is also lacking in many survey
reports. The discrepancy between the evidence and the clinical
use may be a result of research not aligning with the clinical
outcomes targeted or that the studies have not investigated
the minimal therapeutic application and specific techniques
that demonstrate a clinical improvement.
Within our clinical practice treating pediatric patients with
burn injuries, we use scar massage regularly as an adjunct to
other scar management treatments and have the clinical
impression that it improves the scar outcome of our patients.
Within the past five years, we have evolved our approach with
massage to include a more formalized application using
defined techniques and duration and comprehensive educa-
tion about the use of massage as part of a home program after
discharge with caregivers. The purpose of this study was to
retrospectively determine if this more structured and formal-
ized scar massage program applied with pediatric burn
patients resulted in improved scar outcomes.
2. Methods
This was a retrospective chart review of pediatric patients who
had received burn rehabilitation at one pediatric burn center
between January 2014 and April 2017. Data extracted from the
medical record included: basic patient demographics, mas-
sage treatment information, and scar assessment results.
Inclusion and exclusion criteria are described in Table 1.
2.1. Massage protocols
We compared two different scar massage protocols used with
pediatric burn survivors at one burn center in Central America,
APROQUEN. From January 2014 to June 2015, patients at our
burn center received a general massage protocol, lacking
specific techniques, with minimal parent/patient education
Exclusion criteria
Patient has less than two burn scar evaluations
Pre-existing skin condition or allergies
Patient with only superficial burns
Patient 16 years old or older
Patient with keloid scars
 burns 46 (2020)
and direction with home application (Protocol A). In July of
2015, burn therapists in Central America underwent a
consensus exercise led by author IP to define the most
common scar massage techniques used for burn scars. The
procedures for these techniques were described and recorded
on a training video and written/pictorial instruction handouts
were created [8]. From July 2015 until April 2017, patients at
APROQUEN received the more structured scar massage
instructions using these well-defined techniques which were
applied with standard application time (Protocol B). In addition
to applying the massage using specific standardized methods,
we also implemented a more formal caregiver educational
program on how to perform the massage, a written home
program detailing instructions for home application, pre-
scribed frequency (3/day) and duration (5 25min per area),
ongoing education with the caregiver at outpatient appoint-
ments as needed and follow up assessment of caregiver
competence with the techniques. Scar massage Protocols A
and B are described in Table 2. For both protocols, massage was
initiated at discharge from inpatient when the majority of
wounds had healed and the same lubricants were used
(petroleum jelly for most patients).
2.2. Scar assessment
During the Protocol A time period, the original version of the
Vancouver Scar Scale [18] was administered with pigmenta-
tion omitted. Pain and itch were evaluated with 0 10 visual
analogue scale (VAS). During the Protocol B time period, our
team had changed to a modified version of the scale (mVSS)
[19] and pain was evaluated with the Wong-Baker Faces pain
scale [20] and itch with the Itch Man scale [21]. During both
time periods scar height, pliability and vascularity, itch and
pain were assessed. For data analysis in this study, the itch and
pain scores were transformed from the scale used during
Protocol A to the scale used during Protocol B due to different
scales used to measure these parameters during the two time
periods. Scar assessment was done by the clinician at baseline
(discharge from inpatient) and during follow up outpatient
visits after discharge from the hospital. A paper body diagram
Table 2 – Details of massage Protocol A and B.
Protocol A
3 massage techniques without specific names with focus on circular
massage using deep pressure.
Scar massage initiated at discharge.
The application time of the massage techniques was from 5 to
10 min for each affected area.
The massage techniques were performed by a physical therapist
with minimal instruction for caregiver follow through.
Therapist had no specific training in scar massage.
Patients and their caregivers received general information on
applying the techniques to do at home and no follow up training or
check of competency.
1869
was used to indicate scar location and relocation for each
assessment.
2.3. Data analysis
Within subject data was analyzed comparing pre-treatment
(baseline) to post-treatment (follow up) evaluation. Compar-
isons were made between baseline and follow up for itch, pain,
vascularity, pliability (only Protocol A) and height for each
group and between subjects receiving Protocol A and those
receiving Protocol B for the same scar characteristics.
Student's t-test for matched pairs was used to analyze within
protocol changes in itch. McNemar's test was used separately
for each protocol to compare within protocol changes over
time for pain, vascularity and pliability. However, pliability
could not be analyzed for Protocol B because it violated the
requirements of McNemar's test. Logistical regression analy-
ses were performed as a comparison between scar massage
protocols for pain, vascularity, and pliability. Student's t-tests
were used to determine within group changes in scar height for
Protocol A and B and to compare results between the protocols.
2.4. Ethics
This study was reviewed and approved by the ethics com-
mittee of Hospital Vivian Pellas, Direccion de docencia e
investigacion.
3. Results
A total of 100 records of pediatric burn survivors were
retrospectively reviewed: 57 patients had received scar
massage Protocol A and 43 patients had received scar massage
Protocol B. Demographic data for both groups is reported in
Table 3. The average time between the two scar assessments
(baseline and follow up) was 193 (115) days for the entire
group with no difference between Protocol A (17596 days)
and Protocol B (214131 days). However, both baseline and
Protocol B
10 standardized massage techniques with specific names and
descriptions [8].
Scar massage initiated at discharge.
The application time of the massage techniques was approximately 5
to 25min per area (depending on the area size) in outpatient.
The massage techniques were provided by the physical therapy team
while in outpatient and the caregiver while at home (3 times/day).
All of the rehabilitation team received specific training on the
techniques applied on the patients and applied consistently.
Patients and their caregivers received multiple education sessions on
applying the techniques to do at home and check of competency.
Families were provided with a color, trifold hand out detailing the
massage techniques named for ease of recall v. medical terminology
and education provided in pictures and words (appendix download).
1870 burns 46 (2020)

Table 3 – Demographic data.

Subjects receiving Subjects receiving All subjects
Protocol A (n=57) Protocol B (n=43)
% Male 54% 53% 54%
Mean age 5.0 3.3 years 3.8 3.0 years* 4.5 3.2 years
Mean TBSA 7% 8% 7%
Mean time from burn injury to baseline scar evaluation 56 38 days 112 105 days* 80 79 days
Mean time from burn injury to follow up scar evaluation 230 111 days 329 160* 273 143
Mean time between baseline and follow-up scar evaluation 174 96 days 214 131 days 193 115 days
*
p 0.05.

follow up scar assessments were conducted later after burn
injury for patients receiving Protocol B (Table 3). The mecha-
nism of injury is shown in Fig. 1.
3.1. Itch
Mean itch scores reduced with time for patients who received
both Protocol A (p<0.0001) and Protocol B (p=0.02). However,
when comparing the mean changes between the groups, there
was no difference (p<0.41).
3.2. Pain
For pain evaluation, there were large numbers of patients who
had no pain at baseline and follow-up, therefore the scale was
dichotomized to (pain vs. no pain). The incidence of pain did
not significantly reduce with time in patients receiving
Protocol A (p=1.00) nor Protocol B (p=0.60). The majority of
patients reported no pain at baseline and no pain at follow up
for both groups. All patients who reported pain at baseline had
reduced or no pain at follow up however some patients had no
pain at baseline but acquired pain reported at follow up
(Table 4). Logistic regression analysis was used to compare the
probability of having pain after treatment, after adjusting for
pain at baseline, between the protocols and the analysis
revealed there was no difference (p=0.78).
3.3. Scar characteristics of the VSS
3.3.1. Vascularity
Scar vascularity demonstrated a statistically significant
reduction with time for Protocol A patients (p=0.001) and
Protocol B patients (p=0.02). However, between group analysis
revealed no significant difference in scar vascularity changes
(p=0.52).
3.3.2. Height
Within group comparison of changes in height over time
revealed a significant increase with Protocol A (p=0.004) and
non-significant decrease with Protocol B (p=0.82). When
comparing the mean changes in height between the
protocols, there was a significant difference (p=0.03).
However, because there was no significant difference in
mean height over time for Protocol B, the difference stems
from the mean height increase with Protocol A and
therefore, this cannot be interpreted that there is an
improvement in scar height with Protocol B but suggests
an area for future work.
3.3.3. Pliability
Within group comparison for improvement in pliability could
only be done for Protocol A because Protocol B violated the
requirements of McNemar's test. There was no significant
improvement in pliability with Protocol A. Ordinal logistical
regression was used to compare Protocol A to Protocol B and
revealed there was no significant difference (p=0.88) between
the groups.

3.3.4. Caregiver satisfaction with scar

During the time Protocol B was implemented, caregivers were
asked to rate their satisfaction with the esthetic aspects of the
scar at each evaluation using a 1 10 Likert scale (0 being

Table 4 – Descriptive statistics for changes in reported pain

for patients receiving each protocol.
Protocol A Protocol B
No pain at baseline or follow up 77% 65%
Pain at baseline, reduced or none at 12% 23%
follow up
Pain at baseline and increased at 0% 0%
follow up
No pain at baseline but pain at 11% 12%
follow up
Fig. 1 – Etiology of burn injury.
 burns 46 (2020)
unsatisfied and 10 being fully satisfied). Caregiver satisfaction
improved between the two assessments points in 53.46% of
respondents with an average improvement of 5.1 Likert points.
Decreased satisfaction was found in 29.02% of caregivers with
an average decrease of 3.3 Likert points and 17.52% of
caregivers reported no change in satisfaction. A comparison
between protocols could not be conducted because satisfac-
tion data about scar outcome was not collected during the time
Protocol A was implemented.
4. Discussion
This study demonstrated improvements in itch and vasculari-
ty over time with both scar massage protocols. However, it has
been shown that vascularity and itch improve with normal
scar maturation as well [22,23] so without a control group, it
cannot be concluded from this data that massage influenced
those scar parameters. Although both massage protocols were
initiated at the same time frame after burn and scar evaluation
was within the first year after injury, the data showed that
Protocol B evaluations were conducted at a later time after
burn than Protocol A (Table 3). It appears that the decline in
itch and vascularity therefore was stable during both of these
time frames.
This study evaluated two different protocols and found no
difference in scar outcome however, the massage dose may
not have met the minimally effective dose nor targeted the
most effective types of massage, since these parameters have
not yet been determined. Our study contributes more
information about massage protocols with different techni-
ques, frequency and duration of massage used in clinical
practice (Table 2) to the body of knowledge that can be used for
future investigations.
Despite these underwhelming findings regarding the
influence of massage to change scar parameters, we are not
Fig. 2 – Photographs of patients at baseline and follow up.
1871
yet recommending that scar massage be eliminated from
the burn rehabilitation regimen for patients. Although the
evidence to support massage is somewhat weak, it should not
be entirely dismissed at this juncture because there are still
significant methodological concerns noted within the current
body of literature on scar massage [5] and despite inconsistent
evidence, experienced and qualified practitioners continue to
have the clinical impression that scar massage benefits their
patients [2] and caregivers/patients themselves report benefits
(Table 4 and Fig. 2). This merits exploration of how future
research can be improved to best study the impact of this
modality.
One critique of scar massage literature is related to the
methods of measuring scar outcome. Our study evaluated scar
outcome with commonly used clinical tools the Vancouver
Scar Scale (VSS) and the modified Vancouver Scar Scale (mVSS)
[18,19]. The original VSS and mVSS are clinically feasible tools
that can be administered quickly at follow up visits. These
tools numerically represent the clinician's subjective assess-
ment of scar parameters and the mVSS includes patient report
of pain, itch and satisfaction. Despite their widespread use,
these scales have undetermined construct and content
validity [24]. Patino et al. also used a modified version of
VSS to measure the effect of massage on a small group of
pediatric burn survivors and found no changes in pliability,
vascularity or height of the scars [13]. A study by Roh in adult
burn survivors assessed with the original VSS [18], found
improvements in all of the scar parameters as well as pruritus
and decreased levels of depression in the patients [14].
However, three years later, Roh and colleagues used a different
subjective scar scale (the Patient and Observer Scar Assess-
ment Scale [25]) and found no differences in scar character-
istics for patients receiving massage [26]. The conclusions of
our study and these other studies cited should be taken in the
context of the documented limitations with using VSS [24,27].
For this study, it may be that there truly are no observable
1872 burns 46 (2020)

benefits of massage or it may be that the tools to measure the
changes were not appropriate for the targeted outcomes.
Some massage studies [6,7] have used objective measures
such as ultrasonography, Mexameter1 Cutometer1 as these
tools are thought to be more reliable and better able to detect
changes in scar characteristics than the subjective measure
used in this study [28 30]. However, those studies also show
conflicting results regarding the impact of massage on scar
outcome with Cho et al. showing significant scar improve-
ments with massage patients compared to control patients
and Nedelec et al. finding no long-term differences in any scar
parameters in an intra-individual comparison of scars [6,7].
Another thought for consideration is that scar massage
may have less impact on scars when applied in isolation.
Typically, scar massage is applied in conjunction with other
rehabilitation interventions aimed to improve the cosmetic
and functional outcome of scars, such as compression and
orthotic application [31]. Research investigating the use of
massage within the context of, or in conjunction with, other
rehabilitation interventions for scar management may pro-
vide valuable insight. There is evidence of immediate patient
and scar tissue changes with massage [7,11,32]. So it may be
that massage is preparing the tissues to benefit from other
therapeutic interventions (e.g. stretching, orthotic use, com-
pression) that have a longer term benefit on scar outcome.
The time after burn injury to the initiation of massage,
frequency and duration of massage and optimal techniques of
massage have not yet been defined. Our study attempted to
standardize techniques and although massage was initiated
with the patients at similar time frames after burn, the
frequency and duration of the massage performed by the
caregiver was not quantified. Most studies have evaluated the
impact of massage on hypertrophic scars and none have
evaluated the effect massage may have when applied
preventively to mitigate the formation of hypertrophic scar.
Massage may have more holistic benefits to the burn
survivor than simply changes in physical scar parameters that
are not currently detected with subjective and objective scar
assessment tools. Table 5 presents qualitative feedback from
caregivers regarding massage with their children. Massage
appears to influence a patient's experience with burn recovery
[12] and therefore patient reports that capture their experience
with factors such as itch, pain, satisfaction, anxiety and
depression are a necessary and valuable component of any
scar massage research. In addition, there is evidence in the
literature showing decreased anxiety and pain with massage
[12,15]. It may be that by decreasing patients’ fear and
perceived pain through massage, they are more receptive
and adherent with burn therapy which is a valuable gateway to
improving outcome. Lastly, massage has shown improve-
ments in itch [6,15] which is very problematic for many burn
survivors [33] and if more can be learned about how massage
influences pruritus, then it has the potential to improve overall
quality of life after a burn injury [23]. Perhaps, greater
emphasis on burn scar-specific health related quality of life
measures could detect the broader benefits of massage [34].
4.1. Limitations
There are multiple limitations to this study. The first of which
is that it was conducted retrospectively so only data available
in the medical record could be evaluated and no control group
established. It was conducted in pediatric patients only. There
are no studies currently that compare the difference between
massage on adults and children so it is unknown if age
influences scar outcome with massage. Although Protocol B
was more structured than A, we did not objectively quantify
the amount of massage or compliance with the protocol that
was actually applied to the patient which would have been
helpful in the interpretation of the scar height findings in
particular between the protocols.
As previously discussed, the assessment tools chosen for
this study are subjective and may not have been sensitive
enough to detect scar changes. Components of the scar
evaluation used with each protocol differed. The conversion
of the itch scales was a conversion from continuous data
(Protocol A) to categorical data (Protocol B), which has
limitations, however, since self-reported itch is subjective,

Table 5 – Qualitative statements from caregivers/patients receiving massage (English and Spanish).
“The massage has helped reduce the thickness of the scars and match the color of the scars with her skin tone. They look smoother and she has
less itching. The skin grafts feel softer and are more sensitive. Additionally the massages help the skin stretch more.” mother of patient age 5.
“Las técnicas de masaje han ayudado a reducir el grosor de la cicatriz y a que esta sea del mismo color de su piel. Se ven más lisas y ella tiene menos picazón. Los
injertos se sienten más suaves y con mayor sensibilidad. Adicionalmente los masajes ayudan a que la piel se estire más.” - madre paciente de 5 años de edad.
“I consider massages to be a good treatment because it helps keep my child's scars soft and prevent them from raising.” mother of patient age 2
“Considero que los masajes son un buen tratameinto ya que ayudan a mantener la cicatriz suave y previenen que se hagan verdugones.” - madre de paciente de 2
años de edad.
“The massages have been a great help and made a significant difference in the rehabilitation process by reducing itching, softening the scar and
helping hydrate the skin.” mother of patient, age 2
“Los masajes han sido de gran ayuda y han hecho una diferencia significativa en el proceso de rehabilitación al reducir la picazón, suavizar la cicatriz e hidratar la
piel.” - madre de paciente de 2 años de edad.
“Massage has been an excellent treatment because they have improved the scars of my son. Every day they feel softer and it helps in the esthetic
and emotional aspect given my son was very depressed. His skin is very smooth, more uniform and in the psychological aspect there has been a
radical change. The key is consistency, patience and discipline. The massage techniques have helped my adolescent son have a better self-esteem
and self-assurance.” mother of patient age 11.
“Los masajes han sido un excelente tratamiento ya que han mejorado las cicatrices de mi hijo. Cada día se siente más suaves y el masaje ayuda en la parte estética
y emocional, ya que mi hijo se sentía muy deprimido. Su piel está más suave, más uniforme y en el aspecto psicológico ha habido un cambio rádical. La clave es
consistencia, paciencia y disciplina. Las técnicas de masaje han hecho de mi hijo un adolescente con mejor autoestima y seguridad.” - madre de paciente de 11 años
de edad.
 burns 46 (2020)
no matter what measurement tool is used, we believed that the
two measurement approaches were comparable. In addition,
scar evaluations for Protocol B were done later after burn injury
than for Protocol A, which means that the data should be
interpreted with consideration of the time frame in which
the evaluation was conducted. However, it is important to note
that both time frames were within the expected time of scar
maturation. Lastly, the duration of follow up in this study
(average 193 days) may not have been sufficient to capture
changes in the scar with massage.
5. Conclusion
In conclusion, we did not find clinically meaningful changes in
scar characteristics with a structured scar massage program
compared to a general approach to massage. Both protocols
were associated with decreased vascularity and itch suggest-
ing massage may influence those parameters no matter the
protocol used. This study serves as just one piece to the
ongoing puzzle of understanding the role and influence of
massage in the recovery of burn survivors. The burn
community should continue to research the effects of massage
using well-designed massage protocols, appropriate and
relevant outcome measures and burn survivor input before
final conclusions can be made regarding use of this modality.
We are recommending that clinicians and researchers work
together to reflect on the observed clinical benefits of massage
and design research studies that use systematic and objective
outcome measures to target the specific indications for
massage while including patient and caregiver input.
Conflict of interest
The authors declare that there is no conflict of interest.
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at https://doi.org/10.1016/j.burns.2020.
05.013.
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