Evaluatie en conservatieve behandeling van littekens na brandwonden

After a severe burn injury, patients have an increased catabolism that leads to loss of lean body mass and this causes muscle weakness and decreased functional capacity. The prolonged bed rest and the lack of physical activity have an important impact on recovery after burn injuries in the rehabilitation process. The most frustrating and annoying complication after a severe burn injury remains hypertrophic scar formation leading to scar contractures and decreased range of motion, a problem frequently associated with pain and itching. Accordingly, physiotherapy takes a crucial role in the treatment and rehabilitation process of burn patients and includes a variety of treatment methods such as exercise therapy, cardiopulmonary training, joint mobilization, positioning, splinting and topical scar management. However there is no consensus on the actual effect of the various treatment modalities and the evidence is not clear or even lacking. Six to 8 weeks after re-epithelialization hypertrophic scars usually develop and they are characterized by a red to deep purple color. The scar becomes more elevated and firm, hypersensitive, itchy and tends to contract. More specifically, the development of hypertrophic scarring after burn injury affects the appearance, the range of motion and compromises the skin’s protective function. Change in color, thickness and pliability (elasticity) are the most frequently reported physical features. The most important physiological characteristics of hypertrophic scars are a change in transepidermal water loss (TEWL) and water content. All these parameters provide information on scar maturation, function and aesthetics of the scar and can be evaluated using scar assessment scales (such as the POSAS questionnaire) or objective scar assessment tools. However there is need for further research in reliable objective measurement tools to investigate elasticity as a physical property of a hypertrophic burn scar and TEWL and water content as physiological properties of post-burn scars. The scope of this doctoral project was threefold. The first objective was to expand the test battery for clinical and objective evaluation tools to optimize the evaluation of (burn related) scars and the assessment of different treatments and interventions and to evaluate some relevant and lacking objective assessment tools in the assessment of physical and physiological properties of burn related scars (Chapters 1 and 2). Secondly, the most frequently used non-invasive treatments of burn scars were summarized and evaluated (Chapter 3). Finally the effects of two physiotherapeutic interventions, being hydrotherapy (Chapter 4) and massage therapy (Chapter 5) using a mechanical suction device in burn scars were investigated. In Chapter 1 the reproducibility of repeated elasticity and transepidermal water loss (TEWL) measurements with the DermaLab on 32 active burn scars and healthy skin was investigated. Results showed good ICC values (ICC ≥ .86) and rather high SEM values (SEM ≤ 0.89) for intra- and inter-observer reproducibility of elasticity measurements. For TEWL measurements, ICC values were good (ICC ≥ .78) and SEM values were high (SEM ≤ 2.76) for inter- and intra-observer reproducibility. There was a significant difference between the estimated mean elasticity values of normal skin and grafted scars and between normal skin and spontaneously healed scars (p ≤ .003). For the estimated mean TEWL values, there was a significant difference between normal skin and spontaneously healed scars (p = .036). A significant negative relation was reported between mean TEWL and time after burn injury (p = .008). In clinical trials it is necessary to interpret patient-specific changes in elasticity and TEWL with caution, since the SEMs of both modes are rather high. We therefore recommend the use of a mean of 3 repeated measurements of elasticity and TEWL to decrease the SEM. However in clinical practice the limited amount of suction of the DermaLab (elasticity mode) is an important disadvantage, thus it would not be possible to measure elasticity using the DermaLab in severe rigid scar tissue and therefore we recommend to use another suction-based device, the Cutometer. The reliability of repeated water content measurements with Corneometer on 30 (burn) scars was investigated in Chapter 2. Results revealed excellent ICC values (ICC ≥ .984) with relatively low WSCV (WSCV ≤ 10.6%) for intra- and inter-observer reliability. However, the Bland-Altman plot showed that more than 5% of differences were expected to exceed 4 AU, the limit of what has been defined as a clinically acceptable difference. Results for day-by-day variability showed good ICC value (ICC = .849) and higher WSCV (WSCV = 20.5%). Based on our results, we conclude that the instrument can be used in clinical trials, but only under very strict conditions with a standardized test protocol, preferably in combination with the evaluation of other physiological parameters. We recommend the use of the mean of 5 repetitive water content measurements. However if at least two values differed by more than 4 AU, we suggest an additional 6th measurement to balance the average of the repetitive measurements. This will result in a more accurate estimate of the true value for water content. In Chapter 3 the available literature on the effects of conservative treatments of burn scars in adults was summarized. Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) were sought in three databases, reference lists of retrieved articles and relevant reviews. The Scottish Intercollegiate Guidelines Network scoring system was used to assess the quality of the selected studies. Twenty-two articles were included into the review and categorized in six topics: 5 on massage therapy, 4 on pressure therapy, 6 on silicone gel application, 3 on combined therapy of pressure and silicone, 3 on hydration and 1 on ultrasound. Pressure and silicone therapy are evidence-based conservative treatments of hypertrophic scar formation after a burn injury and produce clinically relevant improvement in scar thickness, redness and pliability. Massage therapy could have a positive result on scar pliability, pain and pruritus, but with less supporting evidence. The use of moisturizers and lotions can have an effect on itching, but the findings are contradictory. Of all other non-invasive treatments such as splinting, casting, physical activity, exercise and mobilisations no RCTs or CCTs were found. Chapter 4 explored for the first time the short-term effects of hydrotherapy in adults after burn injuries in a pilot comparative controlled study. Forty-two patients were allocated into one of three groups: 3-week treatment in a spa resort (passive hydrotherapy); or 3 weeks aquatic exercise (active hydrotherapy); or only the usual care therapy. Physical and scar-related outcome measures were assessed at baseline, during intervention and at follow-up until 3 months. In active hydrotherapy group (AHT) a significant increase in hand grip strength was shown. In passive hydrotherapy group (PHT) hand grip strength decreased temporary during intervention which returned to baseline at 3-month follow-up. In all groups there were significant improvements in redness and POSAS vascularity score over time, although a temporary increase of redness and vascularity score during the intervention in PHT group. A significant lower itching score in PHT group was found during intervention. So far, pressure and silicone therapy are the only evidence supported treatments in burn scar after care. But we believe that hydrotherapy can offer some added value to the current usual care therapy. Chapter 5 represented the effects of the depressomassage on the recovery of color and TEWL in burn scars. Depressomassage is a non-invasive massage technique using a mechanical suction device frequently used in the treatment of traumatic or burn scars. A total 43 patients were included and allocated into 2 groups. All patients received standard physical therapy, only the test group received additional depressomassage during 6 months. Color was assessed using the POSAS questionnaire (for color, vascularity and pigmentation) and the Minolta Chromameter. TEWL was measured using DermaLab. Patients of both groups were evaluated at baseline, after 1, 3 and 6 months and after 1 year. The evidence for a difference in evolution of color and TEWL between both groups was minimal. In practice, proper indications to start depressomassage have to be kept in mind. Perhaps other scar abnormalities such as decreased elasticity, increased thickness, excessive pain or itching could be the reason to start depressomassage and need to be assessed. This doctoral project made an important contribution to the test battery for clinical and objective evaluation tools to optimize the evaluation of in particular the physiological characteristics (TEWL and water content) of burn related scars and the assessment of different treatments and interventions. Based on the review, we were able to identify the effects of the most frequently used non-invasive treatments of burn scars. The effects of the two physiotherapeutic intervention studies, hydrotherapy and depressomassage, in burn patients were minimal, however these findings provided several insights for further research.nrpages: 222status: publishe