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of Pages 8

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Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/locate/burns

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: [email protected] (C.H. Seo).
http://dx.doi.org/10.1016/j.burns.2014.02.005
0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: Cho YS, et al. The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: A randomized
controlled trial. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.005
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2 burns xxx (2014) xxx–xxx

Medical staff not involved in the study randomly assigned

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

Please cite this article in press as: Cho YS, et al. The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: A randomized
controlled trial. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.005
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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- 3. Statistical analysis
Khazaka Electronic GmbH, Germany). The measurement is
based on the principle of grease-spot photometry. The Collected data were analyzed by using SPSS 21.0 program
measuring head of the cassette with its special tape is placed (SPSS Inc., Chicago, USA). Fisher’s exact test and independent
on the skin. It is then inserted into a slot in the device, where samples t-test were used for homogeneity test. Independent
the transparency is measured by a light source passing samples t-test was used to ensure homogeneity between the 2
through the tape. A photocell measures the transparency. A groups at the initial assessment. Paired t-test was used to
microprocessor calculates the result, which is shown on the compare the pre- and post-treatment status, and the analysis
display in mg sebum/cm2 of the skin [31]. of covariance (ANCOVA) was used. p Value below 0.05 was
considered statistically significant.
2.1.5. Measurement of scar elasticity
Skin elasticity was measured using Cutometer SEM 5801
(Courage-Khazaka Electronic GmbH, Colongne, Germany). 4. Results
This device pulls skin using negative pressure on an 8-mm
diameter probe and indicates the skin’s maximum level of 4.1. Demographic and clinical characteristics of the
distortion by a numerical value. Two seconds of negative patients
pressure of 450 m bar is followed by 2 s of recess, and this
consists of a complete cycle. Three successions of cycles A total of 146 patients comprised 111 men and 35 women. Of the
were carried out, and the average value was obtained 76 subjects in the massage group, 61 were men and 15 were
[26,30]. women, while the control group comprised 50 men and

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

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Fig. 2 – Comparison of scar thickness. yp < 0.05. Fig. 5 – Comparison of scar TEWL. *p < 0.05.

Fig. 6 – Comparison of scar sebum level.

Fig. 3 – Comparison of scar melanin. *p < 0.05.

showed no significant difference (CI, 0.003–0.368; p = 0.17). The

4.6. The change in scar sebum immediate distension increased in the massage group. The
difference between initial and follow-up immediate disten-
The scar sebum increased in the massage group. No significant sion showed a significant difference (CI, 0.111–0.310; p = 0.01).
difference was noted (CI, 1.2–7.1; p = 0.51) (Fig. 6). The biologic skin elasticity increased in the massage group.
The difference between the initial and follow-up biologic skin
4.7. The change in scar elasticity elasticity showed no significant difference (CI, 0.084–0.206;
p = 0.13). The gross skin elasticity in the massage group. The
The skin distensibility increased in the massage group. The difference between the initial and follow-up gross skin
difference between initial and follow-up skin distensibility 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.
Fig. 4 – Comparison of scar erythema. p < 0.05.
Hypertrophic scars are morphologically characterized by an

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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 In this study, the massage group received an average of
fibers; persistent cellularity; alterations in the abundance and 12.46  7.17 burn rehabilitation massage therapies during
composition of proteoglycans; and a prolonged, chronic 34.69  22.53 days in average. Each session of 30-min treat-
inflammatory reaction, which includes increased vascularity ment included effleurage, friction, and petrissage massage
and deposition of ground matrix [32]. after applying whitening cream, anti-redness cream, and
Although the management of hypertrophic scars has moisturizing oil, and this massage treatment improved pain,
advanced in the past years, the lesions remain difficult to pruritus, and scar characteristics (thickness, melanin,
prevent and treat. Hypertrophic scarring after burns requires a erythema, TEWL, elasticity) to a significantly greater degree
specific therapeutic approach since the scars are often non- than only standard therapy.
linear and widespread [18]. Recurrences are common patient A study by Morien at al. reported that 8 children who were
satisfaction with the treatment is variable [18]. Extensive treated with 20–25 minute-long daily massage therapy for 3–5
research has increased the knowledge base regarding the days improved the ROM in the knees, neck, and shoulders [33].
pathophysiologic processes of wound healing and scar Roh et al. compared 18 subjects who received massage therapy
formation [5], but there is still no consensus regarding the and 17 who received standard therapy for 3 months and
best treatment strategy for reducing and preventing hyper- reported that the massage-therapy group showed greater
trophic scarring. improvements in pruritus, VSS score, and depression [19].
Physicians and therapists have used and reported a variety Filed at al. reported greater immediate and long-term
of therapeutic modalities for the treatment of hypertrophic improvements in pruritus, pain, anxiety, and mood in the
scar. Techniques such as silicone gel application, pressure 10 subjects who received massage therapy for 5 weeks than
therapy, intralesional corticosteroid injection, laser therapy, the 10 subjects who only received standard therapy [34].
cryotherapy, radiation, and others have been used but are yet Previous studies on the effects of massage therapy lacked
to demonstrate any objective, reproducible improvement in objectivity in scar condition measurements. However, Ultra-
the character of hypertrophic scars. One of the techniques sound, Mexameter1, Tewameter1, Sebumeter1, and Cut-
reported to soften restrictive fibrous bands and improve the ometer1 were used in this study to objectively measure scar
pliability of the scar tissue is massage therapy. conditions, and the measurement revealed that the scar
They are many types of massage, such as effleurage, thickness, melanin, erythema, TEWL, and elasticity of the scar
friction, and petrissage. Basically, the effects of massage are improved to a significantly greater extent with massage
reflex and mechanical. The reflex effects of massage therapy therapy than with the standard therapy alone.
are realized through the stimulation of the afferent peripheral However, evidence to support the use of scar massage is
nerves to the central nervous system to produce muscle inconclusive, although its efficacy appears to be greater in
relaxation, a decrease in painful sensations, and an overall postsurgical scars. There is much variability and inconsis-
sense of well-being. The mechanical effects of massage are tency with regard to when treatment should be initiated, the
related to an improvement in venous return and lymphatic appropriate treatment protocol and duration, and evaluation
drainage. Further, massage therapy stimulates movement and measurement of outcomes. Because these results are
between muscle fibers, which results in more fluid muscle difficult to interpret, evidence-based recommendations can-
movement. not be made. Potential positive effects of scar massage include

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involving patients in their treatment, hastening the release not identified. Second, evolution of hypertrophic scar was not
and absorption of buried sutures, aiding the resolution of considered. Typically, burn scars undergo hypertrophy
swelling and induration, and economic value, especially between 6 and 12 months and tend to regress between 18
compared to silicone gel application. Possible negative aspects and 24 months [30]. In addition, there may be a positive
of this therapy include wasting the patient’s time if massage is correlation between pruritis and hypertrophy of the burn scar.
not an efficacious treatment, irritation from friction, and Thus, the effect of massage may differ depending on whether
developing irritant or contact dermatitis from the lubricant the burn scar is in the early or late stages of maturation. Future
used for massage. studies should focus on comparing the effect of massage on
The natural history of acute wound healing progresses ‘‘new’’ and ‘‘old’’ burn scars.
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 6. Conclusion
matures and improves in appearance and pliability. This
process occurs in the absence of any intervention. Although Burn rehabilitation massage therapy can be one of the
the effect of massage on this phase of wound healing is modality for controlling post-burn hypertrophic scar pain,
unknown, it may shorten the time needed to form a mature pruritus and the scar characteristics (thickness, melanin
scar. deposition, erythema, TEWL, and elasticity). However, further
Notwithstanding the lack of evidence, massage should studies are needed to establish a standard protocol for burn
theoretically be effective. One hypothesis supporting its use is scar massage therapy on the basis of the long-term ther-
that mechanical disruption of fibrotic tissue increases the apeutic effects and evolution of hypertrophic scars.
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]. Conflict of interest
A study of cultured human skin fibroblasts by Kanazawa
and colleagues revealed a decrease in messenger ribonucleic None declared.
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 Acknowledgment
factor has been implicated in maintaining fibrosis induced by
transforming growth factor-beta [40], its downregulation may This study was supported by a grant of the Korean Health
prevent abnormal scarring. In another in vitro model, human Technology R&D Project, Ministry of Health & Welfare,
hypertrophic scar samples responded to mechanical loading Republic of Korea (A120942).
by inducing apoptosis and decreasing levels of tumor necrosis
factor-alpha [41], although another study showed that biaxial references
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Please cite this article in press as: Cho YS, et al. The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: A randomized
controlled trial. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.005
JBUR-4298; No. of Pages 8

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Please cite this article in press as: Cho YS, et al. The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: A randomized
controlled trial. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.005