Burn scar contracture, perspectives on prevalence, severity, and rehabilitation interventions.
Authors:   , Schouten Hendrikus Johannes 
Published: December 2023

SUMMARY
The goal of this thesis was twofold. Firstly, creating awareness of the possibilities and impossibilities of preventing or minimizing burn scar contracture development by splinting therapy and stretching interventions.
Since the rationale behind splinting therapy is to counteract the contractile forces of the healing scar tissue, the literature was reviewed for the response of the contracting burn wound to the mechanical load applied using splints.
Many experimental studies have reported that mechanical tension exerted by static splinting therapy will actually stimulate myofibroblast activity, resulting in the synthesis of new extracellular matrix (collagen) and the persistence of contractile activity.
This suggests that static splinting therapy may even worsen the scar contracture formation, and thus contradict its purpose. In view of these findings, it is uncertain if splinting therapy is a realistic intervention for the prevention of burn scar contracture.
Furthermore, an ex-vivo experimental study was conducted to examine the effect of stretch on healthy skin and matured scar tissue with the focus on collagen orientation and structure.
Results of this study showed that scar tissue had significantly less potential to increase in length compared to healthy skin.
The results of the review on splinting therapy and the ex-vivo experimental study on stretching matured scar tissue suggest that stretching exercises and splinting therapy may not be effective interventions.

And secondly, a long term prospective multicenter cohort study was conducted for the first time to identify the prevalence and severity of burn scar contracture development.
The results of this study showed that conservatively healed superficial burn wounds, across or adjacent to joints, were of no threat for burn scar contracture development in the long term, despite a rather high prevalence of ROM limitations in the acute phase.
Burn scar contracture development in the long term was exclusively the result of joints that were skin grafted. However not all joints that were skin grafted resulted in a burn scar contracture. More than half of the ROM limitations of those joints seen in the acute phase resolved within 12 months. Furthermore, the degree of ROM limitation of all joints diminished overtime and a part of them even normalized to the full ROM.
Indicating that the prevalence and degree of ROM limitations in the acute phase have little predictive value for the prevalence and degree of ROM limitation of burn scar contracture development in the long term. Furthermore, the pattern of the course of the prevalence and degree of developing burn scar contractures differed markedly between joints and planes of motion. Interpretation of the degree of limitation of a burn scar contracture in terms of severity is not just a matter of qualifying the loss of range of motion of a joint, but depends largely on the extent to which impaired joint mobility interferes with the functional needs of the individual burn patient in terms of daily activities and participation in society.
Comparing the overall results of this longitudinal study with previous studies showed little consistency, which stresses the need for uniform study designs, measurement protocols, study population, timing of measurement and definition of a burn scar contracture.