PART 5 OUT 5: This article discusses skin injuries of burns, scarring, and decubitus ulcers starting with a description of the condition and following up with massage considerations and a look at evidence-based practice. Please check previous blogs for bacterial infections, fungal infections, viral infections, and inflammatory infections.
Skin can be injured by burns, surgical procedures, diseases, and sustained external pressure over bony prominences. Massage has been found to produce positive effects on several skin injuries with precautions applied.
Burns: A burn is an injury that may cause damage to the epidermis, dermis, hypodermis, or organs underneath. There are four degrees of burns based on the depth of tissue damage A first-degree burn, also called a superficial partial thickness burn, damages only the epidermis. An example of a first-degree burn is mild sunburn. A second-degree burn, also called a deep partial-thickness burn, is deeper and more severe than first-degree burns and involves both the epidermis and upper layers of the dermis. A third-degree burn, also called a full-thickness burn, destroying the epidermis, dermis, hair follicles, and associated glands and possibly extending into the subcutaneous tissue and underlying soft tissue. A fourth-degree burn is a full-thickness burn that extends down to the muscle or bone.
Massage Therapy and Burns: Avoid massage over the burned area until it has completely healed. Healing time depends on many factors, such as degree of severity, which ranges from several weeks to several months.
Once healed, massage and scar tissue mobilization is permissible. Massage was found to reduce itching (1, 2), pain (1-3), and anxiety (4). Massage also improved burn scar pliability, vascularity, pigmentation (3), and height of scar tissue (2, 3). In other studies, massage increased the range of motion in areas containing scar tissue from previous burned areas in children (5). Massage given before débridement decreased depression (3, 4) and anger, and people were less anxious and reported lowered stress levels (4). Massage was also shown to decrease behaviors indicating distress in children who were severely burned when administered before procedures such as cleaning the area and changing bandages (6).
Before massaging the affected area, obtain verbal consent. Some clients with disfiguring burns or scarring may feel self-conscious while they are on the massage table. If consent is granted, ask the client how sensitive the affected area is and adjust the pressure accordingly. Large burns can be devastating to the client. Provide positive reinforcement, being aware that each client will progress through different states of grief during the recovery processes.
Scars: A scar is a mark left on damaged skin or other tissues after it is healed. The damage may result from trauma, burns, surgical procedures, or disease such as acne, chickenpox, or shingles. During the healing process, local collagen production increases to repair damaged tissues. The resulting scar is usually stronger than the tissue being replaced. But because scar tissue is different from the original tissue type, there is usually some loss of function. Two types of abnormal scars are hypertrophic and keloid scars. Both types of scars are the result of excess collagen production, which causes a thick, elevated scar. Hypertrophic scars do not extend beyond the boundaries of the original wound. Keloid scars extend beyond the boundaries of the original wound.
Massage Therapy and Scars: Avoid massage over the affected area until it has completely healed. Healing times vary, and a good rule of thumb is to wait until the wound or incision is clean and dry. Afterward, scar mobilization is permissible.
Use deep friction (cross-fiber, circular, chucking) and skin-rolling techniques near and directly over the scar with or without lubricant. Be sure to mobilize tissues in several directions because scar tissue is arranged haphazardly. Inquire about sensitivity while working on scar tissue. Adjust your pressure according to your client’s tolerance for pressure while staying below their pain threshold. During the procedure, be sure the scar is relaxed during a portion of the treatment time. For example, if the scar is over the anterior knee, place the knee in an extended position before working over the scar.
Massage was found to decrease pain (2, 7), reduce itching, decrease anxiety, and improve mood (2) in individuals who had burn scars or surgical scars. An additional effect of decreased tissue tension in areas of extensive scarring after a mastectomy surgery was also found (7).
Decubitus Ulcers: Decubitus ulcers are localized injury to the skin and/or underlying tissues, usually over a bony prominence from sustained external pressure. Areas of involved tissue can extend downward to underlying bones and joints. Individuals who are immobile, such as those who are bedridden or confined to a chair, are at higher risk of decubiti. These ulcers are major threats to a client’s health. Decubitus ulcers are also called decubiti, bedsores, pressure sores, and pressure ulcers. Ulcers are classified in four stages based on the depth of tissue damage from superficial tissue layers (stage I) all the way down to bones and joints (stage IV).
Massage Therapy and Decubitus Ulcers: Postpone massage if the ulcer is emitting a discharge or has a foul odor because these are hallmarks of infection.
Local massage is contraindicated over areas at risk for ulcer formation. At-risk areas for bedridden clients are back of the head, over the scapula, the elbows, the sacrum, and over the heels. At-risk areas for chair-bound clients are over the scapula, the sacrum, the ischial tuberosities, the popliteal areas, and plantar surfaces of the feet. The therapist cannot rely on assessment to determine the presence of developing decubiti because the client may have inflammation manifesting as nonblanching skin that is difficult to observe, particularly in individuals with darker skin.
Furthermore, the National Pressure Ulcer Advisory Panel (8) states that massage or vigorous rubbing should not be used over skin that is at risk of developing pressure ulcers because it is painful and may cause further tissue damage or promote inflammatory reactions, especially in frail older adults. Guy (9) and Shahin et al (10) also advised to avoid at-risk areas because massage pressure may exacerbate local tissue damage.
Articles and Journals Referenced:
- Cho YS, Jeon JH, Hong A, et al. The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: a randomized controlled trial. Burns. 2014;40(8):1513-1520.
- Field T, et al: Postburn itching pain, and psychological symptoms are reduced with massage therapy, J Burn Care Rehabil 2000 21(3):189–193, 2000.
- Roh YS, Cho H, Oh JO, Yoon CJ. Effects of skin rehabilitation massage therapy on pruritus, skin status, and depression in burn survivors. Taehan Kanho Hakhoe Chi. 2007;37(2):221-226.
- Field T, et al: Burn injuries benefit from massage therapy, J Burn Care Rehabil 19:241–244, 1998.
- Morien A, Garrison D, Smith NK. Range of motion improves after massage in children with burns: a pilot study. J Bodyw Mov Ther. 2008;12(1):67-71.
- Hernandez-Reif M, et al: Children’s distress during burn treatment is reduced by massage therapy, J Burn Care Rehabil 22:191–195, 2001.
- Wilk I, et al: application of tensegrity massage to relive complications after mastectomy: case report, Rehabil Nurs 40(5):294–304, 2015.
- National Pressure Ulcer Advisory Panel: Prevention and treatment of pressure ulcers: quick reference guide, 2014. http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf
- Guy H: Does massage help to prevent pressure ulcers? Nursing Times 107:32–33, 2011. http://www.nursingtimes.net/nursing-practice/specialisms/wound-care/does-massage-help-to-prevent-pressure-ulcers/5033735.article
- Shahin ES, Dassen T, Halfens RJ: Pressure ulcer prevention in intensive care patients: guidelines and practice, J Eval Clin Pract 15(2):370–374, 2009.
Susan Salvo is a board certified massage therapist with 30+ years of experience. Susan is passionate about massage therapy and massage education. You can contact her at firstname.lastname@example.org.