975624

research-article2020
SBH0010.1177/2059513120975624Scars, Burns & HealingMoortgat et al.

Original Article

Scars, Burns & Healing

The effects of shock wave Volume 6: 1­–10

DOI: 10.1177/2059513120975624
https://doi.org/10.1177/2059513120975624

therapy applied on hypertrophic

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© The Author(s) 2020

burn scars: a randomised

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controlled trial
Peter Moortgat1 , Mieke Anthonissen1,2, Ulrike Van Daele1,3,
Tine Vanhullebusch1,3, Koen Maertens1,4, Lieve De Cuyper1,5,
Cynthia Lafaire1,5 and Jill Meirte1,6

Abstract

Introduction: A wide variety of non-invasive treatments has been proposed for the management of hypertrophic
burn scars. Unfortunately, the reported efficacy has not been consistent, and especially in the first three
months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock
wave therapy (ESWT) is a new non-invasive type of mechanotherapy to treat wounds and scars. The aim of the
present study was to examine the objective and subjective scar-related effects of ESWT on burn scars in the
early remodelling phase.
Material and methods: Evaluations included the Patient and Observer Scar Assessment Scale (POSAS) for scar
quality, tri-stimulus colorimetry for redness, tewametry for trans-epidermal water loss (TEWL) and cutometry
for elasticity. Patients were randomly assigned to one of two groups, the low-energy intervention group or
the placebo control group, and were tested at baseline, after one, three and six months. All patients were
treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or
placebo) once a week for 10 weeks.
Results: Results for 20 patients in each group after six months are presented. The objective assessments showed
a statistically significant effect of ESWT compared with placebo on elasticity (P = 0.011, η2P=0.107) but
revealed no significant effects on redness and TEWL. Results of the clinical assessments showed no significant
interactions between intervention and time for the POSAS Patient and Observer scores.
Conclusion: ESWT can give added value to the non-invasive treatment of hypertrophic scars, more specifically to
improve elasticity when the treatment was already started in the first three months after wound closure.

Keywords
Extracorporeal shock wave therapy, hypertrophic scar, mechanotransduction, elasticity, low-energy shock waves,
non-invasive treatment, scar management

1OSCARE, Antwerp, Belgium

2Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
3University of Antwerp, Rehabilitation Sciences and Physiotherapy, Antwerp, Belgium
4Department of Clinical and Lifespan Psychology, Vrije Universiteit Brussel, Brussels, Belgium
5ZNA Stuivenberg, Burns Center, Antwerp, Belgium
6University of Antwerp, Rehabilitation Sciences and Physiotherapy, REVAKI-MOVANT, Antwerp, Belgium

Corresponding author:
Peter Moortgat, OSCARE, Van Roiestraat 18, Antwerp, B-2170, Belgium.
Email: [email protected]

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 2 Scars, Burns & Healing

Lay Summary

Pathological scarring is a common problem after a burn injury. A wide variety of non-invasive treatments
has been proposed for the management of these scars. Unfortunately, the reported efficacy of these
interventions has not been consistent, and especially in the first three months after wound closure,
fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a
relatively new non-invasive therapy to treat both wounds and scars. The aim of the present study was to
examine the scar-related effects of ESWT on burn scars in the early phase of healing.
The scars were subjectively assessed for scar quality by the patient and an observer using the Patient
and Observer Scar Assessment Scale (POSAS). Objective assessments included measurements to assess
redness, water loss and elasticity. Forty patients were randomly assigned to one of two groups, the low-
energy intervention group or the placebo control group (the device simulated the sound of an ESWT
treatment but no real shocks were applied), and were tested at four timepoints up to six months. All
patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT
treatment (real or placebo) once a week for 10 weeks.
The objective assessments showed a significant improvement of elasticity in the intervention group when
compared with placebo but revealed no significant effects on redness and water loss. Results of the clinical
assessments showed no differences between the groups for the POSAS Patient and Observer scores.
ESWT can give added value to the non-invasive treatment of pathological scars more specifically to
improve elasticity in the early phase of healing.

Introduction dermal scarring,11 so the outcomes of clinical trials

investigating cellulite may be transferred to patho-
The development of hypertrophic scarring is a logical scarring.12 Previous research has established
common problem after a burn injury or other positive effects of ESWT on scars. In a pre-post
complex and/or prolonged wound healing con- study of ESWT for postburn scar contractures,
ditions. A hypertrophic scar is characterised by hypertrophic scars and keloids became less pain-
red, raised and firm scar tissue that contracts and ful, less stiff and thinner with more similar scar col-
limits normal movement of the skin. It is also our to the surrounding skin and more acceptable
associated with other physical and psychological appearance.13 In a prospective, single-blind, pla-
consequences such as limited range of motion, cebo-controlled study, a significant reduction of
increased pain sensation, pruritus, elevated anxi- scar pain in burn patients was observed in favour of
ety levels and lowered health-related quality.1–3 the patient treated with ESWT.14 In another ran-
Physiotherapy plays an important role in domised clinical trial, ESWT was found to be effec-
scar treatment and includes scar massage, exer- tive for the treatment of painful, retracting scars of
cise therapy, joint mobilisation, cardiopulmo- the hands. The subjective clinical appearance of
nary training, positioning, splinting and topical scars, the motion function of the underlying joints
scar management.2,4 Unfortunately, the reported and the subjective pain improved significantly.15
efficacy has not been consistent, with contradic- All of these studies applied low-energy ESWT with
tory results for scar massage5,6 and splinting, for a total energy for each impulse in the range of
example.7–9 0.15–0.37 mJ/mm2. But so far, in the published
However, in the early phase of scar remodel- studies on the effects of ESWT on scars, the only
ling during the first months after wound closure, objectively measured scar-related outcome param-
fragility of scarred skin could limit the treatment eter was blood perfusion.16
options. Therefore, extracorporeal shock wave In this study, we aim to examine both the
therapy (ESWT) is promising as a non-invasive objective and subjective scar related outcomes of
type of physical intervention to treat scars. Non- low-energy ESWT on burn scars in the early phase
randomised clinical data suggest that ESWT is ben- of scar remodelling. This study has a randomized
eficial in terms of improved skin elasticity and double blinded design with an objective assess-
revitalising dermis in women with cellulite.10 ment of elasticity in addition to the use of subjec-
Fibrillar adipose tissue fibrosis looks very similar to tive scar scales.

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 Moortgat et al. 3

Material and methods

Study design
This study was a prospective, randomised, double
blind, placebo-controlled, single-centre trial. Data
was collected between September 2013 and
November 2016 at our organization for burns, scar
after-care & research (Oscare, Antwerp, Belgium).
Patients were randomly assigned to one of 2
groups: the low-energy ESWT group or the pla-
cebo ESWT group. Details of the allocated group
were given on cards contained in sequentially Figure 1. Duolith®-SD1 T-Top ESWT device.
numbered, opaque, sealed envelopes. The patients
in both groups were also given standard treatment.
This consisted of pressure therapy, the use of sili-
cone and physical therapy, such as manual mobili-
zation techniques and scar massage, as prescribed
by the treating physician. Patients of the low-energy
ESWT group were additionally treated with a
Duolith® SD1 shock wave device. The other
patients received a placebo ESWT treatment using
a foam-filled placebo shock wave treatment head
that did not generate any output. Both the patients
and assessors were blinded to treatment
allocation.
Figure 2. The C-Actor handpiece with stand-off device II with
10 mm depth of focus zone.
Study population
To be included, patients had to meet the follow- The scar site was prepared with contact gel to
ing inclusion criteria: age ⩾ 18 years; split thick- conduct the shock waves. All scars were treated for
ness grafted or spontaneously healed burn scares 10 weeks with ESWT or placebo, one treatment/
after complete wound closure; and full wound week, 30–50 shocks/cm², with an energy flux den-
closer obtained less than six months before the sity of 0.25 mJ/mm² and a frequency of 6 Hz.
baseline assessment.
Exclusion criteria were as follows: central
neurological diseases; peripheral paralysis; pace- Measurement procedure, measurement
maker; coagulation disorders; medication use of tools and outcome measures
anticoagulants (e.g. Marcumar®); thrombosis; To acclimatise and to stabilise cutaneous blood
tumour; previously received shock wave therapy flow, all patients were asked to enter the testing
for wound closure; cortisone therapy up to six room at least 15 min before measurements were
weeks before the first treatment; and pregnancy. started and to remove pressure garments and sili-
Patients have agreed to participate in the study cone. The temperature and the humidity in the
and signed the informed consent. This study was test room were registered using a thermometer
approved by the Ethics Committee of ZNA and a hygrometer.
Antwerp 009 OG.031 (E.C. approval n° 4200). The scar site to be measured was placed in a
horizontal position. All measurements on the
hand or forearm were taken in a sitting position
Intervention
with the forearm lying on the table. Measurements
Patients of the ESWT group were treated with the on the upper arm, the trunk and the anterior side
Duolith®-SD1 T-Top from Storz® Medical of the legs were done with the patient in supine
(Figure 1). The C-Actor handpiece with stand-off position. The measurements on the back and pos-
device II with 10 mm depth of focus zone was terior side of the legs were performed in the
used17 (Figure 2). For the patients in the placebo prone position. Measurements on the contralat-
group, a foam-filled placebo handpiece was used, eral limb or adjacent healthy skin were performed
which sounded like real shocks but did not allow for comparison. The various test sites were pre-
shocks to pass through. cisely marked using a standard circular patch

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 4 Scars, Burns & Healing

(diameter = 30 mm) and written in the patient Sample size calculation

chart. Digital photographs were taken to ensure To detect a change with an effect size of at least
standardisation of location of the measurements 0.8 (Cohen’s d), with a two-sided 5% significance
over time. with an 80% power a sample size of 20 partici-
Patients in both groups were measured at pants per group was calculated. An estimated
baseline (T0), after one (T1), three (T2) and six drop-out rate of 5% was taken into account for
months (T3) each time before the treatment. this calculation.
After the period of 10 weeks of application of
ESWT, the remaining treatment consisted only of
standard of care for both groups. Statistical analyses
All scars were subjectively assessed using the
Descriptive analyses were performed for age, scar
Patient and Observer Scar Assessment Scale V2.0
age (time since complete wound closure), gen-
(POSAS)18 and objectively assessed for colour,
der, aetiology and anatomical location. An inten-
transepidermal water loss (TEWL) and vertical
tion-to-treat analysis with the last observation
elasticity. The colour was measured using a
carried forward was applied. Sensitivity analyses
Minolta Chromameter® CR-400 (Konica Minolta
were carried out to detect significant differences
Sensing Inc., Osaka, Japan). The Chromameter®
between the analysis with or without the missing
is a tristimulus colorimeter using the L*a*b* col-
data. A two-way mixed ANOVA, with the interven-
our system, of which we analysed two of three
tion being the between-subjects factor and time
components: L* (color brightness) and a* (level
+ scar parameter being the within-subjects fac-
of red component).19 For TEWL, we used the
tor, was carried out.
DermaLab Skin Testing® (expressed in g/
The dataset was tested for outliers and normal
m²/h).20 The vertical elasticity or extensibility
distribution (tested with the Shapiro–Wilk test
(the ability of skin to stretch, calculated by lifting
and histogram). The outliers were kept if they
a fold of skin in the direction perpendicular to
had no significant influence on the results and
the skin surface) was objectively measured using
were removed if a significant difference between
the Cutometer®21 (Courage & Khazaka GmbH,
the results with or without outliers could be
Cologne, Germany). The R0 value represents
detected. If the assumption of normality was vio-
the vertical deformation of the skin in millime-
lated, a data transformation with SQRT or LOG10
tres when that skin is lifted by means of a prede-
was applied. The homogeneity of variances and
termined vacuum suction force into the circular
co-variances were tested and discussed.
aperture of a probe, 6 mm in diameter.21
When the assumption of sphericity was vio-
The choice for colour and TEWL can be
lated, a Greenhouse–Geisser correction was
explained by the evolutive character of the scars
applied. When the dataset showed significant
in our population. Since redness and TEWL are
non-equality of baseline values, a baseline correc-
parameters that tend to decrease over time up to
tion was applied with ANCOVA.
maturation,3,22 this seemed the best choice.
The Bonferroni post hoc test with pairwise
Elasticity is one of the most important features in
comparisons was used to determine statistically
scar assessment. It represents the reduced exten-
significant differences between the different time-
sibility of the collagen fibre network and quanti-
points. Estimates of effect size were also reported.
fies mechanical tension on scarred skin. This
inextensibility may manifest itself by limiting
joint mobility in the patients with hypertrophic Results
scars. High scar grading is synonymous with
increased stiffness and decreased extensibility.23
Patient and scar-related characteristics
As a primary outcome parameter, the change Forty-two patients agreed to participate in this
in vertical elasticity, measured objectively with study. Forty patients completed the study. Two
Cutometer® after six months compared to base- patients dropped out; one due to illness and one
line, was chosen. This choice was based on the did not attend the first follow-up. This resulted in
lack of objective elasticity measurements in litera- an equal number in each study group. Patient
ture and the importance of scar pliability in and scar-related characteristics are reported in
restoring function. The objective assessment of Table 1. In general, the descriptive characteristics
scar colour with the Chromameter®, TEWL with of both groups were comparable. The mean age
DermaLab® skin testing and the subjective assess- of patients in each group differed by 5 years. The
ment of the scars with the POSAS were the sec- mean scar age of both groups was less than three
ondary outcome parameters. months at baseline.

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 Moortgat et al. 5

Table 1. Patient and scar-related characteristics of patients in

the ESWT and placebo groups.

ESWT Placebo

Number of patients 20 20

Gender

Men 11 11

Women 9 9

Age (years) 44.4 ± 18.2 39.1 ±14.9

Scar age (months) 2.4 ± 1.4 2.7 ± 1.8 Figure 3. After adjustment for baseline values, a statistically
Scar type significant mean difference of 0.232 mm for elasticity between
the interventions was found after six months in favour of the
Hypertrophy 16 14 intervention group.
Retraction 1 2
Secondary outcomes
Adhesion 3 4
There was no statistically significant interaction
Healing between intervention and time for the individual
items of the POSAS Patient Scale. This indicates
Skin grafted 13 11
that neither group performed better over time.
Spontaneously healed 7 9 For the overall opinion of the POSAS Patient Scale,
a statistically significant difference between the
Values are given as n or mean ± SD. interventions was found after three months (P =
ESWT, extracorporeal shock wave therapy. 0.045) and after six months (P = 0.013). The
results at the different timepoints of all POSAS
Patient scores are presented in Table 2.
Primary outcome There was no statistically significant interac-
There were two outliers in the data, as assessed tion between intervention and time for the indi-
by inspection of a boxplot for values > 1.5 box- vidual items of the POSAS Observer Scale. This
lengths from the edge of the box. One of the indicates that neither group performed better
outliers was found in the control group after over time. For the pliability score (P = 0.015)
one month compared to baseline; another out- and the overall opinion (P = 0.027) of the POSAS
lier was found in the intervention group at base- Observer Scale, a statistically significant differ-
line. Both outliers were kept, since comparison ence between the interventions was found at six
between the results with or without outliers months in favour of the ESWT group. The results
showed no significant differences. The data at the different timepoints of all POSAS Observer
were not normally distributed, as assessed by scores are presented in Table 3.
Shapiro–Wilk test of normality (P < 0.05). There were no statistically significant differ-
However, the histogram showed normally dis- ences between the interventions for the bright-
tributed data. This non-normality did not affect ness and the redness parameter of colorimetry
our analysis since comparison of with or without and for TEWL. The results at the different time-
transformed data showed no significant differ- points of objective assessment results are shown
ences. There was a statistically significant inter- in Table 4.
action between the intervention and time with
moderate effect size on elasticity, F(3,114) = Discussion
4.562, P = 0.011, partial η2 = 0.107. After adjust-
ment for baseline values, a statistically signifi- The present study is the first randomised con-
cant mean difference of 0.23 mm for elasticity trolled study on humans to investigate the effects
between the interventions was found after six of ESWT on the elasticity of burn scars with an
months in favour of the intervention group, objective assessment device. This study’s results
F(1,37) = 9.288, P = 0.004, partial η2 = 0.201. pointed out that the ESWT group performed sta-
Please note the large effect size here. The results tistically significantly better than a placebo group
are set out in Figure 3. to improve vertical elasticity of burn scars.

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 6

Table 2. POSAS Patient scores of ESWT versus placebo at baseline (T0), after one month (T1), three months (T2) and six months (T3).

ESWT Placebo

T0 T1 T2 T3* T0 T1 T2 T3*

Pain 2.90 (1.88–3.92) 2.15 (1.44–2.86) 2.00 (1.21–2.79) 1.35 (0.88–1.82) 2.65 (1.63–3.67) 2.20 (1.49–2.91) 2.35 (1.56–3.14) 1.55 (1.08–2.02)
0.56 0.64

Itch 3.65 (2.42–4.88) 3.00 (1.95–4.05) 2.75 (1.63–3.87) 1.95 (1.16–2.74) 3.45 (2.22–4.68) 3.00 (1.95–4.05) 3.30 (2.18–4.42) 2.65 (1.86–3.44)
0.82 0.34

Colour 6.65 (5.70–7.60) 5.95 (4.74–7.16) 4.65 (3.67–5.63) 4.05 (3.09–5.01) 7.40 (6.45–8.35) 6.20 (4.99–7.41) 5.55 (4.57–6.53) 4.80 (3.84–5.76)
1.67 1.06

Stiffness 6.35 (5.27–7.43) 4.80 (3.79–5.81) 4.30 (3.21–5.39) 3.55 (2.59–4.51) 6.70 (5.62–7.78) 5.20 (4.19–6.21) 4.80 (3.71–5.89) 4.20 (3.24–5.16)
1.27 1.14

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Thickness 4.10 (2.92–5.28) 3.80 (2.82–4.78) 2.95 (1.92–3.98) 2.80 (1.91–3.69) 4.40 (3.22–5.58) 4.05 (3.07–5.03) 4.05 (3.02–5.08) 3.45 (2.56–4.34)
0.65 0.38

Irregularity 4.20 (3.12–5.28) 4.15 (3.04–5.26) 3.70 (2.57–4.83) 3.45 (2.37–4.53) 5.15 (4.07–6.23) 4.60 (3.49–5.71) 4.75 (3.62–5.88) 3.75 (2.67–4.83)
0.39 0.53

Overall opinion 5.80 (4.55–7.05) 5.05 (4.02–6.08) 4.10 (3.08–5.12) 2.95 (2.17–3.73) 5.80 (4.55–7.05) 5.20 (4.17–6.23) 5.40 (4.38–6.42) 4.20 (3.42–4.98)
1.34 0.68

Values are given as mean (95% CI). Values in italics are Cohen’s d.
*Estimates of effect size based on differences between means after 6 months compared to baseline.
CI, confidence interval; ESWT, extracorporeal shock wave therapy; POSAS, Patient and Observer Scar Assessment Scale.
Scars, Burns & Healing
 Moortgat et al.

Table 3. POSAS scores of ESWT versus placebo at baseline (T0), after 1 month (T1), 3 months (T2) and 6 months (T3).

ESWT Placebo

T0 T1 T2 T3* T0 T1 T2 T3*

Vascularity 4.95 (4.27–5.64) 4.35 (3.71–4.99) 3.90 (3.27–4.53) 3.00 (2.53–3.47) 5.00 (4.32–5.69) 3.90 (3.26–4.54) 3.80 (3.17–4.43) 3.20 (2.73–3.67)
1.58 1.38

Pigmentation 2.75 (1.91–3.59) 2.70 (2.03–3.37) 2.65 (1.97–3.33) 2.25 (1.74–2.76) 3.25 (2.41–4.09) 3.05 (2.38–3.72) 3.00 (2.32–3.68) 3.00 (2.49–3.51)
0.37 0.15

Thickness 3.10 (2.48–3.72) 2.85 (2.24–3.46) 2.60 (1.98–3.22) 2.35 (1.86–2.84) 3.05 (2.43–3.67) 2.60 (1.99–3.21) 2.55 (1.93–3.17) 2.65 (2.16–3.14)
0.61 0.34

Relief 3.45 (2.92–3.98) 3.10 (2.63–3.57) 3.00 (2.47–3.53) 2.50 (2.03–2.97) 3.10 (2.57–3.63) 2.85 (2.38–3.32) 3.00 (2.47–3.53) 2.75 (2.28–3.22)

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1.34 0.30

Pliability 5.50 (4.78–6.22) 4.05 (3.37–4.74) 3.40 (2.83–3.97) 2.45 (2.03–2.87) 5.30 (4.58–6.02) 4.25 (3.57–4.93) 3.70 (3.13–4.27) 3.10 (2.68–3.52)
2.58 1.64

Surface area 5.00 (4.87–5.13) 4.70 (4.37–5.03) 4.35 (4.00–4.70) 4.30 (3.87–4.73) 5.00 (4.91–5.09) 4.75 (4.45–5.05) 4.65 (4.20–5.10) 4.15 (3.49–4.81)
1.54 1.52

Overall opinion 5.05 (4.64–5.46) 4.20 (3.75–4.66) 3.55 (3.12–3.98) 3.00 (2.66–3.34) 4.90 (4.49–5.30) 4.20 (3.75–4.66) 3.80 (3.37–4.23) 3.55 (3.21–3.89)
2.48 1.72

Values are given as mean (95% CI). Values in italics are Cohen’s d.
*Estimates of effect size based on differences between means after 6 months compared to baseline.
CI, confidence interval; ESWT, extracorporeal shock wave therapy; POSAS, Patient and Observer Scar Assessment Scale.
7
 8 Scars, Burns & Healing

The results of this study were somewhat con-

tradictory. The POSAS Patient and Observer

54.45 (51.8–57.1)

13.21 (11.9–14.5)

13.99 (10.3–17.7)

0.54 (0.42–0.66)
scores did not reveal any statistically significant
time versus intervention interactions between
the two groups, while the objective measurement
0.86

1.01

0.40

0.27
of elasticity with Cutometer® showed a statisti-
T3*

cally significant difference between the groups

over time in favour of the ESWT group. This
52.53 (50.2–54.9)

14.80 (13.7–15.9)

13.32 (10.0–16.6)

0.53 (0.40–0.66)
means that the subjective results did not back up
the objective outcomes. This could be explained
by the different assessment methods. The three
assessment methods assess different mechanical
properties.23 For the POSAS Patient Scale, the
T2
Table 4. Objective assessment results of ESWT versus placebo at baseline (T0), after one month (T1), three months (T2) and six months (T3).

patient is asked whether the stiffness of the scar is

51.19 (48.7–53.7)

15.25 (14.0–16.5)

15.00 (11.6–18.4)

different from normal skin; in the POSAS

0.47 (0,34-0,60)

Observer Scale, the observer is asked to assess

suppleness by wrinkling the scar between thumb
and index finger; and with the Cutometer® the
skin is lifted vertically by suction. On considera-
T1

tion of these definitions, it may seem difficult to

compare stiffness, pliability and extensibility.
50.93 (48.6–53.3)

16.37 (14.9–17.8)

17.57 (13.9–21.3)

0.48 (0.36-0,59)

The question remains on how the beneficial

effects of ESWT on fibrosis can be explained.
Placebo

On a histopathological level, the effects of

ESWT on fibrosis are plural. A downregulation of
T0

alpha-SMA expression, myofibroblast phenotype,

TGF-β1 expression, fibronectin and collagen type
57.91 (55.2–60.6)

13.4 (11.8–14.5)

0.77 (0.65–0.89)
10.55 (6.8–14.3)

I are measured.15,24,25 Inhibition of the TGF-β1/

Smad signalling pathway and decreased fibroblast
CI, confidence interval; ESWT, extracorporeal shock wave therapy; TEWL, trans-epidermal water loss.
*Estimates of effect size based on differences between means after 6 months compared to baseline.

density are also observed.26,27 A significant

increase in dermal fibroblast like phenotype with
1.29

1.30

0.89

1.10
T3*

low contractility and high migratory ability, small

vessel density and precursors of extracellular
54.42 (52.1–56.8)

14.46 (13.3–15.6)

0.68 (0.55–0.81)

matrix components, probably leads to new and

11.59 (8.3–14.9)

thinner collagen fascicles and parallel orientation

to the dermo-epidermal junction.24,25 All these
findings are closely related to a mechanotrans-
duction effect induced by ESWT, where these bio-
T2

Values are given as mean (95% CI). Values in italics are Cohen’s d.

mechanical forces are converted in biochemical

responses, thus influencing some fundamental
52.74 (50.3–55.2)

15.33 (14.1–16.6)

13.87 (10.5–17.3)

0.56 (0.43–0.68)

cell functions as migration, proliferation, differ-

entiation and apoptosis.28 The formation of
fibrous tissue can be prevented by ESWT (at the
origin) during wound healing processes, but it
T1

can also be remodelled in a second phase of scar

formation. Primary data shows that height, plia-
51.02 (48.7–53.4)

17.14 (15.7–18.6)

17.12 (13.4–20.8)

0.46 (0.34–0.58)

bility, vascularity and pigmentation, all relevant

scar parameters, were improved after the applica-
tion of ESWT.13,15 The changes in these physical
ESWT

and physiological parameters will probably lead

T0

to amelioration in function,15 which was con-

firmed by our results with improved elasticity as
Brightness

the primary outcome.

Elasticity
Redness

For a full treatment protocol outline, the

TEWL

energy flux density (EFD), the number of pulses,

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 Moortgat et al. 9

the pulse frequency, and the number and interval does seem to give added value to the ‘standard of
of treatments are the most relevant parameters.29 care’ to improve the elasticity of burn scars.
Differences in the device settings can lead to vary-
ing outcomes, emphasising the dose dependency
of these mechanotransduction events.30 High- Conclusion
energy ESWT can suppress cell growth, while ESWT can give added value to the non-invasive
lower-energy shock waves might enhance cell pro- treatment of hypertrophic burn scars, more spe-
liferation.31 Since ESWT settings of 0.22 mJ/mm2 cifically to improve elasticity already in the first
and 1000 pulses seem to be ideal for fibroblast three months after wound closure.
viability and growth,32 and an EFD of 0.32 mJ/
mm2 reduces the expression of type-I collagen,24
Declaration of Conflicting Interests
we opted for an EFD of 0.25 mJ/mm2 and 30–50
shocks per cm2. This was also comparable with The author(s) declared no potential conflicts of interest
the previous studies performed on scars.13–15 with respect to the research, authorship, and/or publica-
tion of this article.
Two studies reported a significant decrease of
burn-associated pruritus.16,33 This finding is con-
sistent with the results from this study of which Funding
the POSAS Patient Scale revealed a significant The author(s) received no financial support for the
reduction for the itch parameter only for the research, authorship, and/or publication of this article.
ESWT group. However, this result did not lead to
a statistically significant difference between both ORCID iD
treatment arms, which can be explained by the
Peter Moortgat https://orcid.org/0000-0002-6840-762X
application of a ‘standard of care’ including
hydration and silicone for both groups. In the
studies by Joo et al.16 and Samhan et al.,33 75% of Bibliography
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