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Journal of Burn Care & Rehabilitation:
Features: Burn Rehabilitation Forum

Changes in Subjective vs Objective Burn Scar Assessment Over Time: Does the Patient Agree With What We Think?

Martin, Daniel BSc, MD; Umraw, Nisha OT, OT(R); Gomez, Manuel MD, MSc; Cartotto, Robert MD, FRCS(C)

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Abstract

It is not known whether objective measurements of burn scar quality reflect, or even bear any relationship to, the patient’s opinion of their scar. The purpose of this study was to determine whether any correlation exists between the rehabilitation therapist’s rating of the scar using the Vancouver Scar Scale (VSS) and the patient’s subjective opinion of their scar. A total of 37 scars in 20 adult patients (mean age, 34 ± 13 years; 30% female; mean %TBSA burn, 16 ± 11%) were evaluated at 3.1 ± 1.9 months after injury (early assessment). Patients were asked to rate their own scar (question 1) and to rate how they perceive other people view the scar (question 2). A visual analog scale (VAS) was used to score the answers to both questions. A burn occupational therapist who was blinded to the VAS scores performed a VSS rating of the scar. These evaluations were repeated 1.5 years after injury (late assessment). At the early assessment, there was no correlation between the VSS score and VAS scores for question 1 (r = .291) or question 2 (r = .371). At the late assessment, there was significant improvement in the VSS score and the VAS score for question 2. Also, a significant correlation developed between the VSS score and the VAS score for question 1 (r = .646, P = .003) but not between the VSS score and VAS score for question 2 (r = .099). The VSS measurement of the scar bears no relationship to the patient’s opinion of their scar early after a burn injury. As the scar improves over time, the patient’s opinion of their scar appears to improve and shows better correlation with the VSS rating. Conversely, the patient’s impression of what others think of the scar continues to bear no relationship to the VSS rating, suggesting that scar acceptance by the patient is incomplete despite objective improvement in the quality of the scar. Although the VSS was never intended to measure a patient’s opinion of their scar, these preliminary findings emphasize the necessity of including a patient-centered subjective component to routine scar monitoring and assessment.

Ultimately, for the patient who survives a burn injury, scar formation and alteration in appearance become highly significant issues during the rehabilitation phase. In contrast with other forms of trauma, burn patients often wear a permanent reminder of their injury. Numerous reports have drawn attention to the deterioration in self esteem and the distortion of body image that burn patients of all ages experience for months to years after their injury. 1–4

Despite widespread recognition of this phenomenon, routine scar assessment during the rehabilitation phase is invariably driven from the perspectives of the rehabilitation therapist and physician. Scar-rating tools, such as the Vancouver Scar Scale (VSS), 5,6 are commonly used to follow the progress of a scar and its response to treatment. However, this type of approach rates scar severity from the healthcare professional’s point of view without considering the patient’s opinion. In fact, none of the many scar evaluation methods 5–14 reflect or even consider the patient’s perspective on their scars. Although most healthcare professionals who treat burn patients would readily agree that the patient’s thoughts about their scars are highly important, the fact remains that the month-to-month follow-up of a patient’s scars is heavily based on some form of practitioner-based measurement. As a result, the slow-but-steady change in the physical appearance of the burn scars typically becomes one of the primary focuses during rehabilitation.

Is an objectively “good” scar well accepted by the patient? Do patients adapt and adjust to their scars as objective improvement in the scar takes place over time? Surprisingly, these questions have never been formally approached or answered. These are important clinical questions because of the possibility that routine clinical scar assessment methods may overlook or misrepresent the patient’s subjective opinion of their scars. Because diminished self-esteem and altered body image are so prevalent after a burn injury, scar assessment and monitoring should be comprehensive and should take into account the patient’s perspective.

There are no published studies that have examined the relationship between a patient’s subjective scar evaluation and the rehabilitation therapist’s objective measurement of the burn scar. In a recent publication, Powers et al 15 have drawn attention to the possible discrepancy between a patient’s subjective rating and the rehabilitation therapist’s objective burn scar measurement. A case study was used to demonstrate a situation where the subjective aspect of a burn scar was as important, if not more important, than the quantitative objective assessment of the scar. However, no data beyond this were available to make any firm conclusion on the relationship between routine scar rating and the patient’s opinion of their scar.

The purpose of this study was to examine the relationship between a burn rehabilitation therapist’s rating of the burn scar and the patient’s subjective opinion of their scar and to follow this relationship over time from the injury. Specifically, we were interested in determining whether there is any correlation between a patient’s subjective opinion of their scar and the VSS 5,6 score, which is the standard burn scar rating tool used at our institution. Our hypothesis was that the objective measurement of the physical appearance of a burn scar bears no relationship to the patient’s opinion of their scar, both early and late in the rehabilitation phase.

©2003The American Burn Association

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