Shin and Bordeaux [65] conducted a systematic review of studies investigating the effectiveness of scar massage regimes for scars due to burn and trauma, and included four randomized controlled studies, three prospective controlled studies, one prospective study, and two case reports. Across ten reports, the total number of subjects was 220 with 144 receiving scar massage. The standardized outcome measures included the Observer Scar Assessment Scale and the Vancouver Scar Scale (VSS), as well as subjective assessments of scar thickness, perfusion, color, pain, and itching. For patients who had surgical scars and received massage, 90 % improved. Foo and Tristani-Firouzi [66] recommend that postsurgical scar massage commence during the proliferative phase, 2–3 times per day, for 3–5 min, for 3–4 months.

Pressure application may be applied using self-adherent wraps, neoprene splints, tubular elastic, and custom fit pressure garments. Pressure inhibits fibroblastic activity [66], via ischemia and hypoxia resulting in degeneration of fibroblasts and slowed synthesis of collagen [67]. Despite a long history of inclusion of pressure in the treatment of scar, definitive evidence regarding its efficacy is lacking.

In a meta-analysis of six published randomized controlled trials and one unpublished trial examining the benefit of pressure therapy for burn scar, researchers found no difference between scars treated with pressure therapy and controls [68]. More recently, a randomized controlled study of treatment of burn scar demonstrated significant improvement on the VSS using pressure therapy alone (p < 0.001), but also found significant improvement with combined pressure therapy and application of silicone gel sheeting (p = 0.001), and combined pressure therapy and silicone spray (p < 0.001). Patients with two similar scars from split-thickness grafts were randomized into either a silicone gel sheeting group or silicone spray group, but all used pressure therapy. Differences between the groups were not significant [69]. Widgerow [83] suggests pressure garments are more appropriate for widespread scar seen in burn injury; however, in maintenance of tape or silicone gel sheeting on the hand of a young child can be challenging. Use of a pressure garment may discourage self-removal of treatment modalities held in place by the garment, including the garment itself. In a laboratory study of fibroblastic activity under pressure, researchers showed pressure application may be applied at higher levels over shorter periods of time or at lower levels for longer periods of time to reduce fibroblastic proliferation [66].

If using self-adherent wrap, care in wrapping and maintained supervision are indicated to avoid a tourniquet-like effect due to lifting, slippage, and rolling [72]. Use of neoprene patches or orthoses for at least 8 h per day was retrospectively studied in a small population of children and young adults with burn scar (n = 8 participants, 12 scars). Duration of treatment ranged from 1 to 11 months. Scars were evaluated pre and post treatment and differences for mean VSS was significantly lower after treatment (p = 0.0001). This study is useful to therapists working with children because neoprene splints are often used long term across several diagnostic groups for limb positioning and so could also serve to manage scar [73].

Silicone gel may serve to prevent hypertrophic scars and improve characteristics of existing hypertrophic scar. In a narrative review of eight RCTs and an analysis of 27 trials, the International Advisory Panel on Scar Management concluded that use of silicone gel sheeting is “safe and effective”; however, the panel distinguished adhesive silicone gel sheeting from other adhesive gels, liquid silicone, and nonadhesive silicone gel sheeting [74]. O’Brien and Pandit [75] conducted a meta-analysis to determine the effectiveness of silicone dressings to prevent hypertrophic or keloid scarring in people with newly healed wounds and to treat established keloid or hypertrophic scars. The study included randomized or quasi-randomized controlled trials, and controlled clinical trials comparing silicone dressings to other nonsurgical treatment, no treatment or placebo. Included trials compared adhesive silicone dressings with control; non-silicone dressings; silicone gel plates with added vitamin E; laser therapy; triamcinolone acetonide injection, and nonadhesive silicone dressings. Scar quality was determined by blood flow, color change, hyperpigmentation, thickness, and shape. Studies that set out to determine effectiveness of silicone to treat existing scars measured change in scar size and did so using a ruler, taking an impression, or via ultrasound. Across 15 studies, 615 people between 2 and 81 years-of-age were included. Compared with no treatment silicone reduced the incidence of hypertrophic scar (RR 0.46, 95 % CI 0.21–0.98). For established keloid and hypertrophic scar SD significantly reduced scar thickness (RR −1.99, 95 % CI −2.13 to −1.85) and improved color (RR 3.05, 95 % CI 1.57–5.96). Silicone dressings produced superior results compared to controls in two trials, no difference was found in two trials, and the control group fared better in one trial. This study included clinical trials of varied rigor and most were subject to bias thus there is weak evidence for use of silicone dressing to prevent or improve scars. An update to this review was published in 2013; five new studies were included but the same conclusion was offered [76].

The proposed mechanism of action of silicone gel is thought to be hydration and occlusion [77], though non-silicone gels may be equally effective as silicone. In a prospective, randomized study patients (n = 24) with existing hypertrophic or keloid scars (n = 41) present for longer than 3 months, including incisional scars, were randomly assigned to one of three groups: treatment with silicone gel (n = 16 scars), treatment with non-silicone gel (n = 14 scars), or control (n = 11 scars). Treatment was applied 24 h per day for 4.5 months. No statistically significant differences were found between SD and NSD groups for color, size, induration, and symptoms, although significant differences were noted when SD and NSD were compared to controls for color, size, induration, and scar pliability [78].

Tension on scar is believed to stimulate collagen production due to mechanosensitive fibroblasts [71, 79, 80]. Tape applied to scars may reduce tension and prove effective in preventing hypertrophic scar [81, 82]. Porous tape should be applied longitudinal to and directly over the scar to adequately provide support and reduce tension [83]. When scars cross joints, use of an orthosis may help to reduce tension on scar.

Clinicians utilize AROM, active assisted ROM, passive range of motion (PROM), joint mobilization and orthoses to achieve greater range of movement. Michlovitz et al. [84] conducted a systematic review of interventions to promote joint motion in the upper extremity. The review included 26 studies that examined interventions in adults, but excluded children and congenital hand differences. In their summary, the researchers noted moderate evidence for the use of orthoses or casts and passive exercise to increase ROM after joint trauma or immobilization. Following this study, Glasgow et al. [85] published a narrative review to develop a set of recommendations for mobilizing the stiff hand. After a review of 29 studies of varying levels, these authors recommended active and active assisted exercise during all stages of tissue healing, passive exercise during the proliferative and remodeling phases, and joint mobilization during the remodeling phase. Orthoses for management of stiffness via mobilization were recommended during the proliferative and remodeling phases.

When the purpose of an orthosis is to increase motion, orthosis prescription must consider tissue compliance and the length of time the restriction has been present. Therapists must decide on orthosis type (including no orthosis), wear time (hours per day and duration), and the magnitude of force to apply. Flowers [86] offered a hierarchy for decision-making when treating stiff joints using a modified Week’s test [87]. After pre-conditioning, those whose PROM measures change by 20° may not need a splint; by 15° may require a static splint with no overpressure; by 10° may require a dynamic splint; and by 5° or less may required a static progressive splint with overpressure. This decision-making process may prove useful with older children; but may not be feasible with infants and toddlers due to required exposure to thermotherapy.

Consensus on wear time of an orthosis to resolve motion restrictions is lacking, although many studies provide guidance. Flowers and LaStayo [88] executed a study to determine if duration of orthosis use impacted outcomes for stiff joints. Patients (n = 15) with 20 PIP flexion contractures between 15° and 60° were randomly assigned to continuous casting for 6 days then 3 days or 3 days then 6 days. There was a statistically significant difference (p < 0.005) in gains made with 6 days of wear achieving a mean increase of 5.3° and 3 days of wear achieving 3°. Glascow et al. [89] prospectively investigated optimal hours of daily orthoses wear in 43 subjects with joint restrictions in the hand following trauma. Subjects with similar levels of stiffness—as determined via torque range of motion (TROM)—were randomly allocated to a <6 h or 6–12 h per day group. There was a statistically significant difference between the groups, with better TROM observed in the 6- to 12-h group. It is not clear if increasing time more than 12 h provides greater benefit. In a follow-up randomized study of 22 patients with PIP joint flexion contractures, no significant differences were found for PROM, AROM, or TROM between 6–12 h of wear and 12–16 h of orthosis wear after 8 weeks of treatment [90].

While orthotic management and surgery are intervention options for camptodactyly [92], ROM exercises may prove beneficial especially for children with an infantile onset of deformity. Rhee et al. [93] retrospectively evaluated the effectiveness of passive stretching to correct flexion deformities in children younger than 3 years with camptodactyly. Records of children with simple camptodactyly who had not received surgery or intervention with an orthosis were included, but those with flexion contractures of less than 10° were excluded. Parents were taught a PROM technique, to be implemented at home, requiring the PIP joint be extended with the wrist and metacarpophalangeal (MCP) joint in extension. Instructions were to complete gentle PROM, while the child was sleeping, 20 or more times per day with a hold time of 5 min. Exercise frequency was reduced to five or ten times per day when near full extension was achieved. Duration of intervention was individualized and poorly defined. The intervention could be realistically applied; however, the burden of applying PROM only when children are sleeping could compromise adherences rates. Pre- and post-intervention measurements, recorded by the same physician, were compared. Across groups, 13 males and 9 females with a mean age of 12 months (range 3–36 months) were included in the study. Digits were further classified into mild deformity (<30°, n = 12 digits), moderate deformity (30–60°, n = 36), and severe deformity (>60°, n = 13) as per goniometric measures. Groups were expected to be different with regard to extent of deformity but no analysis was performed to assure they were similar for age, sex, and dominance. Final PROM for PIP extension was compared to initial measures. Mean change in PROM were as follows: −20° to −1° for the mild group, −39° to −12° for the moderate group, and −75° to −28° for the severe group. Differences from pretest to posttest were significant for all groups: mild (p < 0.001), moderate (p < 0.001), and severe (p < 0.001). Mean time from start to end of intervention (either correction or cessation of change) for the mild group was 5 months, moderate group was 10 months, and severe group 13 months. Researchers found a relationship between degree of flexion contracture at the start of intervention and final measure. No relationship was found between initial flexion contracture, handedness, digit involvement, and number of digits or hands involved. Differences between pretest and posttest AROM values were statistically significant. No statistical analysis was performed to determine clinical significance, however all but two children (in the moderate group) improved and gains were maintained during a prolonged follow-up period (mean of 26 months, range of 12–47 months). The researchers concluded children under three who have camptodactyly should be treated with PROM only and orthoses are not necessary; however, this statement is unfounded since no comparison was made between PROM and use of an orthosis. The researchers recognized the weaknesses of the study including use of retrospective design and absence of a control group. The outcomes cannot be applied to all children with camptodactyly since only children under the age of three with simple syndactyly were studied, and children with syndromic or adolescent onset camptodactyly were not included [93].