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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1072_Библиотеки_им_академика_М_И_Перельмана
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224
https://t.me/med1917
T. Koller
Strong punctual mechanical vibrations show
clinically similar effects; a scientic proof is still
missing.
Practical Tips intheUse
ofCompression Suits andSilicone
Inserts
For the orthotist, any large or circular scar area is
a challenge. Especially, the concave-shaped areas
of the body, such as the palms of the hand or the
décolleté area, are not, or only insufciently,
compressed by compression garments. This is
where a custom-made silicone insert can help.
The second challenge is to put on the compression garment without generating shear to the scar.
Excessive shear forces damage the fragile scar
surface and inevitably lead to a new inammatory reaction.
The choice of dressing aids is large, varied,
and tolerated very individually by patients. In this
chapter, a small selection of dressing aids is used,
and illustrated with video sequences (see supplementary material), to explain dressing that is
gentle on the tissue and avoids shear forces.
Does Compression Garment Always
Compress Equally Well?
Compression garments compress better over
straight and convex scar areas than over concave
areas of the body. Over concave areas of the
body, such as the décolleté, or back area, the
scar area to be compressed is often only
“spanned” (see Fig. 7a, b). Custom-made silicone pads can be used to compensate these cavities. If the area is very large, full silicone can no
longer be used because the specic weight of
silicone is very high. For this purpose, either
foam materials are ground into shape or silicone
foam is cast, and then covered with a thin layer
of silicone.
A practical example illustrates the effect of
increased compression by a tted silicone pad.
Figure 8a shows a compression class II glove
without a silicone pad in the palm of the hand.
The spanned cavity can be depressed. If a silicone pad is placed on the concave palm (Fig.8b,
c), there is no longer a cavity and the compression
force can act on the scar tissue through the silicone. Fig.8d, e, shows how effectively a silicone
insert can transfer the compression force to the
scar tissue.
a b
Fig. 7 Insufcient compression of uneven and concave
scar areas (Courtesy of Rehaklinik Bellikon). (a)
Compression is insufcient in the area marked in red. The
compression garment “spans” these areas. (b) With an
Low to insufficient compression
Cross section of concave scar area without silicone inlay
Optimal compression with an individual silicone inlay
Silicone
Cross section of scar area with silicone inlay
individually crafted silicone inlay (for example modeled
after a plaster cast), the compression force can be homogeneously distributed over the uneven scar surface
de
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225
a
bc
Fig. 8 Effect of silicone inserts on compression forces
(Courtesy of Rehaklinik Bellikon). (a) Compression class
II glove without silicone pad in the palm (red circle).(b, c)
Compression class II glove with silicone pad in the palm
(green circle). (d) Pressure measurement [2mmHg] in the
palm of the hand without silicone padding. (e) Pressure
measurement [23 mmHg] in the palm of the hand with
silicone padding. The unit of measurement [mmHg; millimeters of mercury] is used to indicate the static pressure.
Measuring instruments for compression therapy are
offered by the company TT Meditrade (Denmark), for
example Kikuhime
®
Compliance asaBasic Prerequisite
Caution!
Compression garments may exert insufcient to no compression on concave and
uneven scar surfaces. Custom-made silicone inserts help transfer force to scar
tissue.
The basic prerequisite for effective compression
therapy is the patient’s consent and willingness to
wear the compression garment for 23 h daily.
This usually continues until the scar has fully
matured (up to 2 years). To achieve this ambitious goal, the individual needs (tolerance level)
of the patient must always be considered. If a
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T. Koller
c
Fig. 9 Silicone collar with light compression (Courtesy
of Rehaklinik Bellikon). (a) Fabricated plaster model
(positive) based on a plaster cast. (b) Silicone collar with
patient does not agree with the aid, it will not be
used. Often, less is more! If a patient with extensive full-body scarring would have to wear a fullbody compression suit but is unwilling to do so,
perhaps individual parts in severely affected
areas can be a compromise solution.
Following technical prerequisites can increase
the patient’s compliance:
form- giving silicone reinforcements. (c) Patient with silicone collar and compression garment
mechanical shear forces. This will in turn
result in less scar irritation and better compli-
ance on the patient’s part.
– Silicone instead of compression: If no com-
pression is tolerated (for example in the neck
area), just an individually shaped silicone
collar can also achieve a good effect. The
compression force is missing here, but the
hydrating and micro-massaging properties
– Proper suture placement: sutures should not
pass directly over joints. If this cannot be
avoided, they should be placed in such a way
of the silicone also have a positive effect on
the function and quality of the scar tissue
(Fig.9).
that there is as little friction as possible during
movement. For example, at the knee medial
and lateral to the knee joint. This also applies
Dressing Aids That Avoid Shear Force
andAre Gentle ontheTissue
to zippers.
– Adapted knitting technique: Especially around
the joints, a different knitting technique (similar like kneecaps) can signicantly reduce
Arion Easy-Slide® Donning Aids
These donning aids are suitable for compression
stockings with open toe or hand tip. They can
ab
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Fig. 10 Donning aid Arion Easy-Slide® for open foot and hand tips (a) and for closed foot and hand tips (b) (Courtesy
of Rehaklinik Bellikon)
227
Fig. 11 Arion Dactyna® donning aid for open nger cots or gloves (Courtesy of Rehaklinik Bellikon)
also be used to put on silicone-coated compression stockings without putting too much strain on
the fabric and skin. A special Easy-Slide® version
is also available for closed-toe compression
stockings (Fig.10a, b). The correct donning procedure is shown in Video 1.
The Arion Dactyna® donning aid is suitable
for donning nger cots or entire gloves (Fig.11).
DOFF N’DONNER® (DND) Donning Aid
DOFF N’DONNER® is a revolutionary donning
aid that is very soft and allows the compression
stocking to roll over the limb particularly easily
(Fig.13). It is suitable for both open and closed
compression stockings.
The donning technique requires some practice
at the beginning (Video 4).
Here, too, the compression material can be
applied over the ngers in a way that is very gentle on the tissue (Video 2).
Clinical Tip
Medi Butler® Dressing Aids
These donning aids are particularly suitable for
patients who have little hand strength (Fig.12).
The leg can be pressed into the compression
stocking relatively easily. The ribbed stocking
then also rolls over the extremity in a way that is
gentle on the tissue (Video 3). In addition, rubber
Perfectly tting compression garments
with correctly positioned seams or zippers
and silicone pads are of no use at all if they
are not worn regularly!
Acceptance is always very individual
and must be claried in advance with the
patient.
gloves can be used to help a little.
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Fig. 12 Dressing aids for arms/gloves “medi Butler®” (a) and for legs “medi Lang-Griff Butler®” (b) (Courtesy of
Rehaklinik Bellikon)
T. Koller
Scar Care
This is done by consistently applying cream or
by using silicone pads. When choosing a cream,
Scar care is of great importance for patients with
burns, sometimes even for the rest of their lives.
Depending on the depth of the burn, the natural
moisture regulation of the skin is reduced or no
longer present. This requires care with cream or,
in some cases, with silicone pads. Silicone pads
are particularly recommended in areas with high
mechanical tension such as scar strands, very
hypertrophic scars, scars that are difcult to
move, over joints, and in circular scar areas.
In general, there is weak to no evidence
regarding the effectiveness of scar-specic care
products. However, daily, and consistent application of cream to the scar is clinically very relevant. Fewer open areas due to mechanical
inuences, an increase in mobility, less itching,
and less painful scar areas can be observed as
clinical effects.
it is important to ensure that the proportions of
lipids and urea are sufciently high. An oil-inwater base mix works as a good carrier for this.
The lipid additive in creams is supposed to
prevent the scar surface from drying out with a
thin lipid lm, smooth the rough surface, and
make the scar more elastic and resistant. Urea has
the advantage that it can attract and bind water in
the tissue. In this way, the substance allegedly
ensures a balanced and high moisture content in
the skin or scar and thus also has a positive effect
on itching.
It is not possible to explicitly recommend a
specic cream; rather, attention should be paid to
the proportions of the ingredients “lipid” and
“urea.” Clinically, good experiences have been
made with the following products (list not
exhaustive):
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229
supports the formation of new cells and increases
their biosynthesis capacity [31, 32]. In addition,
dexpanthenol increases the skin’s ability to retain
moisture, which nourishes the skin and improves
its elasticity [33]. Furthermore, dexpanthenol
also has an antipruritic and anti-inammatory
effect [31, 33, 34].
Another approach is creams with the ingredient “Extractum Cepae.” This active ingredient
derived from onions is said to have an antiproliferative, antiphlogistic, tissue loosening, and
smoothing effect on scar tissue. Systematic
reviews on the benet of “Extractum Cepae” for
the prevention or therapy of hypertrophic scars
and keloids do not exist; the available evidence
from clinically controlled studies is limited.
Clinically, no relevant effect could be found
when applied to several patients. Side effects
such as itching and reddened areas after applying
a cream with the active ingredient “Extractum
Cepae” predominated in these cases.
Fig. 13 DOFF N’DONNER® donning aid for arms and
legs (Courtesy of Rehaklinik Bellikon)
– NutrientCream (NCR®) (lipid content 40%)
– Excipial® U Hydrolotio (lipid content 11%,
urea content 2%)
– Excipial® U Lipolotio (lipid content 36%, urea
content 4%)
– Bepanthen® (depending on the product up to
22% lipid content and 5% dexpanthenol)
Bepanthen® also contains the active ingredient
“dexpanthenol.” The most important function of
dexpanthenol is wound healing of the skin, especially the epidermis. Applied to the skin as a
water–oil emulsion, the active ingredient is
quickly absorbed by the skin. There it is converted to pantothenic acid, which is necessary for
the development of coenzyme A. Coenzyme A
Application
Bepanthen® is recommended in the early phase.
This cream can already be applied to crusted
wounds. Its additional ingredient “dexpanthenol”
has been shown to positively support wound
healing.
NCR® is also a good cream for the early phase.
It should only be applied to closed wounds without scabs. It is suitable for areas that are repeatedly dry and under great mechanical tension. It
has a very greasy consistency and is therefore
somewhat tedious to apply.
Later on, it is increasingly possible to switch
to Excipial® U Lipolotio and Excipial® U
Hydrolotio. Due to its lower fat content,
Excipial® U Hydrolotio can be applied with
ease. For more exposed areas, it is recommended to use the more lipid-rich Excipial® U
Lipolotio.
Basically, the skin must be creamed as often
as possible so that it does not show any dry
patches. The frequency varies depending on the
product used. It is often necessary to treat certain
areas with an oilier product than other areas.
Clinically, in the early phase, 2–3 times a day is
recommended, later 1–2 times a day.
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Fig. 14 Scar surface after applying oily cream for too long
with clogged sebaceous glands (light dots) (Figure: Property
of the Bellikon Rehabilitation Clinic)
Caution!
If a cream containing too much oil is used
for too long, the skin pores become clogged
and small sebaceous inclusions form,
which can be seen as light spots (Fig.14).
The remedy is to change to a less oily
product and to shower regularly (if the
wound situation allows this). The sebaceous inclusions are reversible. However, it
takes months for the body to break them
down again.
Important to Know
• Goal: NO dry patches and no sebaceous
inclusions.
• Lifelong care: It is important to nd a
product that suits the patient and that
they can and will use regularly. Strong
fragrances are not recommended!
• Combination with silicone: Care
should be taken that there is no cream
under the silicone. This means: Clean
the silicone after wearing it and let it
dry, apply cream to the skin and let it
dry as well, then apply the silicone again
a few hours later. As a rule, areas with
T. Koller
silicone pads should only be treated
with cream once a day.
• Costs: The costs for the creams are not
fully covered by all insurance companies.
It is essential to clarify what is paid for by
the respective insurance (also countryspecic); otherwise there is a risk of
immense costs for the patient. If possible,
switch to a product paid for by the insurance company in the inpatient setting so
that the patient can be discharged well
prepared for the outpatient setting.
Sun Protection
As long as the scar or scarred areas are active
(increased vascularization), consistent sun protection is strongly recommended. UV radiation
can lead to hyperpigmentation, so the scars must
be consistently covered or creamed!
After scar maturation, the scar should continue to be protected with at least sun protection
factor 50.
Manual Scar Therapy
Manual scar therapy is not clearly dened in the
literature. Terms such as “scar massage” or “soft
tissue techniques” are also used. The manual scar
techniques described in the following belong to
the category of “Soft Tissue Techniques” and are
gentler, more specic, and easier to dose.
Basically, the anamnestic procedure is identical to that for patients with physiotherapy or
occupational therapy indications. The evaluation
only includes a few additional questions and
examinations of the skin tissue.
Acquisition Findings
Anamnesis: Additional scar-specic questions
– Ask about itching: How often? At what time
of day? Where?
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– Intensity of itching? Coping strategies?
– Painful scars? Pulling scars?
– Scar areas, scar strands, and wounds?
– Which scars/scar strands restrict which func-
tion most?
– Which scars/scar strands are aesthetically the
most disturbing?
– Is compression clothing available? Is it
applied?
– Are any aids available, e.g., splints?
– What is the frequency and duration of
application?
– Are compatibility and useability given? Are
there any problems?
– Are other aids necessary?
Objective examination: Additional examina-
tions for scars
– Inspection of the scars: The patient must be
undressed so that hypertrophic areas, scar
strands, open wounds, etc. can be identied.
– Evaluation criteria: Color, surface, open
areas, mechanically stressed areas, and scar
strands.
– General active range of motion: Assessment
at the activity level from a functional point of
view.
– Recognize compensation strategies with:
“Hand to mouth,” “Tilt upper body forward,”
“Adjust the longitudinal axis of the body to be
neutral in sitting and standing position,”
“Dressing,” “Gripping,” “Walking,”
“Stairclimbing,” etc.
– Passive range of motion: What structure limits
the motion?
Where in the tissue do mechanical tensions
arise? Where is the rst or second signicant increase in connective tissue
resistance?
Specic Tests According toJaudoin
As a rule, patients should not have any fresh
cream applied before all specic testing or
manual scar treatment. Otherwise the therapist’s
hand will slip over the skin. As a result, neither
a specic diagnosis nor a treatment is possible.
In addition, the application of shear forces is a
contraindication in all phases of wound
healing.
Capillary Rell Test (CRT)
The Capillary Rell Test makes it possible to
determine the wound-healing phase in which
the scar is currently in. This is decisive for the
later dosage of the techniques (collagen type III
or I). Inammatory mechanisms lead to an
enlargement of the capillaries in the periphery.
The time required for revascularization is
inversely proportional to the inammatory factors still active in the tissue [35]. Scientic evidence on the Capillary Rell Test is not yet
available.
Procedure: Apply pressure to the scar for
about 3s, release and stop the time until the color
has completely adapted to the surrounding tissue
color:
– Revascularization <3s—>high inammatory
state of the tissue
– Revascularization >3s—>inammatory pro-
cesses subside
Shifting Test (Displaceability)
With the shifting test, the mobility of the tissue
in different directions can be measured. In
physiological tissue, the greatest displacement
is between the subcutis and fascia (or, depending on the location, in relation to the periosteum) [1].
Procedure: Place the hand at on the tissue
and let it sink in well.
Then slowly move the tissue in each direction
until the rst or second marked increase in connective tissue resistance is reached. The therapist
documents the restricted directions in steps of
thirds:
– Freely movable
– 1/3 restricted=slight restriction
– 2/3 restricted=medium restriction
– 3/3 restricted=no movement possible
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T. Koller
The displaceability is tested on all functionally relevant scars in cranial-caudal and mediallateral directions. It is important to focus on the
entire scar and to test all areas.
Example: Scar strand in the axilla. The tissue
on the thorax must be movable cranially. This is
the basic prerequisite for adequate shoulder
function.
Lift-O Test
This test measures the displaceability of the tissues relative to each other as well as the density
of the tissue. The decrease in density can be
achieved by compression through controlled
ischemia (apoptosis of myobroblasts) [3].
Procedure: Let thumb and index nger slowly
“sink” into the tissue. To prevent pinching, the
therapist initiates a supination movement of the
forearm. Now a skin fold develops between the
ngers, which must be assessed. To ensure objectivity, the therapist measures the approximation
of the thumb to the index nger [in cm].
Depending on the region of the body, place the
ngers 1–3cm apart at the beginning and measure the distance again after the skin fold has
formed.
Extension Test
This test measures how far point A can be moved
from point B.The therapist tests at the beginning
and end of the scar strand as well as on the scar
strand itself. In addition, measurements are taken
in neutral position and at the end of the movement (limited by the scar strand). Only tissue in
the same wound-healing phase should be between
the hands. Open or mechanically fragile areas
between point A and point B are not allowed.
Procedure: “sink” into the tissue with both
hands and then move the hands apart until the
rst or second marked increase in connective tissue resistance is reached. Usual range: for
extremities and thorax at least one hand width, on
the neck, face, and ngers at least one nger
width. Documentation is once again possible in
thirds:
– Freely movable
– 1/3 restricted=slight restriction
– 2/3 restricted=medium restriction
– 3/3 restricted=no movement possible
The following treatment techniques were developed by the therapists Godeau, Jaudoin, and
Guillot [35–37]. The procedure described here
corresponds to current evidence [5]:
This applies to all treatment techniques:
– No sliding over the skin (friction/shear forces).
– Do not use creams.
– Avoid open wounds.
– Techniques are not painful, patient tolerates
pulling.
– Dosage: Depending on the phase of wound
healing, note the rst and second increase of
connective tissue resistance and the type of scar
(see Figs.4 and 5).
Shifting Technique
“Sliding” (without sliding on the skin): make
contact with the skin, “sink in,” slowly move the
tissue until resistance is felt (can also be done
circular). Notice tissue resistance (adhesions)
and then intensify movement in the functional
direction. Continued movement in the tissue is
prevented by recessing or delimiting, i.e., xates
the fragile or unaffected area with one hand,
with the other he mobilizes the scar (Fig. 15;
Video 5).
Shifting Technique at theWound Margin
One hand holds the scar tissue in place; the
other hand gently moves the unaffected tissue in
a circular motion. In this manner, the therapist
tries to inuence the margin of the wound. The
procedure can also be performed the other way
round: hold the unaffected tissue and gently
move the scar tissue in a circular motion
(Fig.16; Video 6).
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233
a
b
Fig. 15 Shifting technique (a) and shifting technique
with stop (b) (Courtesy of Rehabilitation Clinic Bellikon)
a
b
Fig. 17 Form skin fold (a); in the remodulation phase,
form skin fold and move within (b) (Courtesy of
University Hospital Zurich)
Fig. 16 Displacement technique at the wound margin. Fix
the upper hand and move the lower hand. (Figure:
University Hospital Zurich)
Lift-O Technique
Proliferation phase: Gently “sink” into the tissue
with thumb and forenger, lift off the skin fold
via a slight supination of the forearm, and hold it
(Fig.17; Video 7).
From the remodulation phase onwards, the
skin fold can be moved gently within itself (without slipping over the skin). This technique can
also be applied directly on a scar strand.
Extension Technique
In order to achieve an extension of the tissue,
extension techniques are used in the area of the
scar strand as well as in the area before and after.
Two techniques can be distinguished.
The two-point technique is suitable for plane
and convex scar surfaces (e.g., thorax, extremities, MCP joints, ventral knee, etc.). The threepoint technique is used for concave scar surfaces
(e.g., axilla, neck, elbow bend, rst commissure,
etc.). The scar tissue between the hands must be
in the same wound-healing phase. Open areas
must be left out.
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