Physical Therapists as Scar Modifiers

CAROLE L. JOHNSON

Hypertrophic scars, a common sequelae to burn injuries, represent an overgrowth of dermal components like collagen. To the burn-injured patient, the red, raised, rigid scars represent impaired function and distorted appearance. Physical ther­apists modify scars by treating with pressure and stretching to minimize the devastating effects. Healing time, location of the injury, condition of the unhealed and healed areas, and treatment cost influence physical therapy. This article describes scarring and provides practical guidelines for pressure materials and stretching techniques. With an appropriate program, caring for a patient with burns becomes extremely beneficial and rewarding.

Key Words: Burns, Collagen, Wound healing, Physical therapy, Pressure.

Physical therapists (PTs) treat patients with burn injuries to maintain function, to maximize cosmetic results, and to return them to their preinjury life styles. Treatment begins at admission and concludes at discharge from outpatient clinic. Because scarring can impair function, cosmesis, and life style, knowledge of the scarring process and methods to modify this process are critical to a therapist's effective treatment of these patients. No single protocol effectively treats all patients. The PT is challenged to be flexible and creative. The purpose of this article is to describe some details of scarring and to provide some guidelines on pressure garments and stretching techniques to modify this potentially devastating consequence of a burn injury.

SCARRING

The prolonged maturation process of the healing burned tissue complicates rehabilitation. Scarring interferes with nor­mal function and acceptable appearance. The clinical appear­ance of red, raised, rigid scars constitutes the three Rs of hypertrophic scarring (Fig. 1). Usually, the newly healed skin appears flat and smooth when the patient is discharged. Within the next three months, the maturing dermis promotes dramatic scar formations.

Dermal fibroblasts produce collagen, the major fibrous constituent of skin. The change in collagen after an injury is dramatically shown by scanning electron microscopy (SEM). In normal skin (Fig. 2), the collagen layers are covered with epidermis. Subadjacent to the epidermis is a layer of fine collagen bundles, the papillary dermis. The larger bundles form the reticular dermis. A burn wound at 24 hours is pictured in Figure 3. The epidermis is severely altered and the upper layers are compacted. The reticular dermis seems rela­tively intact at this stage. Compare this with a SEM of a deep burn at 72 hours postinjury, which failed to heal in three weeks (Fig. 4). No uniform blanket or surface covers the underlying tissue. The fibrils lie in relatively haphazard fash­ion. Extensive fraying of collagen has occurred. With time,

the fibrils will coalesce into large aggregates, but the normal network architecture, such as seen in uninjured dermis, is seldom restored.1

New collagen can be found in healing wounds as early as the second day.2 Scar tissue begins to form when the collagen molecules aggregate into fibrils.3 As the wound remodels, many of the randomly oriented smaller collagen fibers disas­semble and reassemble into thick bundles. The bundles are usually oriented in parallel, but in hypertrophic scars, the large collagenous bands tend to form in whorls, centering about clusters of cells and small vessels.

In addition to the abnormal orientation, collagen synthesis remains highly elevated.4 Currently, no animal model similar to man exists for studying excessive collagen deposition be­cause in animals, collagen resorbs when the tissue insult ceases. In other words, animals normally exhibit no hyper­trophic scarring. Humans not only exhibit hypertrophic scar­ring but can also develop keloids. By definition, a keloid is

Fig. 1. The three Rs of a hypertrophic scar-red, raised, and rigid-are evident. Although comparatively small, this typical scar repre­sented a serious cosmetic defect to the patient.

Ms. Johnson, a former member of the Board of Trustees of the American Burn Association, is currently a graduate student in the Department of Biolog­ical Structure, University of Washington, Seattle, WA 98195. Address all correspondence to 19130 66th P1, NE, Seattle, WA 98155 (USA).

This invited paper was submitted October 6, 1983, and was accepted March 5, 1984.

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Fig. 2. A SEM of normal skin; e = epidermal layer, p = papillary dermis with fine collagen bundles, r = deeper reticular dermis with larger collagen bundles. Arrows point to blood vessels. Magnification 185 x.

tissue formed by excessive amounts of collagen during con­nective tissue repair and extends beyond the boundaries of the original skin wound. In uninjured tissue, a balance exists between build-up and breakdown or synthesis and lysis (Fig. 5). When humans develop a hypertrophic scar, the regulation of synthesis and lysis is somehow destroyed.

As well as collagen synthesis, angiogenesis or the develop­ment of blood vessels occurs. Large numbers of small blood vessels form throughout the wound. The capillaries originate as budlike structures on nearby vessels and penetrate the wound. As capillaries from different sites migrate through the wound, they meet and form an interconnecting network of vessels.

The usual concept of scar shrinkage is progressive inter-molecular cross-linking of scar collagen.5 First, an excess of collagen accumulates. A large portion of this collagen changes rapidly. Scar collagen cross-links between molecules and fibers in the wounded area, which the patient tends to have in a shortened, comfortable, resting position to minimize pain from the tender scar. The adage, "The position of comfort is the position of contracture," has a physiological basis.

In summary, a hypertrophic scar represents an overgrowth of dermal components (collagen, cells, and vascular elements) within the boundary of the original wound. The three Rs of hypertrophic scars-red, raised, and rigid-are briefly ex­plained by increased vascularity and abnormalities in collagen bundles.

PRESSURE

At the beginning of the 1970s, Larson and associates were among the first to describe the use of continuous pressure to control scar hypertrophy.6 The exact mechanism of control remains unknown. In theory, application of firm pressure at about capillary level (25 mm Hg) induces realignment of the collagen bundles and reduces the vascularity. Pressure may control the hypertrophic scar by producing a relative ischemia, which retards collagen synthesis.

Guidelines for Applying Pressure

Even though a decade has passed, no perfect solution exists for applying pressure. Many materials have been used. Figure 6 shows a few examples. The Appendix lists the suppliers of the materials I will discuss. These guidelines on the character­istics of burn treatment can help PTs select methods of pressure: 1) healing time of the burn, 2) size of the unhealed areas, 3) fragility or condition of the healed skin, 4) location of the burn, and 5) treatment cost.

Healing time. Deitch and associates made four therapeutic recommendations, which were based on healing time, at the 1982 national meeting of the American Burn Association.7

1. No prophylactic pressure therapy is required in any patient whose wounds heal in less than 10 days.

2. If the burn requires 10 to 14 days to heal, black patients of all ages should be offered prophylactic pressure therapy.

Fig. 3. A SEM of a bum wound at 24 hours postburn. The surface appears melted. The uppermost zone is condensed. The deepest area appears to have intact collagen bundles at this stage. Magnifi­cation 325 x.

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Fig. 4. A SEM of a burn wound at 72 hours postbum. At the surface, no protective covering appears above totally disorganized collagen. The bundles appear like frayed or unwoven strands of rope. Magnification 325 x.

3. Patients of any age and race whose burns require 14 to 21 days to heal should have prophylactic pressure therapy offered.

4. If the burn wound requires more than 21 days to heal, prophylactic pressure is mandatory.

These recommendations are particularly helpful because they consider race with regard to scarring. Although this expres­sion, "the darker the race, the greater the tendency for scar­ring," is not always true, clinicians should be aware of this possibility.

Size of unhealed areas. Large open areas being treated with silver sulfadiazine (Silvadene®) or other topical agents may intersperse with healed areas that would benefit from pressure. Therapists should scrutinize these areas with the positive attitude of how pressure can be applied. The material used to apply pressure should facilitate topical treatment. For scat­tered open areas larger than a quarter, fine mesh gauze or nonadherent dressing cut to the size of the open areas protects new tissue. If pressure appears to be enlarging unhealed areas, reevaluating and probably discontinuing pressure treatment is best until the wound appears less fragile.

Fragility of healed skin. The condition of the healed burn skin can be very frustrating to patient and PT. Blisters, skin breakdowns, and hypersensitivity frequently distress outpa­tients. In some cases, early application of pressure toughens the skin, and some patients report a decrease in itching, another common problem. Other patients, however, com­plain about the heat from wearing the pressure garments and general increased discomfort. Because new skin sunburns easily and must be protected from the sun, pressure garments

can serve a double role of providing protection and pressure to exposed areas like the hands. The person applying the garment, however, must be careful in applying or removing pressure that the shearing forces do not destroy or macerate the new skin. Zippers are mandatory in commercially avail­able garments if the patient's healed skin tolerates no shear.

Location of the burn. The burn sites themselves may influ­ence the need for pressure garments. Lower extremity burns may require pressure not only to minimize scarring, but also

WOUND HEALING Fig. 5. Fibroblasts synthesize collagen. Factors like the enzyme collagenase destroy collagen. Remodeling is an ongoing normal process, but in scar formation, the process is impaired.

to minimize persistent edema and discoloration. Patients who have a preburn history of "ankle swelling" usually belong in this category. Venous return can be impaired, however, if pressure is applied proximal to open areas. Sometimes edema is difficult to treat when the hand has a lot of small (even smaller than a dime) open areas, for example, when little blisters break. If the burned hand has too many or too large unhealed areas to tolerate even a soft glove, pressure applied to the arm can cause the hand to stiffen and become edema­tous. In this case, the resulting edema and stiffness of the hand negate any positive effects of pressure on the arm.

Fig. 6. Examples of pressure devices. Isotoner glove has closed fingertips; Jobst has open ones. Two kinds of adhesive backed foam are shown in upper left. A catalyst has to be added to elastomer to form the rubbery insert below the elastomer jar.

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Treatment cost. Cost to the patient must be considered when determining the most efficient means of pressure appli­cation. Some patients cannot afford commercially made gar­ments. Some cannot afford the return clinic visits for reval­uation of pressure devices. Some live too far away for adequate follow-up. The social situation, in some instances, dictates the therapy, and the therapist needs to be knowledgeable about other health professionals or agencies that could provide care.

Methods for Applying Pressure Elastic wraps. Properly applied elastic wraps are a good

method of applying effective, inexpensive pressure early. When large open areas exist, elastic bandaging is acceptable over dressings regardless of the topical agent. After receiving instruction on how to apply a figure-of-eight bandage distally to proximally to promote venous return, the patient demon­strates the wrap. Although a figure-of-eight wrap has proven effective in decreasing edema, the bandaging skill of the patient determines the amount of pressure. Ridges of tissue indicate that the degree of pressure application was variable. The wraps also seem unsightly and uncomfortable to some patients, and compliance may be poor.

Tubular compression bandages. As the skin's shear toler­ance improves and open wounds heal, tubular compression bandages, Tubigrip or Dermafit (Appendix), easily fit extrem­ities of all ages and the trunks of children. A tension guide helps the therapist select the appropriate fit. The hospital can stock the material so that it is readily available as the patient's healed and unhealed areas dictate. Rose and Deitch docu­mented cost and compliance of Tubigrip in a pediatric group.8

Currently, both their pediatric and adult patients are initially treated with Tubigrip garments, either as a temporary dressing before using specifically measured garments or as the defini­tive compression garment.

Spandex. Bruster and Pullium describe a protocol for a gradient pressure using Lycra spandex material (Appendix).9

Therapists have constructed gloves and other garments from simple patterns. These spandex garments, like the tubular compression garments, are applied when the skin is dry and flaky and requires light lubrication. Garments may have to be discontinued if major skin breakdowns occur. As the skin toughens, a commercial garment is prescribed.

Clothing adaptations. Because a delay may occur before specifically measured garments are available to the patient, ingenious use of ready-made garments can be quite effective. For example, Isotoner gloves (Appendix) are available at most large department stores. Patients are first instructed to wear the glove inside out so the seams will not press into their new skin. The glove is usually cosmetically acceptable, and some individuals will also wear a glove on an uninvolved hand when in public. Mothers have used tights with suspenders, a size smaller than their children usually wear, to apply pressure on the children's burned legs; the tights have been surprisingly effective in providing temporary pressure. A long line bra, if the patient can tolerate it, provides pressure over anterior and posterior trunk. A standard elastic back support can fit lower areas of the trunk.

Commercial garments for burns. Construction of an indi­vidually fitted garment may be the best solution to pressure, especially considering the location of some burns. Malick and Carr,10 as well as literature from the Jobst company (Appen­dix), detail the correct garment for the burn area. Jobskin

garments are expensive. For example, the 1984 price for a mask is $54.50, $95.00 for a vest, and $11.00 for a zipper. Bio-Concepts garments (Appendix) are an alternative to Jobst. Their garments are also individually fitted to specific body measurements.

Regardless of manufacturer, accurate fit is imperative. Weight gain or loss definitely influences this fit as do children's growth spurts. Other problems arise. Wearing a face mask embarrasses many patients. Skin breakdowns may occur, and further precautions need to be added to the patient's program. For example, some patients need to wear nylon hose under­neath Jobst garments for lower extremities to minimize break­down from friction. The Jobst or Bio-Concepts garments, however, are probably the pressure garment most burn pa­tients wear until complete maturation of the scar.

Scar maturation illustrates a reversal of the three Rs; instead of red, the area becomes pale; instead of rigid, the scar softens; and instead of raised, the scar flattens. For any pressure garment to help mature a scar, the patient is told to wear the garment 23 hours a day. Enough garments provide the patient with "one to wear and one to wash." Garments work best over even surfaces. Irregular contours challenge the therapist attempting to apply pressure.

Irregular contours, such as the side of the nose, axilla, sternal notch, or areas around the breast, require inserts of various materials. The ability of a material to mold to the area depends on its flexibility, texture, and compressibility. Polycushion, betapile, silicone elastomer, and thermoplastics like Polyform (Appendix) have advantages and disadvantages, clearly described by Alston et al.11 For example, betapile is soft, nonabrasive, and compressible, but because of the com­pressibility, consistent pressure fails to be maintained. Silicone elastomer is a catalyzed liquid that pours over the area and hardens to a rubbery consistency. It contours well because of the method of application, but some patients develop prob­lems of sweating and maceration of the skin.

I could have chosen many other examples than these. Therapists should also be aware of materials used for other treatments that might be advantageous. For example, some therapists are evaluating the applicability of dressings and materials to prevent skin breakdowns in patients with or­thopedic problems. Versatility and awareness can progress treatment methods.

Scar maturation illustrates a reversal of the three Rs; instead of red, the area becomes pale; instead of rigid, the scar softens; and instead of raised, the scar flattens. For any pressure garment to help mature a scar, the patient is told to wear the garment 23 hours a day. Enough garments provide the patient with "one to wear and one to wash." Garments work best over even surfaces. Irregular contours challenge the therapist attempting to apply pressure.

Irregular contours, such as the side of the nose, axilla, sternal notch, or areas around the breast, require inserts of various materials. The ability of a material to mold to the area depends on its flexibility, texture, and compressibility. Polycushion, betapile, silicone elastomer, and thermoplastics like Polyform (Appendix) have advantages and disadvantages, clearly described by Alston et al.11 For example, betapile is soft, nonabrasive, and compressible, but because of the com­pressibility, consistent pressure fails to be maintained. Silicone elastomer is a catalyzed liquid that pours over the area and hardens to a rubbery consistency. It contours well because of the method of application, but some patients develop prob­lems of sweating and maceration of the skin.

I could have chosen many other examples than these. Therapists should also be aware of materials used for other treatments that might be advantageous. For example, some therapists are evaluating the applicability of dressings and materials to prevent skin breakdowns in patients with or­thopedic problems. Versatility and awareness can progress treatment methods.

STRETCHING

Instigating the appropriate pressure at the appropriate time represents an important aspect of rehabilitating the patient, but pressure must be accompanied by effective stretch of all involved joints. Slow sustained stretching is perhaps the most effective method in maintaining and increasing length of the scar tissue.12 Skin blanching indicates the beginning of rele­vant stretching of scar tissue. The therapist educates the patient about the need for stretching early in the treatment course. As soon as areas of blanching appear on the patient, the therapist has the patient observe the blanching as he exercises to help him comprehend the extent of scar stretch­ing. For some scar bands, the patient needs to look in a mirror.

If the scar crosses more than one joint, the patient sees how isolated joint stretching causes some blanching. Only concur­rent joint stretching demonstrates the extent of scar blanching. For example, the patient may be able to extend his elbow

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fully with his arm adducted. He may be able to flex his shoulder fully with his elbow flexed. Full shoulder flexion with full elbow extension, however, may create blanching from the trunk to as far below the elbow as the burn extends. Visualizing the process helps many patients to understand the problem and the need for stretching.

If the patient demonstrates the ability to stretch effectively, the patient should help develop a program for treating scarred areas. If the joints are difficult for the patient to work, family members may become "stretchers." Children are a particu­larly difficult group to stretch effectively, and therapists and families must work together to maintain maximum range. If family members cannot perform adequately, the therapist's time with the child increases and more emphasis has to be given to splints.

Gravity and assistive devices such as pulleys or traction units effectively stretch involved joints. For example, if the patient has a band of scar tissue forming in the antecubital space, sitting with the flexed arm resting in the lap encourages the formation of a contracture. If the patient sits with the arm extended over the side of a chair or table, gravity helps pull the elbow into extension. If the patient puts a weight, such as a 1-lb (0.37-kg) can of vegetables in the hand, he gains further extension. Valuable treatment time is acquired even though the patient may be sitting watching TV or visiting with a friend.

Simple exercise equipment and techniques are more im­portant to the patient who is being discharged than elaborate gym facilities. How effectively the patient maintains end range at home determines the frequency of supervised therapy. Simple home programs take the place of frequent trips to the therapist. A thorough understanding of the lengthy scarring process motivates the patient to maintain the necessary long-term exercise program.

Attempting to stretch dry, flaky, or cracking skin creates unnecessary pain. A light application of an appropriate lubri­cant facilitates less irritating stretching. The application of paraffin as described by Head and Helm combines the benefits of heat, lubrication, and stretch.13 The patient first achieves the maximum stretch. Then, by dipping or brushing, the involved area is covered with paraffin. The stretch is main­tained for 20 to 30 minutes. Splints, positioning, weights, and wrapping with elastic bandages promote the maximum stretch. For both children and adults, diversion helps distract the patients from their discomfort. Reading or playing games with a child or exercising another area of an adult makes the time go faster for the patient. Although the information is not well-documented, several therapists have found improved results with deep heating of tissues with ultrasound, especially when they use a lotion medium in conjunction with stretching techniques.

Splints serve as extremely valuable devices. They can pro­vide both pressure and stretch simultaneously. Although my intent in this article is not to describe the techniques, types, versatility, and precautions of splinting, any therapist man­aging individuals with burn wounds must be well-acquainted with methods of splinting. Devising the appropriate splint for a particular problem challenges even the most experienced therapist.

Facial burns present a unique set of problems.14 Scarring of the face is an especially traumatic experience, and although the principles of pressure and stretch still apply, the psycho­

logical adjustment of the patient may be quite difficult. Face masks apply effective pressure on areas of the face overlying bony structures. Areas of irregular contours around the nose and eyes require additional inserts. Stretching exercises are valuable but are difficult to document compared with meas­uring increased range of motion for joints. Prevention appli­ances for microstomia (MPAs) provide both pressure and stretch to the mouth, and several ingenious designs have been published.15-17 Lack of compliance makes evaluation difficult in many cases.

CASE STUDIES

Case One

A 6-year-old boy sustained a 24 percent total body surface area burn to trunk and upper extremities when his shirt caught fire. The child received grafting to portions of his chest and was discharged in approximately three months. He returned to the clinic with decreased range of motion of the left shoulder because of scar bands and hypertrophic scars around his scapular area. At the time of discharge, the child wore a correctly fitted Jobst vest.

Outpatient therapy goals included providing more pressure and additional stretch. The therapist designed a specifically cut, wide crescent-shape foam pad to fit under the axilla and over the vest. Elastic bandages secured the pad in the axilla in a figure-of-eight wrap and were fastened in the back to prevent the child from loosening them. The child's mother demonstrated the application several times and verbalized the child's need to wear the pad with the Jobst vest for 23 hours a day.

The vest, apparently, had failed to apply even pressure over the entire trunk scar. The therapist tried an elastomer mold because of the development of the hypertrophic scar on the scapular area. The base with catalyst was poured directly over the scar (Fig. 7). Because of the scar's location and size and

Fig. 7. Elastomer poured directly onto this child's back to form a mold.

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Fig. 8. Patient holding polycushion insert before putting on a pres­sure glove.

the danger of skin irritation from the child's perspiration, the mold was used mainly at night to encourage softening and flattening of the scar. When the weather became cooler, this mold was incorporated into a snug fitting T-shirt.

In therapy, the child was allowed to "play" at games that increased the shoulder range, such as throwing the ball and receiving rewards for reaching the top rung of a ladder system. After more active exercise, the child chose his favorite story for diversion and began 20 to 30 minutes of static stretching for shoulder flexion and abduction. The therapist put lotion on his shoulder and stabilized his trunk so that gentle increases in either flexion or abduction were effective. The child con­sidered the story a reward and gained confidence in the treatment.

Later, he brushed paraffin on unburned skin and eventually allowed the therapist to apply the paraffin to the scar bands while he stretched. When full range of motion was achieved, the frequency of treatments decreased. A year later, the child continued to have full range of motion without reconstructive surgeries.

Discussion. Law and associates at Shriners Burns Institute in Cincinnati describe five patterns of deformity formed by burn scars of the axilla.18 The first pattern is an anterior axillary scar with web formation. The second pattern is com­bined involvement of both axillary folds but sparing of the axillary fossa. Complete burns of the axilla involving both folds and the entire axillary fossa represent the third pattern. The fourth pattern consists of a band of scar tissue over the deltoid areas like a shoulder strap. Pattern five is an unburned axillary web of normal skin between spars of the arm and chest. All patterns are difficult to treat. Individuals performing activities of daily living usually have their arms at their sides, but gravity pulls the shoulder into a position of scar deformity. Patients are uncomfortable with big pads in their axillas.

Clothes are unsightly if bulky pads are worn underneath; yet the pressure devices are obvious if worn over apparel. Trunk substitution may minimize what the patient considers effec­tive exercising, and a functional scoliosis can develop. If the patient is a child, the age of the child may be especially important in follow-up care in this regard. If possible, these patients need monitoring frequently after discharge to avoid future surgeries.

Case Two

A 32-year-old woman sustained burns to her hands while cooking. The patient was wearing an Isotoner glove at dis­charge and subsequently was measured for a Jobst glove with no zippers and open fingertips. Because the scar tended to bridge the space between the digits, greater pressure was needed to prevent syndactylism or two digits united or limited by webbing. Web-spacer inserts of narrow soft strips of beta-pile were designed immediately to be worn under the Isotoner glove.

A complicating form of syndactylism occurred between her thumb and index finger. A blanching scar was observed when the patient tried to stretch her two fingers apart, for instance, as she tried to reach for a large can. A polycushion insert backed with moleskin (Fig. 8) was cut with a hole for her thumb to secure the insert. She wore the insert under the gloves throughout the day for additional pressure in the web space.

For additional stretching, a polyform mold was devised to stretch and also apply pressure (Fig. 9). Betapile straps were effective to secure the "stretcher." The patient was instructed to apply this device several times throughout the day. She could not sleep with it because it caused numbness in her hand. Because the patient was compliant, intelligent, and attentive to precautions, the therapist could develop untried devices.

The patient's major complaint was general stiffness in her hand. The exercises during therapy began with the patient

Fig. 9. Arrows point to betapile straps used to hold thumb web spacer. Additionally, betapile is used to flex the little finger to prevent hyperextension deformity (courtesy of Mary Ann Cooney, OTR).

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actively exercising each isolated joint in the hand. If full isolated motion was not achieved actively, the therapist pas­sively stretched the joint to maximum range. The patient exercised again actively, and the therapist repeated passive stretching if required. The next set of exercises involved active fisting. The patient used equipment such as a hand exerciser, putty, and wall weights that encouraged tight fisting. If full active fisting was unachievable, the therapist passively stretched the joints concurrently for full fisting. The patient was allowed again to work actively followed by passive stretch­ing on her fisting. When maximal active fisting was achieved, the patient dipped her hand into paraffin until a thick coat covered the fist. The therapist wrapped the fist in a plastic bag and used an elastic bandage to maintain the fisted posi­tion. Although the patient quickly achieved full active fisting, she continued treatment for several months to help minimize the stiffness and increase the agility of her hand.

Discussion. Generalized stiffness in the hand is unfortu­nately a common complaint. In addition to therapy, some physicians prescribe aspirin for prolonged complaints of joint stiffness when motion is full. Some therapists initiate therapy

with joint manipulations to assess joint stiffness that is perhaps unrelated to skin tightness. This patient epitomizes the prob­lem when the entire hand is involved. If too much time is spent in flexion, extension becomes difficult and scar bands form. If too much emphasis is given to extension, fisting and flexion activities become difficult. The therapist must contin­ually reevaluate the patient's problems. No one modality solves all the problems created with a circumferential hand burn.

SUMMARY

Hypertrophic scarring can significantly impair the restora­tion of patients with burns to their preinjury life style. Pressure and stretch minimize scarring and help maintain function and maximize cosmetic results. My guidelines provide prac­tical directions for effective use of multiple pressure devices and stretching techniques. Physical therapists need to instigate an aggressive program of scar modification for rehabilitation. With an appropriate program, caring for a patient with burns becomes extremely beneficial and rewarding.

REFERENCES

1. Forrester J: Collagen morphology in normal and wound tissue. In Hunt T (ed): Wound Healing & Wound Infection: Theory & Surgical Practice. New York, NY, Appleton-Century-Crofts, 1980, p 118

2. Kurkinen M, Vaheri A, Roberts P, et al: Sequential appearance of fibronec-tin and collagen in experimental granulation tissue. Lab Invest 43:47-57, 1980

3. Ross R: Wound healing. Sci Am 220(6):40-50,1969

4. Cohen I, Keiser H, Stoerdsma A: Collagen synthesis in human keloid and hypertrophic scar. Surgical Forum 22:488-89,1971

5. Hunt T: Fundamentals of Wound Management in Surgery: Wound Healing: Disorders in Repair. South Plainfield, NJ, Chirurgecom, Inc, 1976, p 54

6. Larson D, Abston S, Evans E, et al: Techniques for decreasing scar formation and contractures in the burned patient. J Trauma 11:807-823, 1971

7. Deitch E, Wheelahan T, Rose M, et al: Hypertrophic burn scars: Analysis of variables. Abstract. Presented at the 15th Annual Meeting of the American Bum Association, New Orleans, LA, March 16-18,1983

8. Rose M, Deitch E: The effective use of a tubular compression bandage, Tubigrip, for burn scar therapy in the growing child. Journal of Burn Care and Rehabilitation 4:197-201,1983

9. Bruster J, Pullium G: Gradient pressure. Am J Occup Ther 37:485-488, 1983

10. Malick M, Carr J: Manual on Management of the Burn Patient. Pittsburgh, PA, Harmarville Rehabilitation Center, 1982, chap 9,10

11. Alston D, Kozerefski P, Quan P, et al: Materials for pressure inserts in the control of hypertrophic scar tissue. Journal of Burn Care and Rehabilitation 2:40-43,1981

12. Helm P, Kevorkian G, Lushbaugh M, et al: Burn injury: Rehabilitation management in 1982. Arch Phys Med Rehabil 63:6-16,1982

13. Head M, Helm P: Paraffin and sustained stretching in treatment of burn contracture. Burns 4:136-139,1977

14. Johnson C, O'Shaughnessy 0, Ostergren G: Burn Management. New York, NY, Raven Press, 1981, pp 117-132

15. Holt G, Parcel S, Richardson D, et al: The prosthetic management of oral commissure burns. Laryngoscope 92:407-411,1982

16. Silverglade D, Zacher J, Ruberg R: Improved splinting of oral commissure burns: Results in 21 consecutive patients. Ann Plast Surg 9:316-320, 1982

17. Wright G, Colcleugh R, Davidge L: Electrical burns to the commissure of the lips. Journal of Dentistry for Children 44:377-381,1977

18. Law E, Hoefer R, McMillan B: Clinical experience with axillary burns. J Trauma 12:34-44,1972

APPENDIX Compression Materials

Name

Tubigrip

Dermafit

Lycra spandex

Isotoner gloves

Jobskin

Bio-Concepts garments

Polycushion

Betapile

Medical elastomer 382

Polyform

Supplier

Tubiton House Medlock St Olham 011 3HS England

Genetics Lab, Inc 1385 Centennial Dr St. Paul, MN 55113

Thomas Wilson & Co 200 Wilson St Pt. Jefferson Station Long Island, NY 11776

Aris 417 5th Ave New York, NY 10016

Jobst 653 Miami St Toledo, OH 43605

Bio-Concepts, Inc 2430 E Washington St Phoenix, AZ 85034

Fred Sammons, Inc Box 32 Brookfield, IL 60513

Alimed 68 Harrison Ave Boston, MA 02111

Dow Corning Corp Medical Products Midland, Ml 47640

Rolyan Medical Products N93 W14475 Whittaker Way Menomonee Falls, Wl 53051

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