Burns & Compression
Making correct measurements for compression is essential as people with burns wear compression dressing or garments up to 23 hours per day
By Jolynn Weiler
Considered the consensus treatment for scar control today, the effectiveness of compression in treating patients with burn scars came as an unexpected discovery several decades ago. While using compression mainly as a means to manage edema, clinicians began to take notice of a repeat pattern in patient after patient: Scars in compressed areas maintained better appearances than scars in unpressured areas.
The research that followed produced several findings, explained R. Scott Ward, PhD, PT, associate professor and director of the division of physical therapy at the University of Utah, Salt Lake City. According to Dr. Ward, the use of compression in treating patients with burns:
* controls hypertrophic scarring, or raising and thickening of the skin
* maintains the natural contours of affected body parts by preventing hypertrophic scarring
* softens and realigns scar tissue, enabling mobility.
"All of those areas require further study, however," Dr. Ward told ADVANCE. "Just like most everything else, there's ongoing work to demonstrate exactly why it works."
Although researchers have yet to come up with a solid reason to explain compression's influence on scar control, during the past 20 years the procedure's use has flourished. Burn treatment facilities are increasingly turning to compression to reduce noticeable scarring, and the lines of pressure wraps, garments and inserts on the market are quickly growing.
To gain some insight into the widely used procedure, ADVANCE recently checked in with several therapists around the country to see how their facilities utilized compression in treating patients with burns.
Except in cases where compression is used to control edema, therapists generally hold off on applying pressure to burned areas until the patient's wound is well on the road to healing. When the wound appears to be mostly closed and is no longer bleeding or seeping, pressure wraps are applied to begin early scar control.
"We usually will have patients wear the temporary pressure around the clock, 24 hours a day," said Chris Perkins, L/OTR, a therapist with the Baton Rouge General Medical Center Regional Burn Unit. "The process lasts until the wound is healed enough to handle more permanent pressure."
Types of temporary wraps vary. While facility preference certainly plays a role in the selection of compression wraps, the healing progress of the wound and its location on the body also play large roles. Dr. Ward, who also works at the Intermountain Burn Center of the University of Utah Health Sciences Center, said self-adhesive compression wraps are initially applied to the affected area when the wound hasn't closed completely. The material in such wraps sticks only to itself, not the wound or its dressing, and provides compression through its stretchable, elastic quality. As the healing progresses, elastic cotton wraps or garments replace the self-adhesive wraps.
Sometimes a combination of self-adhesive wraps and more durable, cotton wraps is used, depending on the body part undergoing compression. For example, compression of the hand will often involve an elastic cotton dressing for the palm, wrist and arm, while each finger is individually wrapped with self-adherent dressings.
After edema has been controlled and the skin has strengthened adequately, many therapists move on to pressure garments, custom-fit, elasticized permanent pressure supports designed for patient wear of a year or more.
"If the skin is not breaking down at all, if it's not sheering from putting on or taking off the temporary wraps, at that point the skin is ready for donning a pressure garment," explained Kalani D'Andrea, MA, OTR, from the Burn Center at the University of California, San Diego. "The issue with a pressure garment is that when you put it on, you pull against the skin and can sheer it. So the wounds need to be healed enough that it's not going to break open."
Typically, patients are measured for pressure garments while they are still wearing temporary wraps (but after swelling has severely diminished), to allow time for manufacture. Waiting periods for the country's several pressure garment distributors generally last from a few days to a couple of weeks, depending on the patient's need and the specific manufacturer's turn-around time. Some facilities, like UCSD's burn center, manufacture permanent supports in house.
"We have our own garment center here," said D'Andrea. "We find that because the pressure garments need to fit well and we often have to do readjustments, it helps to have the garment center on site."
But because of the extensive process involved in garment manufacturing, therapists at most facilities simply take the patient's measurements and then send away for customized pressure garments.
Patients are usually provided with two pressure supports so they can alternate wear while one is being cleaned. Pressure garments are worn 23 hours a day, leaving the patient up to an hour to bathe and redress. Because scars take about 12 months to mature, the custom-made supports are worn for about one year. Like temporary wraps, pressure garments do not speed scar maturation; but the consistent compression both controls and conforms the scar. Patients lose no range of motion or function from wearing the garments, Dr. Ward said.
At the Baton Rouge General Medical Center, therapists frequently turn to pressure garments because of the large number of children and African Americans making up their patient population. According to Perkins, the abundance of collagen in the skin of individuals in those patient groups increases their chances of hypertrophic scarring. "The general theory is that dark pigmented individuals are more likely to scar than Caucasians. And younger children typically develop more of a scar vs. elderly patients," Perkins explained. "Elderly Caucasian patients with wrinkled, loose skin have no collagen, so they usually have no hypertrophic scarring."
While the exception, some facilities prefer to stay with compression wraps through the entire rehabilitation process due to reimbursement issues or past practices.
According to Perkins, reimbursement for pressure garments is becoming increasingly difficult, with Medicare and Medicaid refusing to reimburse for the custom-made protective garments. For that reason, therapists at Baton Rouge General Medical Center's burn unit require insurance companies to precertify requests for pressure garments before any actual orders are placed.
"With some body parts, no matter how much pressure you put on, you're just not going to get a good fit," said Perkins. "For example, there are too many curved areas around the chest of a female to get good pressure. So with those kinds of body parts, you're going to have to try means other than a pressure garment."
Insert products are available to provide extra support under temporary wraps and pressure garments for a variety of body parts. Sky rocketing in popularity during the past several years have been silicone-based inserts, Perkins explained. Much of the draw to silicone is the product's demonstrated ability to soften scars while flattening their appearances. "Silicone has worked like a miracle product," Perkins said. "Some studies have come out, but they still don't know why silicone works. That's what those looking to the future of pressure management are considering now."
While there are pages of silicone-based products in catalogs, silicone comes in two basic forms: sheets and liquid mixtures.
The sheets, which resemble rubber matting, vary in thickness and are draped onto affected body parts. Silicone mixtures, on the other hand, are poured onto burn areas where, after approximately 15 minutes, they form rubber-like molds. As the scars change in shape, the molds are repoured. Because prices for silicone products tend to run higher than those for other types of padding like foam or neoprene, many facilities reserve the use of silicone for areas demonstrating hypertrophy.
About 80 percent of the time, therapists at the Burn Center at UCSD use inserts made of neoprene, a SCUBA suite-like material. "We try to start with neoprene because it's cheaper than silicone," said D'Andrea. "We use it as a form of increasing the pressure under any large burn sites. But if the scars look like they're beginning to raise up, we'll switch to a silicone-based product."
Some silicone products are hard enough to provide adequate compression for use by themselves, without the aid of temporary wraps or pressure garments.
Casting, Stretch, Massage and Exercise
Another compression procedure employed by therapists at UCSD is casting. When scarring causes patients to contract and lose motion in an elbow joint, for example, D'Andrea said she frequently casts the arm back out into an elbow extension to encourage the skin's pliability.
Softened by underlying cotton wrapping, the cast material itself also works to apply pressure to the skin, preventing hypertrophic scarring.
"We have found that casting has worked wonderfully," D'Andrea said. "You can't take it off, so we know there's compliance. And for the people I've casted, mostly children, I've found their scarring ends up beautiful after they've been casted."
While useful in scar control, compression isn't the only procedure for scar management. Stretch, exercise and skin massaging are also emphasized by therapists working to achieve minimal scarring on patients with burns.
Pointing out that every patient is an individual case and products and methodology change as research advances, Perkins emphasized that therapists need to maintain an eclectic viewpoint when it comes to burn rehabilitation. She recommended all professionals treating patients with burns become members of the American Burn Association to receive up-to-date studies on topics like burn management, and noted that reference books are also helpful.
"As therapists, we need to try to do everything for the patients to help minimize their scarring," Perkins said. "Because in today's society, appearance is so important."
* Contact the American Burn Association at 625 N. Michigan Ave., Ste. 1530, Chicago, IL 60611; (800) 548-2876.
Jolynn Weiler is on staff at ADVANCE.