Why Do We Have Scars?
Scar formation is a normal process in how our bodies respond to an injury or surgery. It is basically our body’s way of making a collagenous glue. It is responsible for holding structures together while our body heals. Scar formation may only involve the superficial layers, but it also can form in the deeper layers of the tissue and involve ligaments, tendons, and nerves.
It is often times an aesthetic concern, however, we know as hand therapist this can lead to a loss of mobility which can lead to functional limitations. Scars can also become very sensitive and painful.
So, how can you help your patients with these dreaded scars? One thing that is important to consider is the maturity of the scar. If the scar is not mature, enough further trauma to the scar can lead to further scar formation.
Tips and Tricks to Managing Scars
Scar Massage
This can help decrease any hypersensitivity and also can help the sensory response to normalize. Scar massage can improve the scar pliability allow to produce and flat moveable scar. You can use an over the counter cream such as cocoa butter or Vaseline. Be sure to educate your patient in avoiding creams that have alcohol as this can dry out the scar. Often times we will prescribe 10 minutes of scar massage, 2x/day.
Scar Pads or Paper Tape
Silicone gel pads can provide light pressure over the scar resulting in a flattened scar. Typically we prescribe wearing this at night. If the scar is an odd shape or a piece of silicone will not work, an elastomere or otoform insert can be made. There is also some evidence to support the use of paper tape as well as some of the stretching tapes such as TheraBand Kinesiology Tape or Rocktape. Theoretically, if the scar has less oxgen it will have an improved appearance.
Vibration
Vibration can help with a scar that is very sensitive. When introducing vibration for scar management, I will allow the patient to be in charge of doing the massage as they are able to identify if the vibration is too painful. Also, if the massage is too aggressive, you can leave the cap on the scar massager. If purchasing a scar massager is too expensive, an alternative is using the end of an electric toothbrush to massage the scar.
Active Range of Motion
Active range of motion can prevent joint stiffness and can also prevent tendon adhesions. Make sure to move through the full range of motion each time and have patient perform composite flexion if the injury allows. For instance, if a patient has a dorsal hand burn you will want them to make a fist, flex their wrist, and to do these movements at the same time.
Orthotic Fabrication
Orthoses would be used if the scar is causing a contracture an is not passively correctable. For instance, if there is a scar on the volar surface of the pip joint and it is limiting the patients full extension, a night-time pip joint extension splint should be considered and also possibly and LMB for night a couple of times during the day.
Desensitization Using Various Textures
When scars are hypersensitive I will often make a desensitization packet for the patient. Start with a really soft texture such as a piece of velfoam and rub the sensitive area for 2 minutes. Have the patient work up to a more abrasive texture such as a washcloth. I typically label each texture 1-4 and have them start with #1 and work their way up to #4.
Phases of Healing
Educate the patient on keeping the immature scar out of the sun. This can be achieved by covering the scar and also using sunscreen.
Educate your patients on the stages of scar healing and that a scar can take a year to 18 months to fully mature.
Phase 1
The skin and deeper tissues are healing. This is typically when there is still a wound or sutures may be in place. At this phase you may be educating the patient on massaging the skin around the scar but no on top of the scar. At this phase the scar is not mature enough to tolerate many mechanical forces.
Phase 2
This is when you will really start waging war on the scars. The scar will often become enlarged and reddened. Typically, this phase lasts 4-8 weeks. This is usually when the scar is very active and can have the following characteristics:
Phase 3
The scar becomes smaller and paler. This typically lasts 2-3 months.
Phase 4
The scar will become soft and pliable and usually the color will continue to fade. A scar will fully mature 12-18 months after the injury or surgery.
After the skin and deeper tissues have healed, the scar goes through four different stages of healing. Although the initial skin scar may be minimal, the scar will often enlarge and become more reddened over the following 4-6 weeks. An active scar is typically red, raised, firm and thick. Sometimes this change can be confused with infection. Also, the outermost layer often loosens while the deeper layers remain intact; this is normal as well.
Following the swelling/reddening phase, the wound becomes smaller and paler over the next 2-3 months. Later, the scar becomes soft and has a more natural color in most individuals.
About the Author
Miranda Materi, OTD, OT/L, CHT
Owner & Manager
Hand Therapy Partners-East
Miranda received her professional clinical doctorate in occupational therapy from Creighton University in 2006. After practicing hand therapy for five years, she became a certified hand therapist. Miranda has a strong interest in research and development in clinical settings and has participated in many studies. She prides herself on treating patients with complex traumatic hand and upper extremity injuries. Miranda's other professional interests include community-based occupational therapy and community prevention programs including fall prevention. Miranda has served as an adjunct faculty member at the Mayo Clinic and currently is an adjunct faculty member at Northern Arizona University.
Miranda enjoys helping patients with a variety of diagnoses, including flexor tendon lacerations, replantations, nerve transfers, brachial plexopathies, amputation with and without prosthetics, various fractures, osteoarthritis, as well as orthotic fabrication for various conditions. Miranda is also certified in myoelectric prosthetic training and has worked with all types of upper extremity amputees.
Miranda often treats patients who have sustained life changing injuries. One of her recent more challenging patients got his arm stuck in a conveyor belt while at work. The patient actually had to break his own arm to remove it from the machine. This patient underwent several limb saving surgeries and required months of therapy. Miranda helped him to retrain his dominant hand and regain function in his injured arm.
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