[libribook.com] Traumatic Scar Tissue Management 1st Edition
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[libribook.com] Traumatic Scar Tissue Management 1st Edition

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OneTwoThreeCommonly referred to as the mild, pitting or reversible stage. Accumulation of protein-rich fluid is presentin the tissues, the affected region or limb appears mildly swollen and pitting is evident (i.e. when you pressinto the skin a temporary dent/pit is seen and persists – termed pitting edema). Elevation of an affected limbtends to resolve or reduce the swelling; however, fluid accumulation will reoccur in time once the limb islowered. Although this stage can include an increase in proliferating cells (e.g. fibroblasts, which in turncan stimulate collagen production), this stage is considered reversible because skin and tissues have notbeen permanently damaged. Proper management at this stage can assist the restoration of normal extremitycircumference and lymphatic function, thereby preventing or reducing the risk of further progressiontoward irreversible changes (Zuther 2011). Once you have acquired mild lymphedema, you are at higherrisk for moderate-to-severe lymphedema than someone who has never had any symptoms and this risk canpersist even if your symptoms resolve with treatment.Commonly referred to as the moderate or spontaneously-irreversible stage. In this stage regional swelling ismore pronounced, there is no reduction in swelling with elevation and pressing into the skin does not leavea dent/pit (termed non-pitting edema). Inflammation and subsequent fibrosis accompany this stage.Hardening, or thickening of the tissue is evident. This stage can be managed with treatment, but any tissuedamage cannot be reversed. A reduction in fluid volume and fibrosis may be achieved through propertreatment (e.g. manual techniques and compression garments) (Zuther 2011). Lymphedema often stabilizesin stage II. However, if untreated, protein-rich fluid can continue to accumulate, sometimes resulting inprogression to stage 3.Commonly referred to as severe or lymphostatic elephantiasis. This – most advanced – stage is relativelyrare in people with breast cancer. With stage 3, the affected limb or area of the body presents as large andmisshapen, the skin takes on a leathery, wrinkled appearance and there is evident skin thickening (fibrosis),hardness and large limb volume (elephantiasis). Pitting is not present in this stage. As noted in Chapter 3,the increase in protein-rich fluid and fibrosis prevents oxygen and other essential nutrients from reachingthe area and creates an ideal environment for bacteria, which in turns sets the stage for subsequent recurrentinfections (lymphangitis). With this stage, fluid reduction is still possible with proper treatment, but in mostcases the duration of intensive complete decongestive therapy has to be extended and repeated severaltimes. In extreme cases the surgical removal of excess skin following the conservative therapy may beindicated.

Table 6.4Stages of lymphedema: 0–3Auxillary Web Syndrome or CordingAxillary web syndrome (AWS), also known as ‘cording’ in the postsurgicalbreast cancer patient, is characterized by painful cording or strings of hardenedlymph tissue in the axilla of the affected side. It affects functioning by causingpain and restriction in arm ROM, especially abduction. Alexander Moskovitzrefers to the syndrome as: ‘axillary pain radiating down the ipsilateral arm,shoulder ROM limitation, and an axillary web of tissue attempts abduction of thearm.’ It appears that the axillary lymph node dissection of the breast procedure isthe trigger to the lymphatic disruption that causes AWS (Bock 2013).AWS may manifest with one large cord or several distinct, smaller cords runningdown the arm. These cords usually start near the site of any scarring in theunderarm region and extend down the inner arm to the inside of the elbow.Sometimes they can continue all the way down to the palm of the hand. In somepeople, cording can extend down the chest wall instead of, or in addition to, theinner arm (BreastCancer. org 2015b).The anatomy of the axilla bears review for a full understanding of AWS. Theaxilla compartment is home to a fascial sheath that contains neurovascularbundles, 20–30 lymph nodes, and is bounded superiorly by the head of thehumerus, covered by the coracobrachialis and the short head of the biceps. Theaxilla is bound anteriorly by the pectoralis major; posteriorly by thesubscapularis, latissimus dorsi and teres major; and inferiorly by the ribcagewhich is covered by the serratus anterior (Calais-Germain 2007).The fasciae that envelopes the regional muscles is continuous with the brachialfascia, which plays a significant functional role (Stecco et al. 2008); forexample, the fascia of the clavicular head of the pectoralis major displays athickening of collagen fibers that extend into the anterior brachial fascia,surrounding the biceps and thereby creating a continuous functional link (i.e.

Table 6.4

Stages of lymphedema: 0–3

Auxillary Web Syndrome or Cording

Axillary web syndrome (AWS), also known as ‘cording’ in the postsurgical

breast cancer patient, is characterized by painful cording or strings of hardened

lymph tissue in the axilla of the affected side. It affects functioning by causing

pain and restriction in arm ROM, especially abduction. Alexander Moskovitz

refers to the syndrome as: ‘axillary pain radiating down the ipsilateral arm,

shoulder ROM limitation, and an axillary web of tissue attempts abduction of the

arm.’ It appears that the axillary lymph node dissection of the breast procedure is

the trigger to the lymphatic disruption that causes AWS (Bock 2013).

AWS may manifest with one large cord or several distinct, smaller cords running

down the arm. These cords usually start near the site of any scarring in the

underarm region and extend down the inner arm to the inside of the elbow.

Sometimes they can continue all the way down to the palm of the hand. In some

people, cording can extend down the chest wall instead of, or in addition to, the

inner arm (BreastCancer. org 2015b).

The anatomy of the axilla bears review for a full understanding of AWS. The

axilla compartment is home to a fascial sheath that contains neurovascular

bundles, 20–30 lymph nodes, and is bounded superiorly by the head of the

humerus, covered by the coracobrachialis and the short head of the biceps. The

axilla is bound anteriorly by the pectoralis major; posteriorly by the

subscapularis, latissimus dorsi and teres major; and inferiorly by the ribcage

which is covered by the serratus anterior (Calais-Germain 2007).

The fasciae that envelopes the regional muscles is continuous with the brachial

fascia, which plays a significant functional role (Stecco et al. 2008); for

example, the fascia of the clavicular head of the pectoralis major displays a

thickening of collagen fibers that extend into the anterior brachial fascia,

surrounding the biceps and thereby creating a continuous functional link (i.e.

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