Mobilizacja blizny jest tylko jednym z licznych sposobów prowadzenia terapii blizn. Polega ona na jej mechanicznym odkształcaniu z pomocą rąk terapeuty, specjalnych przyborów terapeutycznych lub przyrządów – wyjaśniła w rozmowie z Forum Leczenia Ran Katarzyna Młotek, fizjoterapeutka, naturoterapeutka oraz instruktor autorskiego szkolenia w zakresie terapii blizn – Integracyjna Terapia Blizn.
Forum Leczenia Ran, Natalia Janus: Czy każda blizna może być poddana takiej terapii?
Katarzyna Młotek: Manualna terapia blizny jest wykonywana przede wszystkim wtedy, kiedy mamy zaburzoną przesuwalność tkanki powstałej w procesie reparacji, czyli samej blizny, bądź często również tkanek okolicznych. Terapia ta ma na celu w możliwe jak największym stopniu przywrócić odkształcalność tkanek w porównaniu do stanu sprzed powstania uszkodzenia.
Nie każda blizna może być poddana tego rodzaju terapii, ale też nie każda blizna takiej terapii potrzebuje. Ważne żeby umieć ocenić stan blizny, aby zdecydować jaki rodzaj terapii będzie najważniejszy.
Jakie są ogólne przeciwskazania do terapii blizn?
– Nie mobilizujemy blizn przy obecności przeciwskazań ogólnych do terapii, czyli w przypadku występowania gorączki, ostrych stanów chorobowych, ale także m.in. w przypadku skóry pergaminowej, przy intensywnych przerostach blizn w fazie proliferacji, przy zbytniej bolesności odczuwanej przez pacjenta.
Ponadto przeciwwskazaniem do terapii blizn będą problemy z gojeniem blizny świeżej (rozejściem blizny, sączeniem płynów z blizny), kiedy obecne są jeszcze strupy lub szwy, po zażyciu mocnych środków przeciwbólowych, w zespole Sudecka, stosowaniu silnych leków przeciwkrzepliwych czy w ciężkim przebiegu cukrzycy.
Ile trwa skuteczna mobilizacja blizny i od czego zależy?
– Trudno jest określić jednolicie czas przeprowadzania takiej terapii, ponieważ każda blizna ma inną historię, każdy pacjent ma indywidualne predyspozycje, które będą wspierać reparację uszkodzonej części ciała lub ją utrudniać. Przy bliznach świeżych manualna terapia blizn może pomagać szybciej, ponieważ krótki był czas, aby powstałe sklejenia- zwłóknienia się utwardziły. Wtedy przy dobrych warunkach przebiegu procesu gojenia już po pierwszych działaniach terapeutycznych, nawet jeżeli będą delikatne, można zauważać poprawę mobilności blizny.
W starych, przerosłych, sklejonych, sklerotycznych lub zrośniętych bliznach terapia manualna może trwać bardzo długo. Ale przy odpowiednio dobranych technikach i długości ich stosowania również może dojść do poprawy mobilności nawet takiej starszej blizny. Taka sumienna praca nad blizna może trwać nawet do paru tygodni.
Blizny mogą wywoływać zaburzenia w odległych sobie miejscach. Jakie? Czym to jest spowodowane?
– Żadna część naszego ciała nie istnieje sama dla siebie. Nasz organizm to zespół komórek, tkanek, narządów, układów, które cały czas poprzez różne poziomy, ze sobą współpracują i się komunikują. Zaburzenia tzw. przeniesione mogą pojawiać się w miejscach, które na drodze rozwoju embriologicznego są „wspólne”, czyli pochodzą od jednego somitu.
Tym samym blizna może mieć wpływ poprzez dermatomy, miotomy, sklerotomy, itd. na odpowiednie segmenty kręgosłupa, a tym samym również na narządy, części ciała, które z tych samych poziomów są unerwione. Mówimy tu o zależności poprzez oddziaływanie np. łuku odruchowego skórno-trzewnego, skórno-somatycznego. Poprzez współczulne unerwienie danych części ciała możemy również znaleźć takie zależności.
I tak na przykład blizna po endoprotezoplastyce stawu kolanowego może (oczywiście nie zawsze musi) mieć wpływ na stan kręgosłupa lędźwowego na wysokości około L3-L5, natomiast poprzez unerwienie współczulne, które nie pokrywa się z unerwieniem z dermatomów blizna na kończynie dolnej może mieć wpływ na segmenty Th10-L2(3).
Inną drogą poszukiwania przeniesionych zaburzeń powstałych przez blizny będą taśmy mięśniowo-powięziowe. Czyli blizna po operacji w okolicy stopy, a dokładniej kostki przyśrodkowej może mieć wpływ nawet na funkcjonowanie stawu żuchwowo-skorniowego po tej samej stronie.
Czym jest terapia ITB?
– Integracyjna Terapia Blizn to koncept ukazujący różnorodność zaburzeń, które mogą wywoływać blizny i sposoby na eliminacje tychże zaburzeń. Blizna zyskuje zasłużone znaczenie w procesie całej terapii. Do niedawna jeszcze niezbyt często terapeuta interesował się w wywiadzie i ustalaniu przebiegu terapii bliznami, a bardzo sporadycznie już tymi mającymi po kilka, -naście, – dziesiąt lat. A przecież z każdej rany dochodzącej odpowiednio głęboko powstaje blizna.
Jakie powikłania mogą się wiązać z pojawieniem się blizny?
– W trakcie rozwoju technik terapeutycznych na tkankach miękkich, zwłaszcza na powięziach, zauważono, że blizna może mieć negatywny wpływ nie tylko na miejsce, w którym powstała, ale także na odległe części ciała. I to nie tylko „świeża” blizna może być źródłem problemu, ale też taka, o której już często zapomnieliśmy, że posiadamy. Terapeuci na szczęście coraz częściej stosują co najmniej terapię manualną blizny. Szkolenie ITB daje możliwość poznania większej ilości technik, którymi można blizny „wyregulować”.
ITB pomaga też zrozumieć zależności występujące pomiędzy różnymi układami, tkankami, częściami ciała, które mogą wpływać na pojawianie się dolegliwości niekoniecznie w miejscach gdzie blizny się znajdują. Właśnie z takim podejściem, gdzie blizna zostanie zdiagnozowana nie tylko na poziomie lokalnym, ale też na przykład na poziomie zaburzonych ładunków, wegetatywnym czy psycho-emocjonalnym może być poddana dobrej, integracyjnej terapii pomagającej osiągnąć tak ważny dla pacjenta cel, czyli po prostu redukcję uciążliwych symptomów.
W jakich jeszcze przypadkach warto zastosować Integracyjną Terapię Blizn?
– ITB sprawdza się nie tylko wtedy, kiedy pierwotnym powodem zgłoszenia się do terapeuty są właśnie blizny (powstałe po urazach, po zabiegach operacyjnych, po wykonaniu tatuażu lub piercingu), ale też w przypadkach, kiedy terapia pacjentów, nie tylko z dolegliwościami bólowymi – nie przynosi oczekiwanych efektów przy zastosowaniu metod standardowych.
ITB pomaga także przygotować pacjenta na powstanie blizny w związku z zaplanowanym zabiegiem operacyjnym lub innym powodującym uszkodzenie. Tu skupiamy się przede wszystkim na redukcji faktorów zaburzających proces gojenia ran, ale nie tylko.
W jaki sposób i w jakim jeszcze celu można pracować z blizną?
– Z blizną można pracować na wiele sposobów. Wszystko zależy od tego z jakimi spotykamy się zaburzeniami. Jeżeli mamy zaburzenia odkształcalności wtedy stosujemy różne techniki z zakresu terapii manualnych, czyli odpowiednio dobrane chwyty, przybory (pałeczka diagnostyczna, kinesiotape, medicall flossing, techniki z zakresu pinoterapii oraz inne techniki narzędziowe na tkankach miękkich).
Jeżeli mamy do czynienia z zaburzeniami na poziomie wegetatywnym, wtedy będziemy sprawdzać funkcjonowanie układu autonomicznego ogólne, a przy braku równowagi najpierw to doprowadzać do normy, a później bliznę lokalnie prowadzić terapeutycznie. Zaburzenie wegetatywne blizny polega na zaburzeniu odbierania bodźców z otoczenia i przekształcania na odpowiedź ustroju. Objawem takim może być np. odruch Nogiera, to znaczy odpowiedź autonomicznego układu nerwowego, objawiająca się zmianami rytmu serca.
Możemy mieć do czynienia z nieprawidłową strukturą utworzonej blizny. Jaką terapię wówczas zaleca Pani swoim pacjentom?
Przy bliznach przerostowych będziemy stosować m.in. terapię uciskową lub różne formy terapii indukcji kolagenu (laser frakcyjny, mikronakłuwania,…). Przy bliznach keloidowych (czyli bliznowcach) kierujemy pacjenta do specjalistów zajmujących się prowadzeniem terapii skojarzonych, czyli np. terapii odpowiednio dobranymi lekami, radioterapii, chirurgii, krioterapii, itd.
Blizny mogą być również zaburzone na poziomie ładunków elektrycznych. Co to oznacza?
– Oznacza to, że występuje wówczas zbyt małe lub zbyt duże napięcie w obrębie tkanek. Fleckenstein, fizjolog, najlepiej znany z odkrycia blokerów kanału wapniowego, zmierzył, że w bliźnie może zgromadzić się ładunek równy nawet 1,5 V. Natomiast teoria piezoelektryki potwierdza, że w miejscach, gdzie powięź ulega mocnym odkształceniom mogą również w zbyt dużej liczbie gromadzić się ładunki jednoimienne, co tym samym może doprowadzić do odczuwania dolegliwości.
Z blizną można pracować również pośrednio poprzez wcześniej wspomniane połączone „poziomy”. Czyli jeżeli z daną blizną nie mogę popracować lokalnie wybierając inny poziom mogę na nią wpłynąć pośrednio poprzez łuki odruchowe lub też np. zmniejszenie napięć powięziowych na przebiegu danej taśmy.
Kiedy powinniśmy zgłosić się do specjalisty?
– Tak na prawdę praca z blizną powinna zaczynać się, oczywiście jeżeli tylko to możliwe, jeszcze przed powstaniem uszkodzenia ciała, czyli w przypadku pacjentów z planowanymi zabiegami operacyjnymi. Wtedy pacjent może przygotować się, aby proces rekonwalescencji przebiegał jak najlepiej. Wśród takich przygotowań będzie m.in. zmiana odżywiania, jeżeli nie było ono wcześniej pełnowartościowe, odpowiednie nawodnienie organizmu, umiarkowana aktywność fizyczna, rezygnacja z używek.
Do tego etapu zalicza się zapoznanie z przebiegiem procesu gojenia, aby pacjent miał świadomość co jest normą (zaczerwienienie blizny w początkowym okresie, przykurczanie się rany blizny w pierwszych tygodniach), a z jakim objawem powinien udać się do specjalisty. Kiedy może zacząć znowu obciążać uszkodzone miejsce, a kiedy będzie to za wcześnie i doprowadzi do rany przewlekłej, blizny atroficznej bądź do rozejścia blizny. Równie korzystna będzie nauka stabilizacji i pielęgnacji ran i blizny. Czasami jest wskazane przygotowanie miejsca gdzie będzie operacja chirurgiczna, które z pomocą technik manualnych poprawi trofikę skóry, udrożni limfatycznie, a tym samym również pozytywnie wpłynie na odpowiedź organizmu na uszkodzenie. W praktyce również, dobrze jest porozmawiać z lekarzem prowadzącym o wpływie leków na gojenie ran i dobranie takich specyfików przeciwbólowych, które będą jak najmniej zaburzać fizjologiczny stan zapalny w procesie gojenia.
Jakie znaczenie w tym wypadku będzie miało nastawienie pacjenta do zabiegu, rany i późniejszej blizny?
– Z badań wynika, że przygotowanie mentalne ma duży wpływ na rekonwalescencje pacjenta. Pacjent dobrze poinformowany, któremu przedstawiło się przebieg leczenia, możliwe objawy, a także odpowiedziano na wszelkie dręczące go pytania w empatycznym podejściu w związku z czekającą go operacją lepiej przechodzi proces rekonwalescencji.
Opcji pracy z blizną jest mnóstwo. Do każdego pacjenta należy mimo wszystko podchodzić indywidualnie, aby jak najprostszymi metodami, ale zarazem najbardziej skutecznymi doprowadzić do pełnej integracji blizny z ciałem pacjenta.
Przeczytaj także: Pielęgnacja ran i blizn pooparzeniowych – o czym należy pamiętać?
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