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Jak przebiega terapia przykurczy pooparzeniowych? Wywiad z fizjoterapeutką

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„Powodzenie terapii przykurczy pooparzeniowych w dużej mierze zależy od samego pacjenta. Fizjoterapeuta już na samym początku leczenia powinien wyjaśnić pacjentowi, jaki jest podział ról w procesie terapeutycznym, by chory miał poczucie, że uczestniczy w dążeniu do celu” – mówi w rozmowie z Forum Leczenia Ran Katarzyna Młotek, fizjoterapeutka z ponad 18-letnim doświadczeniem, specjalistka terapii blizn.

Karolina Rybkowska, Forum Leczenia Ran: Oparzenia mogą mieć duży wpływ na narząd ruchu i motorykę. Jakie są najczęstsze powikłania oparzeń, którymi zajmuje się fizjoterapeuta?

Katarzyna Młotek: – Następstwa oparzeń, którymi zajmuje się fizjoterapeuta, możemy podzielić na powikłania lokalne i przeniesione.

Do zaburzeń lokalnych należą przykurcze, ograniczenie ruchomości, różnego rodzaju dolegliwości bólowe (zarówno stałe, jak i niespecyficzne, na przykład w związku ze zmianami pogody), przeczulica lub niedoczulica, zaburzenia pigmentacji, obrzęki, swędzenie, zaburzenia elektrodermalne. Powikłania mogą być także związane ze strukturą blizny. Są to np. bliznowce lub przerosty czy uszkodzenia wywołane na poziomie tkanek – neuropatie, niedokrwienie czy martwice.

Powikłania przeniesione mogą z kolei odnosić się do funkcjonowania układu mięśniowo-powięziowego, a także układu wegetatywnego (tutaj głównie w aspekcie regulowania pracy gruczołów w skórze oraz wpływu na napięcie ścian naczyń tętniczych). Na skutek powstawania przykurczy pooparzeniowych może również dojść do ograniczeń ruchomości. Problemy z poruszaniem nie zawsze obejmują jedynie miejsce oparzone, gdzie doszło do powstania przykurczu, ale mogą również dotyczyć innych części ciała. Na poziomie układu nerwowego możemy mówić o zaburzeniach w funkcjonowaniu skóry, tkanki podskórnej, powięzi czy o uszkodzeniach skóry. Ponadto w wyniku oparzeń może się zmniejszać lub zwiększać odpowiedź na różnego rodzaju bodźce zewnętrzne, a także może dochodzić do nieadekwatnego przekazu informacji na drodze nerwowej lub piezoelektrycznej w przypadku powięzi.

Czym są przykurcze po oparzeniach i w jaki sposób powstają? Na jakich obszarach ciała pacjenta najczęściej się pojawiają?

– Przykurczanie tkanki bliznowatej w procesie gojenia się rany pooparzeniowej jest efektem upośledzonego działania miofibroblastów, które mają za zadanie m.in. ściągać ranę w procesie gojenia, zmniejszając jednocześnie jej powierzchnię. Kiedy zakończą swoją aktywność ulegają apoptozie. Natomiast ich nadmiernie wzmożona aktywność doprowadza do zwiększonej produkcji kolagenu i powstania ściągniętej, twardej blizny. Przykurcze pooparzeniowe według badań obserwacyjnych najczęściej rozwijają się w okolicach głowy (nawet do 50 proc. przypadków), szyi, dłoni i pach.

Katarzyna Młotek, fizjoterapeutka

Czym objawiają się przykurcze? Jakie odczucia wywołują u pacjenta?

– Przykurcze strukturalnie objawiają się zgrubieniami tkanki bliznowatej, która usieciowiła się kolagenem w specyficzny sposób, ograniczając ruchomość, odkształcalność samej blizny, a często także okolicznych tkanek.

Obecność przykurczu charakteryzuje się uczuciem ciągnięcia, ograniczenia ruchu, ale też bólem, swędzeniem, pieczeniem, kłuciem. Pacjenci mogą również nie odczuwać niektórych bodźców, jeżeli receptory w skórze i w tkance podskórnej zostały całkowicie uszkodzone na drodze martwicy tkanek. Dolegliwości bólowe i dysfunkcje ruchowe są zależne od rozległości i głębokości uszkodzeń i powstałych przykurczów, a także od etapu procesu gojenia.

Jakie oparzenia najczęściej prowadzą do powstania przykurczy? Czy niektórzy pacjenci mogą być bardziej narażeni na ich powstanie?

– Do powstania przykurczy najczęściej doprowadzają oparzenia stopnia II b bądź wyższego, kiedy doszło do uszkodzenia warstw głębszych skóry właściwej, a powstanie blizny jest niemal pewne. Najczęściej są to blizny przerostowe lub keloidowe.

Dzieci bywają częściej narażone na poważniejsze konsekwencje oparzeń, w tym przykurcze, przede wszystkim ze względu na cieńszą, delikatniejszą skórę. U osób starszych natomiast, zwłaszcza z chorobami przewlekłymi (np. zaburzeniami ukrwienia na drodze miażdżycy), skóra często jest już ścieńczona z powodu zażywania leków, dlatego ci pacjenci również są narażeni na powstawanie przykurczy.

Co mogą zrobić pacjenci, którzy doznali oparzeń, aby zapobiec przykurczom? Czy na etapie hospitalizacji możliwe jest wdrożenie fizjoterapii, aby im zapobiegać?

W pierwszych dobach od oparzenia, jeszcze na etapie hospitalizacji, możliwe, a wręcz wskazane jest wdrożenie fizjoterapii, oczywiście wtedy, kiedy stan pacjenta na to pozwala. Podczas pierwszych etapów gojenia należy wdrożyć terapię ułożeniową, której celem jest zapobieganie przykurczom czy nadmiernym obrzękom, a także prewencję wystąpienia neuropatii z powodu ucisku.

Jeżeli stan pacjenta na to pozwala, przydatne jest również wdrożenie terapii ruchowej, np. kinezyterapii. Polega ona głównie na pracy w miejscu uszkodzenia. W stabilnej sytuacji pacjenta skuteczne są również ćwiczenia innych części ciała, które pośrednio będą wpływać pozytywnie na miejsce oparzenia. Mówimy tutaj m.in. o ćwiczeniach o działaniu kontrlateralnym lub ipsilateralnym, które wykorzystują ruchy kończyną przeciwną lub sąsiednim, wolnym od uszkodzeń stawem gdy np. oparzona kończyna jest unieruchomiona. Ćwiczenia te uruchamiają pośrednio miejsce uszkodzone poprzez aktywacje odpowiednich łańcuchów mięśniowo-powięziowych oraz na drodze odruchowej na poziomie nerwowym (poprzez wspomniany efekt kontraleteralny/ipsilateralny).

Źródło: archiwum zdjęć Katarzyny Młotek.

Jakie jeszcze metody są wykorzystywane w terapii przykurczy u pacjentów po etapie hospitalizacji?

– Fizjoterapia ma szerokie spektrum działania w leczeniu przykurczów. Od wyżej wspomnianych technik ułożeniowych, kinezyterapii w postaci ćwiczeń czynnych, wspomaganych biernych, poprzez metody fizykalne, takie jak jonoforeza, czyli zabieg polegający na wprowadzeniu do tkanek za pomocą siły pola elektrycznego jonów działających leczniczo, laseroterapia, ultradźwięki, do technik manualnych. Formą terapii uciskowej proponowaną przez fizjoterapeutów są również specyficzne aplikacje kinesiotape (które mają obiecujące efekty przy opracowywaniu blizn przerostowych i  zaczerwienionych).

Jakie zagrożenia niesie za sobą niewdrożenie fizjoterapii w przypadku przykurczy pooparzeniowych? Jakie komplikacje mogą się pojawiać?

– Niewdrożenie terapii będzie prowadziło głównie do zaburzeń ruchomości w miejscu obarczonym przykurczami, co będzie się wiązało z dyskomfortem dla pacjenta przy niemal każdym ruchu. Przy przykurczach w strategicznych miejscach może dojść do powstania zaburzeń postawy, co będzie niosło za sobą np. przewlekłe bóle kręgosłupa z powodu utrzymywania wymuszonej przez przykurcze pozycji ułożeniowej. W zależności od miejsca występowania oparzenia, funkcje takie jak chód, chwytność ręki, a nawet zmysły – mogą być zaburzone. U dzieci z kolei brak wdrożenia terapii może skutkować zaburzeniami wzrostu i rozwoju, zwłaszcza u dzieci najmłodszych, które dopiero co uczą się ruchów, funkcji.

Jaka jest rola pacjenta w procesie rehabilitacji? Czy jego nastawienie, konsekwencja w działaniu, sumienność są ważne?

– Jeżeli pacjent jest w stanie świadomie się zaangażować, zawsze powinien wiedzieć, że powodzenie terapii zależy także od niego samego. Najlepiej już na samym początku terapii jasno i konkretnie przedstawić pacjentowi podział ról w procesie terapeutycznym, tak aby miał poczucie, że uczestniczy w dążeniu do celu. Zaniechanie zaleceń, które pacjent otrzymał od lekarza lub fizjoterapeuty, może skutkować brakiem efektów leczenia, a w niektórych przypadkach – nawet pogorszeniem się stanu pacjenta.

Niestety najczęściej to dzieci, a zaraz za nimi osoby starsze, ulegają oparzeniom. Obserwacje mówią nam, że nawet 25 proc. oparzonych to dzieci poniżej 7. roku życia. Terapia oparzeń u dzieci, ze względu na intensywność odczuwania bólu w tej grupie pacjentów, może być w początkowych etapach trudniejsza. Tym bardziej, że u bardzo małych dzieci nie można zastosować wszystkich leków przeciwbólowych, które znajdują zastosowanie u dorosłych i pozwalają na wczesne mobilizacje.

Źródło: archiwum zdjęć Katarzyny Młotek.

Jakie problemy mogą wydarzyć się po stronie pacjenta? Jakie wyzwania stoją przed fizjoterapeutą w odniesieniu do współpracy z pacjentem?

– Przyczyn stojących za spadkiem motywacji pacjenta w terapii fizjoterapeutycznej może być dużo. Dotyczą one m.in. przeciążenia bodźcami, złego odżywiania, zaburzeń w funkcjonowaniu psychiki pacjenta, braku wsparcia ze strony najbliższych, spadku samooceny,  a także kiedy pacjent traci wiarę w możliwości terapii, ponieważ nie widzi efektów terapii gdy zachodzą one powoli.

W wielu tych przypadkach istotna jest współpraca z innymi specjalistami – lekarzem prowadzącym, dietetykiem czy psychologiem.

Z jakimi jeszcze specjalistami współpracują fizjoterapeuci w procesie terapeutycznym? Jak ważne jest zaangażowanie do leczenia interdyscyplinarnego zespołu?

– Interdyscyplinarne podejście w procesie leczenia przykurczów z pewnością wiąże się ze zwiększeniem szans na szybszą rekonwalescencję. Fizjoterapeuci, oprócz wyżej wymienionych specjalistów, przede wszystkim powinni współpracować z lekarzami specjalizującymi się w chirurgii plastycznej, zwłaszcza jeżeli planowana jest rekonstrukcja blizny, np. przeszczep. Przy trudno gojącej się ranie pooparzeniowej istotna jest współpraca z pielęgniarką specjalizującą się w tej dziedzinie. Z kolei przy wygojonych bliznach nieocenioną pomocą służą kosmetolodzy, lekarze medycyny estetycznej, którzy mogą dopasować zabiegi wpływające na polepszenie estetyki blizny. Ważną rolę w procesie leczenia przykurczy pooparzeniowych odgrywają także konsultanci do spraw doboru odzieży uciskowej czy ergoterapeuci.

 

 

 

Katarzyna Młotek, fizjoterapeutka z ponad 18-letnim doświadczeniem, specjalistka terapii blizn

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