TY - JOUR
AU - Edgar, Dale, W
AB - Abstract Compression, a common treatment of choice for the management of edema, is one intervention that is applied with little objective understanding of the optimal parameters of application or efficacy in acute burn wounds. The aim of this study was to determine the effectiveness of different methods of compression for the management of hand edema following burn injury. The primary hypothesis tested was that in acute hand burn injury, the application of cohesive bandage will reduce edema faster than a generic compression glove. It is a randomized controlled study of 100 patients presenting with hand burn injury. Compression was randomized to one of the three methods of application: 1) spiral application of Coban to fingers, figure of eight to hand and wrist; 2) pinch application of Coban to fingers, spiral application to hand and wrist; or 3) a generic compression glove (control condition). Bioimpedance spectroscopy was used to measure hand volumes. Hand and wrist range of movement, pain scores, and QuickDASH were recorded. One hundred patients (68 males) demonstrated significant reductions in hand volumes, using all compression methods. Both methods of applying Coban resulted in significantly greater reductions in edema compared to the generic compression glove. Notwithstanding compression method, all range of movement measures improved, with significant improvement in thumb opposition (P = .046), hand span (P = .020), and wrist flexion (P = .020). QuickDASH decreased between sessions (P < .001). Different methods of applying Coban are superior to generic compression gloves for managing acute hand burn edema. The management of edema following burn injury is integral to the reduction of pain, optimizing function, and minimizing the depth of the burn wound. The three zones of a burn injury are described as 1) the zone of coagulation, the principally damaged tissue due to contact with the burn agent; 2) the surrounding zone of stasis, which may be salvaged but is susceptible to edema; and 3) the outermost zone of hyperemia, which results from increased perfusion to the injury.1–3 Edema is part of the body’s natural response to injury and is especially prevalent following burn injury due to vascular permeability changes, resulting in an expansion of the fluid, primarily in the extracellular space.3–6 This increase in fluid forms a barrier between the burned tissue and the vascular bed, increasing the oxygen diffusion distance and resulting in a reduction of nutrient flow.6,7 Edema management in burns is therefore recognized for its potential to negatively influence the zone of stasis and therefore potentially prevent burn wound conversion.6,8,9 In addition, the decreased oxygen perfusion to the wound associated with edema may result in an increased risk of infection, due to tissue hypoperfusion and poorer oxygenation.6,10–13 In addition to managing edema for prevention of burn wound conversion, poorly managed edema in hand injuries results in poor functional outcomes. Increased volumes of intraarticular fluid within the metacarpophalangeal joint (MCPJ) cause joint extension, which results in flexion of the proximal interphalangeal and distal interphalangeal joints.14 This is exacerbated by the patient naturally adopting this position of comfort,15–17 which, if allowed to persist and contracture occurs, is known as the claw hand deformity.18,19 Compression is a commonly used therapy for more proactive management of edema following burn injury; however, therapists often apply compression with little rationale for their choice of compression or detailed understanding of the method of application.20 The use of compression for managing edema is proposed to restrict the available space for edema to accumulate and to provide a counter-pressure to the muscle pump, which improves circulation efficiency by overcoming the elastic insufficiency of edematous skin and tissues.21 External compression facilitates the flow of edema into the venous and lymphatic systems by the application of a pressure gradient.20–23 External compression has also been shown to increase the efficiency of lymphatic clearance.24 The use of Coban compressive bandage has previously been investigated in a case study of a patient following skin grafting to the dorsum of bilateral hands, which demonstrated reduced volumes with the use of compression.25 In another case report, Coban was shown to reduce observable edema when applied in the postoperative period, 6 days after skin grafting.26 However, there is a paucity of controlled studies for managing local edema following burn injury.27 This study was designed as a randomized controlled trial investigating the use of different methods of compression to manage acute wound edema following burn injury to the hand. The aim of this study was to investigate commonly applied methods of compression for managing acute hand burn edema to determine whether one method was superior to the others. METHODS Participants Participants in this study were recruited from patients presenting to the State Adult Burns Unit at Fiona Stanley Hospital. Patients were approached to participate in this study if they presented with burn injury including a portion of a hand, without restriction to TBSA injured; however, burn injury affecting electrode placements for measurement by bioimpedance spectroscopy (BIS) were excluded. The cohort studied presented with minor burn injury, with only five of the patients requiring surgery. Other exclusion criteria for this study related to BIS manufacturer contraindications included women reporting suspected or confirmed pregnancy or breast-feeding individuals, surgical implants, and stimulators, including cardiac pacemakers. Injuries due to exposure to electrical current were also excluded, due to possible altered tissue current transmission when using BIS. Participants with peripheral vasculopathies and neuropathies and other conditions affecting sensation were also considered contraindications for participation in this study. Intervention The study was conducted as a randomized controlled trial. One hundred patients were recruited to the trial. In order to detect a difference of medium effect size (Cohen’s d = 0.5) with a paired t test, assuming an alpha of 0.05, 30 patients per group were needed with 10% redundancy incorporated for dropouts. Patients were allocated to groups using a random number generator within Microsoft Excel 2010 to receive one of the three methods of applying compression for managing edema. The intervention methods investigated were a control application of a generic compression glove (Norco; North Coast Medical Inc., CA; Figure 1) and two methods of applying a customized elasticized cohesive bandage (Coban) formed into a compressive “glove” to the hand (3M Australia, North Ryde, NSW). A cylindrical application (Figure 2) of Coban used 10 cm Coban applied as a cylinder and pinched along the dorsum of the fingers to achieve a pressure gradient from distal to proximal and then 10 cm Coban was applied in a spiral application with 50% overlap from the hand to the mid-forearm. The spiral application (Figure 3) used 2.5 cm Coban applied to the fingers with 50% overlap, and a figure-of-eight application using 5 cm Coban to the hand and 7.5 cm Coban from the wrist to the forearm. Each application of Coban was applied at an estimated 50% of full stretch.28 Latex-free Coban was used in those patients who reported a known sensitivity to latex. Figure 1. Open in new tabDownload slide Generic compression glove. Figure 1. Open in new tabDownload slide Generic compression glove. Figure 2. Open in new tabDownload slide Cylindrical/pinch application of Coban. Figure 2. Open in new tabDownload slide Cylindrical/pinch application of Coban. Figure 3. Open in new tabDownload slide Spiral application of Coban. Figure 3. Open in new tabDownload slide Spiral application of Coban. The generic compression gloves were sized according to the manufacturer’s instructions. The width of the patient’s hand was measured from the radial border of the second MCPJ to the ulnar border of the fifth MCPJ, along the distal palmar crease, and the corresponding sized glove was fitted following the completion of dressings. Patients were re-measured for compression gloves at subsequent reviews when ongoing edema management was indicated. All patients received a standardized home exercise program of active tendon glide exercises and sustained finger abduction followed by composite finger flexion into a complete fist, which has been demonstrated as resulting in an increased venous outflow compared to fist-clenching alone.29 The home exercise program was modified to include additional exercises based on the location of the burn wounds to facilitate active stretch, including first web space stretching, and active and passive wrist flexion/extension and thumb opposition where appropriate. Patients were encouraged to perform 10 repetitions of range of movement (ROM) exercises hourly when awake, including the use of passive overpressure. Patient education was also standardized to encourage normal use of the affected hand during the performance of activities of daily living. At rest, the patient was encouraged to elevate the affected hand above the level of the heart, including elevating the hand on two pillows when asleep in bed, which was encouraged in this patient cohort based on the decreased hand volumes demonstrated with hand elevation of 30°, while the patient rested supine.30 Patients were educated and made aware of the requirement to report potential alterations to neurovascular symptoms in the fingers and hands (tingling, pins and needles, numbness, and coldness) with the application of compression. The patients were informed to elevate the hand and maintain ROM if these symptoms occurred and to remove the compression if the symptoms did not resolve or worsened. Ethics Ethics approval was granted by the South Metropolitan Health Service Human Research Ethics Committee (HREC) (reference 16-143) and by The University of Notre Dame Australia HREC (reference 016128F). Recruitment commenced in November 2016. The trial was registered with the Australian and New Zealand Clinical Trials Registry, registration number ACTRN12616000810415. Equipment Measurements of BIS were recorded for the affected hand using electrode positions enabling electrode placement on intact skin. The bioimpedance device used to obtain the measures was the Impedimed SFB7 (Impedimed Pty Ltd, Brisbane, QLD), which is a multifrequency bioimpedance analyzer, measuring at 256 discrete frequencies between 4 and 1000 kHz. Bioimpedance spectroscopy is a measure of body composition, which uses the relationship between electrical impedance and water content in the body to provide measures of body composition.31 At a frequency approximating 0 kHz, the current does not penetrate the cell membrane and the current follows the fluid in the extracellular space, providing measures for the resistance of the extracellular fluid, known as R0. The magnitude of R0 is inversely proportional to the volume of the fluid in the extracellular compartment and therefore tissue edema.32 At very high frequencies, the current overcomes the reactance, or capacitance, of the cells, which provides a measure of the impedance of the total body fluid, known as R∞. Direct currents result in significant electrode-skin impedances, and there are practical limitations of using very high-frequency alternating current in the human body.31 As a result, R0 and R∞ are predicted using Cole–Cole plots.33 Following removal of the dressings and washing of the burn wounds using Chlorhexidine Pre-Op wash, the patient rested in supine with the hand resting by their side, abducted approximately 30° from the side of their body. After the hand was dried, intact skin at the location of the electrodes was cleaned with an alcohol swab and allowed to dry. The electrodes used in BIS were Ag/AgCl Eurotrode PFR2034 disposable resting ECG tab electrodes (reference code 12774; Pirrone srl, Milan, Italy). Electrodes placed on the distal phalanx of the middle finger and at the level of the third MCPJ were cut in half lengthways, described by Ward et al,34 and using the alternate electrode positions previously investigated by the authors.35 The distance between the electrode positions was measured using a standard measuring tape. Where the sense electrodes were located on the opposite side of the hand, a linear axial measure was obtained from the proximal edge of the distal sense electrode to the wrist crease in line with the ulnar styloid, at the position of the distal edge of the proximal sense electrode. The use of BIS for measuring hand edema using R0 has been shown to be sensitive, reliable, and valid in patients with hand burn injury.36 BIS measures were completed within 10 minutes of removal of the dressings. Active ROM measures for the hand and wrist were obtained with no compression applied and also with compression in situ at each session. Hand ROM is reduced following burn injury in association with the effects of edema, which alters the biomechanics by stretching the elastic skin on the dorsum of the hand and thereby restricting its normal amplitude of movement.37 Between-session measures of ROM without compression will provide an indication of the association of edema on hand ROM. Measures with compression in situ will determine how restrictive each method is to the movement. Wrist flexion and extension were measured using a BaselineTM 8-inch, 360° transparent plastic goniometer; linear measures for hand composite finger flexion (CFF)—recording the distance from the little finger pulp to the distal palmar crease; and hand span—measuring the distance between the thumb pulp and little finger pulp were obtained using a non-stretch measuring tape.38 Thumb opposition used the Kapandji scale and measured the location touched by the thumb pulp, with 0 indicating no movement, 1 measured to the proximal interphalangeal joint of the index finger, to 10 (ulnar distal palmar crease).39 The shortened version of the Disability of Arm, Shoulder and Hand (QuickDASH) was completed after each session to assess changes in the patient’s self-reported hand function with changes in edema. The QuickDASH has previously been shown to be reliable and valid in patients following upper limb burn injury.40 Statistical Analysis The SFB7 data were downloaded and processed for analysis using the proprietary software (Bioimp version 5.4.0.3; Impedimed Ltd, 2012), thus applying the Cole model to determine BIS variables. All analyses were performed using Stata Statistical Software, release 15 (StataCorp LP, 2017, College Station, TX). Descriptive analyses were completed and presented using means and standard deviations. The SFB7 was configured to record BIS measures in triplicate. All three repeated, within-session measurements were recorded and included in the analysis, using mixed-effects linear regression analyses to assess associations with the BIS variables and compression methods. A series of mixed-effects regression analyses were also performed to determine whether there was a difference in measured ROM outcomes between each session and between each method of compression applied. Hand composite finger flexion is a linear measure with an optimal outcome of zero (0 cm), so this was analyzed using a mixed-effects negative binomial regression. Thumb opposition was analyzed using a mixed-effects tobit regression (censored regression model), to account for the Kapandji measure being bounded at 0 and 10. The results are reported as regression coefficients, with 95% confidence intervals. Contrasts were used to determine the main effects and interactions. A P value of less than .05 was considered statistically significant. BIS variables recorded have previously been shown to be influenced by body mass index, sex, and age. The size and depth of a burn injury are also known to affect edema. Therefore, a stepwise, backward elimination of nonsignificant covariates was completed using a series of mixed-effects regression analyses to assess the effect each of these variables has on the BIS measures. RESULTS Demographics Patient recruitment commenced in November 2016 and was completed in August 2019. One hundred patients (68 males) were recruited. The mean age of these patients was 40.1 ± 13.8 years, and the mean body mass index was 28.4 ± 5.8 kg/m2. Mean TBSA injured was 0.51 ± 0.96%. Table 1 displays these variables for each compression group. Patients were recruited 2.81 ± 1.69 days postinjury (range 0–8 days, median 2 days). Compression was applied for 2.11 ± 0.40 days (range 1–3 days). Three patients had compression applied for 1 day, and 13 patients remained in compression for 3 days. Table 1. Participant summary statistics . Glove . . Cylinder . . Spiral . . P . . Mean (SD) . Median (IQR) . Mean (SD) . Median (IQR) . Mean (SD) . Median (IQR) . . N 34 33 33 Sex Female = 8 Male = 26 Female = 14 Male = 19 Female = 10 Male = 23 NS Age (years) 43.2 (14.2) 41 (23) 37.9 (14.5) 34 (21) 40.3 (13.6) 37 (25) NS BMI (kg/m2) 26.9 (4.84) 27.0 (4.67) 27.7 (5.71) 27.3 (6.52) 29.5 (6.32) 27.9 (5.84) NS Weight (kg) 82.4 (19.5) 83.6 (15.3) 83.4 (19.5) 83.5 (28.2) 90.7 (26.8) 85.7 (18.2) NS Height (cm) 174.5 (10.6) 175 (10) 174.3 (12.0) 175 (15.5) 173.5 (9.69) 172 (12) NS Hand TBSA (%) 0.36 (0.23) 0.3 (0.39) 0.33 (0.25) 0.25 (0.39) 0.37 (0.22) 0.40 (0.30) NS Depth SPT = 25, Mixed = 8, DPT = 1 SPT = 21, Mixed = 8, DPT = 4 SPT = 23, Mixed = 7, DPT = 3 NS . Glove . . Cylinder . . Spiral . . P . . Mean (SD) . Median (IQR) . Mean (SD) . Median (IQR) . Mean (SD) . Median (IQR) . . N 34 33 33 Sex Female = 8 Male = 26 Female = 14 Male = 19 Female = 10 Male = 23 NS Age (years) 43.2 (14.2) 41 (23) 37.9 (14.5) 34 (21) 40.3 (13.6) 37 (25) NS BMI (kg/m2) 26.9 (4.84) 27.0 (4.67) 27.7 (5.71) 27.3 (6.52) 29.5 (6.32) 27.9 (5.84) NS Weight (kg) 82.4 (19.5) 83.6 (15.3) 83.4 (19.5) 83.5 (28.2) 90.7 (26.8) 85.7 (18.2) NS Height (cm) 174.5 (10.6) 175 (10) 174.3 (12.0) 175 (15.5) 173.5 (9.69) 172 (12) NS Hand TBSA (%) 0.36 (0.23) 0.3 (0.39) 0.33 (0.25) 0.25 (0.39) 0.37 (0.22) 0.40 (0.30) NS Depth SPT = 25, Mixed = 8, DPT = 1 SPT = 21, Mixed = 8, DPT = 4 SPT = 23, Mixed = 7, DPT = 3 NS IQR, interquartile range; BMI, body mass index; SPT, superficial partial thickness; DPT, deep partial thickness. Open in new tab Table 1. Participant summary statistics . Glove . . Cylinder . . Spiral . . P . . Mean (SD) . Median (IQR) . Mean (SD) . Median (IQR) . Mean (SD) . Median (IQR) . . N 34 33 33 Sex Female = 8 Male = 26 Female = 14 Male = 19 Female = 10 Male = 23 NS Age (years) 43.2 (14.2) 41 (23) 37.9 (14.5) 34 (21) 40.3 (13.6) 37 (25) NS BMI (kg/m2) 26.9 (4.84) 27.0 (4.67) 27.7 (5.71) 27.3 (6.52) 29.5 (6.32) 27.9 (5.84) NS Weight (kg) 82.4 (19.5) 83.6 (15.3) 83.4 (19.5) 83.5 (28.2) 90.7 (26.8) 85.7 (18.2) NS Height (cm) 174.5 (10.6) 175 (10) 174.3 (12.0) 175 (15.5) 173.5 (9.69) 172 (12) NS Hand TBSA (%) 0.36 (0.23) 0.3 (0.39) 0.33 (0.25) 0.25 (0.39) 0.37 (0.22) 0.40 (0.30) NS Depth SPT = 25, Mixed = 8, DPT = 1 SPT = 21, Mixed = 8, DPT = 4 SPT = 23, Mixed = 7, DPT = 3 NS . Glove . . Cylinder . . Spiral . . P . . Mean (SD) . Median (IQR) . Mean (SD) . Median (IQR) . Mean (SD) . Median (IQR) . . N 34 33 33 Sex Female = 8 Male = 26 Female = 14 Male = 19 Female = 10 Male = 23 NS Age (years) 43.2 (14.2) 41 (23) 37.9 (14.5) 34 (21) 40.3 (13.6) 37 (25) NS BMI (kg/m2) 26.9 (4.84) 27.0 (4.67) 27.7 (5.71) 27.3 (6.52) 29.5 (6.32) 27.9 (5.84) NS Weight (kg) 82.4 (19.5) 83.6 (15.3) 83.4 (19.5) 83.5 (28.2) 90.7 (26.8) 85.7 (18.2) NS Height (cm) 174.5 (10.6) 175 (10) 174.3 (12.0) 175 (15.5) 173.5 (9.69) 172 (12) NS Hand TBSA (%) 0.36 (0.23) 0.3 (0.39) 0.33 (0.25) 0.25 (0.39) 0.37 (0.22) 0.40 (0.30) NS Depth SPT = 25, Mixed = 8, DPT = 1 SPT = 21, Mixed = 8, DPT = 4 SPT = 23, Mixed = 7, DPT = 3 NS IQR, interquartile range; BMI, body mass index; SPT, superficial partial thickness; DPT, deep partial thickness. Open in new tab Four patients did not attend follow-up review—one patient was lost to follow-up, another patient continued treatment at a rural facility, and two others declined additional measurements for the study. In addition, a malfunction anomaly of the BIS device was noted during data download for one additional patient, and this BIS data was unusable, but follow-up ROM measures were included in the analysis for this patient. The data of these five patients were excluded from the analysis. Additionally, four patients removed the compression from fingers due to complaints of numbness, tightness, or restricted movement (three patients from the spiral application group and one patient from the cylindrical/pinch application group). An additional patient (from the cylindrical application group) removed all of the compression, reporting that the dressings were malodorous, which was suspected to be a result of when the dressings and Coban became wet while the patient was cleaning the previous day. There was no clinical sign of infection in this patient. No other complaints or difficulties in wearing each method of compression were reported. The data from these patients who broke protocol by removing compression were included in the analysis. There was a significant difference in the efficiency of edema reduction, as measured by BIS, in favor of both methods of applying Coban compared to the generic compression glove (compression × days postinjury interaction)—Spiral application χ2 (1, N = 720) = 7.31, P = .007; Cylinder application χ2 (1, N = 685) = 6.26, P = .01. There was no evidence of difference in the efficiency of edema reduction between the two methods of Coban application (compression × days postinjury interaction): χ2 (1, N = 733) = 0.00, P = .948. The edema change for each method of compression is displayed in the predicted margins in Figure 4, which accounts for the influence of each significant covariate on the BIS measure R0. Figure 4. Open in new tabDownload slide Predicted margins for the change in edema, measured using bioimpedance spectroscopy (R0), for each compression method. Figure 4. Open in new tabDownload slide Predicted margins for the change in edema, measured using bioimpedance spectroscopy (R0), for each compression method. The measures for active ROM were assessed at each session to determine whether there were changes as edema changed. ROM was assessed both with no dressings and with compression in situ over the wound dressings. Table 2 presents the ROM measures assessed at the follow-up session for patients following the removal of the dressings, to assess the effect of applied compression, change in edema and function achieved with education, and implementation of a home exercise program. There was a nonsignificant improvement in hand composite flexion (P = .467) and wrist extension between sessions (P = .310). These results are representative of a ceiling effect for these ROM measures, as the measures for hand composite flexion and wrist extension were maximized at both time points. All other ROM measures improved significantly. There was a nonsignificant reduction in pain (P = .153), while the QuickDASH improved significantly between sessions (P < .001, CI −15.2 to −8.52). Table 2. Change in outcome measures between sessions for all compression methods (with dressings removed) ROM Measure . Δ Baseline . P . 95% Confidence Interval . . . . . Lower . Upper . Hand CFF (cm) IRR 0.64 .442 0.21 1.99 Thumb opposition (Kapandji scale) 0.36 .046* 0.01 0.72 Hand span (cm) 0.29 .020* 0.05 0.55 Wrist flexion (°) 3.49 .020* 0.56 6.42 Wrist extension (°) 1.98 .247 −1.37 5.32 Pain (VAS) −0.64 .086 −1.37 0.09 QuickDASH −11.9 <.001* −16.5 −7.24 ROM Measure . Δ Baseline . P . 95% Confidence Interval . . . . . Lower . Upper . Hand CFF (cm) IRR 0.64 .442 0.21 1.99 Thumb opposition (Kapandji scale) 0.36 .046* 0.01 0.72 Hand span (cm) 0.29 .020* 0.05 0.55 Wrist flexion (°) 3.49 .020* 0.56 6.42 Wrist extension (°) 1.98 .247 −1.37 5.32 Pain (VAS) −0.64 .086 −1.37 0.09 QuickDASH −11.9 <.001* −16.5 −7.24 Δ = Difference from baseline measures. IRR, incidence rate ratio; ROM, range of movement; VAS, visual analogue scale; CFF, composite finger flexion. *P < .05. Open in new tab Table 2. Change in outcome measures between sessions for all compression methods (with dressings removed) ROM Measure . Δ Baseline . P . 95% Confidence Interval . . . . . Lower . Upper . Hand CFF (cm) IRR 0.64 .442 0.21 1.99 Thumb opposition (Kapandji scale) 0.36 .046* 0.01 0.72 Hand span (cm) 0.29 .020* 0.05 0.55 Wrist flexion (°) 3.49 .020* 0.56 6.42 Wrist extension (°) 1.98 .247 −1.37 5.32 Pain (VAS) −0.64 .086 −1.37 0.09 QuickDASH −11.9 <.001* −16.5 −7.24 ROM Measure . Δ Baseline . P . 95% Confidence Interval . . . . . Lower . Upper . Hand CFF (cm) IRR 0.64 .442 0.21 1.99 Thumb opposition (Kapandji scale) 0.36 .046* 0.01 0.72 Hand span (cm) 0.29 .020* 0.05 0.55 Wrist flexion (°) 3.49 .020* 0.56 6.42 Wrist extension (°) 1.98 .247 −1.37 5.32 Pain (VAS) −0.64 .086 −1.37 0.09 QuickDASH −11.9 <.001* −16.5 −7.24 Δ = Difference from baseline measures. IRR, incidence rate ratio; ROM, range of movement; VAS, visual analogue scale; CFF, composite finger flexion. *P < .05. Open in new tab The outcome measures recorded for each compression method, with the compression removed, are provided in Table 3. These results are compared to the baseline ROM recorded in session one prior to the application of dressings and demonstrate changes due to changes in edema. Hand span, wrist flexion, and QuickDASH improved for all compression methods. Additionally, there was a significant improvement in hand composite flexion and wrist extension for the spiral application of Coban, while thumb opposition improved for the compression glove group. There were nonsignificant decreases in pain scores for each compression method. Table 3. Change in outcomes between sessions (with dressings removed) ROM Measure . Compression Glove . . Cylinder Coban . . Spiral Coban . . . Δ Baseline . 95% CI . Δ Baseline . 95% CI . Δ Baseline . 95% CI . Hand CFF (cm) IRR 0.64 0.18, 2.23 IRR 0.61 0.21, 1.79 IRR 0.23* 0.06, 0.85 Thumb opposition (Kapandji scale) 0.359* 0.02, 0.69 −0.037 −0.33, 0.26 0.291 −0.09, 0.67 Hand span (cm) 0.293* 0.07, 0.52 0.386* 0.10, 0.68 0.403* 0.15, 0.66 Wrist flexion (°) 3.552* 1.43, 5.67 3.017* 0.59, 5.44 4.571* 1.27, 7.87 Wrist extension (°) 1.865 −0.75, 4.48 −0.408 −4.00, 3.19 4.143* 0.51, 7.78 Pain (VAS) −0.610 −1.41, 0.19 −0.200 −1.14, 0.74 −0.439 −1.20, 0.32 QuickDASH −11.87* −15.1, −8.62 −13.03* −16.4, −9.68 −10.44* −14.8, −6.12 ROM Measure . Compression Glove . . Cylinder Coban . . Spiral Coban . . . Δ Baseline . 95% CI . Δ Baseline . 95% CI . Δ Baseline . 95% CI . Hand CFF (cm) IRR 0.64 0.18, 2.23 IRR 0.61 0.21, 1.79 IRR 0.23* 0.06, 0.85 Thumb opposition (Kapandji scale) 0.359* 0.02, 0.69 −0.037 −0.33, 0.26 0.291 −0.09, 0.67 Hand span (cm) 0.293* 0.07, 0.52 0.386* 0.10, 0.68 0.403* 0.15, 0.66 Wrist flexion (°) 3.552* 1.43, 5.67 3.017* 0.59, 5.44 4.571* 1.27, 7.87 Wrist extension (°) 1.865 −0.75, 4.48 −0.408 −4.00, 3.19 4.143* 0.51, 7.78 Pain (VAS) −0.610 −1.41, 0.19 −0.200 −1.14, 0.74 −0.439 −1.20, 0.32 QuickDASH −11.87* −15.1, −8.62 −13.03* −16.4, −9.68 −10.44* −14.8, −6.12 Δ = Difference from baseline measures. IRR, incidence rate ratio; ROM, range of movement; VAS, visual analogue scale; CFF, composite finger flexion. *P < .05. Open in new tab Table 3. Change in outcomes between sessions (with dressings removed) ROM Measure . Compression Glove . . Cylinder Coban . . Spiral Coban . . . Δ Baseline . 95% CI . Δ Baseline . 95% CI . Δ Baseline . 95% CI . Hand CFF (cm) IRR 0.64 0.18, 2.23 IRR 0.61 0.21, 1.79 IRR 0.23* 0.06, 0.85 Thumb opposition (Kapandji scale) 0.359* 0.02, 0.69 −0.037 −0.33, 0.26 0.291 −0.09, 0.67 Hand span (cm) 0.293* 0.07, 0.52 0.386* 0.10, 0.68 0.403* 0.15, 0.66 Wrist flexion (°) 3.552* 1.43, 5.67 3.017* 0.59, 5.44 4.571* 1.27, 7.87 Wrist extension (°) 1.865 −0.75, 4.48 −0.408 −4.00, 3.19 4.143* 0.51, 7.78 Pain (VAS) −0.610 −1.41, 0.19 −0.200 −1.14, 0.74 −0.439 −1.20, 0.32 QuickDASH −11.87* −15.1, −8.62 −13.03* −16.4, −9.68 −10.44* −14.8, −6.12 ROM Measure . Compression Glove . . Cylinder Coban . . Spiral Coban . . . Δ Baseline . 95% CI . Δ Baseline . 95% CI . Δ Baseline . 95% CI . Hand CFF (cm) IRR 0.64 0.18, 2.23 IRR 0.61 0.21, 1.79 IRR 0.23* 0.06, 0.85 Thumb opposition (Kapandji scale) 0.359* 0.02, 0.69 −0.037 −0.33, 0.26 0.291 −0.09, 0.67 Hand span (cm) 0.293* 0.07, 0.52 0.386* 0.10, 0.68 0.403* 0.15, 0.66 Wrist flexion (°) 3.552* 1.43, 5.67 3.017* 0.59, 5.44 4.571* 1.27, 7.87 Wrist extension (°) 1.865 −0.75, 4.48 −0.408 −4.00, 3.19 4.143* 0.51, 7.78 Pain (VAS) −0.610 −1.41, 0.19 −0.200 −1.14, 0.74 −0.439 −1.20, 0.32 QuickDASH −11.87* −15.1, −8.62 −13.03* −16.4, −9.68 −10.44* −14.8, −6.12 Δ = Difference from baseline measures. IRR, incidence rate ratio; ROM, range of movement; VAS, visual analogue scale; CFF, composite finger flexion. *P < .05. Open in new tab Compression potentially restricts ROM, so to determine whether there was a difference between compression methods, active ROM measures were completed with compression in situ. The differences in active ROM between each method of applying Coban compared to the control application of a compression glove are given in Table 4. Both application methods of Coban resulted in a significant reduction in thumb opposition (P < .001) compared to the compression glove. Nonsignificant decreased ROM was noted for all other measures for both methods of applying Coban. There was a nonsignificant increase in hand span with spiral Coban when compared to the compression glove. The reductions in ROM between Coban application methods (when compared to the glove) are not likely to be clinically meaningful due to the short duration that the compression is required to be worn for. Table 4. Outcomes with the application of Coban compared to the control generic compression glove (compression in situ) ROM Measure . Cylinder Coban . . . Spiral Coban . . . . Δ Glove . P . 95% CI . Δ Glove . P . 95% CI . Hand CFF (cm) IRR 1.12 .783 0.49, 2.55 IRR 0.99 .977 0.46, 2.14 Thumb opposition (Kapandji scale) −0.422 .090 −0.91, 0.07 −0.935 <.001* −1.45, −0.42 Hand span (cm) −0.283 .552 −1.22, 0.65 0.410 .410 −0.56, 1.38 Wrist flexion (°) −1.892 .390 −6.21, 2.42 −4.072 .055 −8.23, 0.09 Wrist extension (°) −3.419 .196 −8.61, 1.77 −3.339 .240 −8.91, 2.22 Pain (VAS) 0.271 .518 −0.55, 1.09 −0.327 .466 −1.21, 0.55 ROM Measure . Cylinder Coban . . . Spiral Coban . . . . Δ Glove . P . 95% CI . Δ Glove . P . 95% CI . Hand CFF (cm) IRR 1.12 .783 0.49, 2.55 IRR 0.99 .977 0.46, 2.14 Thumb opposition (Kapandji scale) −0.422 .090 −0.91, 0.07 −0.935 <.001* −1.45, −0.42 Hand span (cm) −0.283 .552 −1.22, 0.65 0.410 .410 −0.56, 1.38 Wrist flexion (°) −1.892 .390 −6.21, 2.42 −4.072 .055 −8.23, 0.09 Wrist extension (°) −3.419 .196 −8.61, 1.77 −3.339 .240 −8.91, 2.22 Pain (VAS) 0.271 .518 −0.55, 1.09 −0.327 .466 −1.21, 0.55 Δ = Difference compared to compression glove. IRR, incidence rate ratio; ROM, range of movement; VAS, visual analogue scale; CFF, composite finger flexion. *P < .05. Open in new tab Table 4. Outcomes with the application of Coban compared to the control generic compression glove (compression in situ) ROM Measure . Cylinder Coban . . . Spiral Coban . . . . Δ Glove . P . 95% CI . Δ Glove . P . 95% CI . Hand CFF (cm) IRR 1.12 .783 0.49, 2.55 IRR 0.99 .977 0.46, 2.14 Thumb opposition (Kapandji scale) −0.422 .090 −0.91, 0.07 −0.935 <.001* −1.45, −0.42 Hand span (cm) −0.283 .552 −1.22, 0.65 0.410 .410 −0.56, 1.38 Wrist flexion (°) −1.892 .390 −6.21, 2.42 −4.072 .055 −8.23, 0.09 Wrist extension (°) −3.419 .196 −8.61, 1.77 −3.339 .240 −8.91, 2.22 Pain (VAS) 0.271 .518 −0.55, 1.09 −0.327 .466 −1.21, 0.55 ROM Measure . Cylinder Coban . . . Spiral Coban . . . . Δ Glove . P . 95% CI . Δ Glove . P . 95% CI . Hand CFF (cm) IRR 1.12 .783 0.49, 2.55 IRR 0.99 .977 0.46, 2.14 Thumb opposition (Kapandji scale) −0.422 .090 −0.91, 0.07 −0.935 <.001* −1.45, −0.42 Hand span (cm) −0.283 .552 −1.22, 0.65 0.410 .410 −0.56, 1.38 Wrist flexion (°) −1.892 .390 −6.21, 2.42 −4.072 .055 −8.23, 0.09 Wrist extension (°) −3.419 .196 −8.61, 1.77 −3.339 .240 −8.91, 2.22 Pain (VAS) 0.271 .518 −0.55, 1.09 −0.327 .466 −1.21, 0.55 Δ = Difference compared to compression glove. IRR, incidence rate ratio; ROM, range of movement; VAS, visual analogue scale; CFF, composite finger flexion. *P < .05. Open in new tab To demonstrate how restrictive to movement each compression method is, the hand and wrist ROM measures with and without compression in situ were compared at both sessions. Spiral application of Coban was more restrictive for hand ROM, with all measures except hand composite finger flexion significantly reduced, while the compression glove was least restrictive (Table 5). Table 5. Reduction in ROM measures with compression in situ, compared to no compression ROM Measure . Compression Glove . . Cylinder Coban . . Spiral Coban . . . Δ No Compression . 95% CI . Δ No Compression . 95% CI . Δ No Compression . 95% CI . Hand CFF (cm) IRR 1.00 0.31, 3.25 IRR 0.94 0.33, 2.72 IRR 0.88 0.29, 2.63 Thumb opposition (Kapandji scale) −0.162 −0.41, 0.09 −0.860* −1.14, −0.58 −1.354* −1.80, −0.91 Hand span (cm) −0.341* −0.57, −0.11 −0.233 −0.51, 0.04 −0.515* −0.74, −0.29 Wrist flexion (°) −1.252 −4.32, −1.81 −3.484* −6.06, −0.91 −2.928* −5.57, −0.29 Wrist extension (°) −3.534* −6.25, −0.82 −4.950* −8.19, −1.71 −4.536* −7.88, −1.19 Pain (VAS) −0.121 −0.85, 0.61 −0.504 −1.30, 0.29 −0.380 −1.04, 0.28 ROM Measure . Compression Glove . . Cylinder Coban . . Spiral Coban . . . Δ No Compression . 95% CI . Δ No Compression . 95% CI . Δ No Compression . 95% CI . Hand CFF (cm) IRR 1.00 0.31, 3.25 IRR 0.94 0.33, 2.72 IRR 0.88 0.29, 2.63 Thumb opposition (Kapandji scale) −0.162 −0.41, 0.09 −0.860* −1.14, −0.58 −1.354* −1.80, −0.91 Hand span (cm) −0.341* −0.57, −0.11 −0.233 −0.51, 0.04 −0.515* −0.74, −0.29 Wrist flexion (°) −1.252 −4.32, −1.81 −3.484* −6.06, −0.91 −2.928* −5.57, −0.29 Wrist extension (°) −3.534* −6.25, −0.82 −4.950* −8.19, −1.71 −4.536* −7.88, −1.19 Pain (VAS) −0.121 −0.85, 0.61 −0.504 −1.30, 0.29 −0.380 −1.04, 0.28 Δ = Difference compared to measures without compression. IRR, incidence rate ratio; ROM, range of movement; VAS, visual analogue scale; CFF, composite finger flexion. *P < .05. Open in new tab Table 5. Reduction in ROM measures with compression in situ, compared to no compression ROM Measure . Compression Glove . . Cylinder Coban . . Spiral Coban . . . Δ No Compression . 95% CI . Δ No Compression . 95% CI . Δ No Compression . 95% CI . Hand CFF (cm) IRR 1.00 0.31, 3.25 IRR 0.94 0.33, 2.72 IRR 0.88 0.29, 2.63 Thumb opposition (Kapandji scale) −0.162 −0.41, 0.09 −0.860* −1.14, −0.58 −1.354* −1.80, −0.91 Hand span (cm) −0.341* −0.57, −0.11 −0.233 −0.51, 0.04 −0.515* −0.74, −0.29 Wrist flexion (°) −1.252 −4.32, −1.81 −3.484* −6.06, −0.91 −2.928* −5.57, −0.29 Wrist extension (°) −3.534* −6.25, −0.82 −4.950* −8.19, −1.71 −4.536* −7.88, −1.19 Pain (VAS) −0.121 −0.85, 0.61 −0.504 −1.30, 0.29 −0.380 −1.04, 0.28 ROM Measure . Compression Glove . . Cylinder Coban . . Spiral Coban . . . Δ No Compression . 95% CI . Δ No Compression . 95% CI . Δ No Compression . 95% CI . Hand CFF (cm) IRR 1.00 0.31, 3.25 IRR 0.94 0.33, 2.72 IRR 0.88 0.29, 2.63 Thumb opposition (Kapandji scale) −0.162 −0.41, 0.09 −0.860* −1.14, −0.58 −1.354* −1.80, −0.91 Hand span (cm) −0.341* −0.57, −0.11 −0.233 −0.51, 0.04 −0.515* −0.74, −0.29 Wrist flexion (°) −1.252 −4.32, −1.81 −3.484* −6.06, −0.91 −2.928* −5.57, −0.29 Wrist extension (°) −3.534* −6.25, −0.82 −4.950* −8.19, −1.71 −4.536* −7.88, −1.19 Pain (VAS) −0.121 −0.85, 0.61 −0.504 −1.30, 0.29 −0.380 −1.04, 0.28 Δ = Difference compared to measures without compression. IRR, incidence rate ratio; ROM, range of movement; VAS, visual analogue scale; CFF, composite finger flexion. *P < .05. Open in new tab DISCUSSION This study is the first randomized controlled trial investigating the most commonly used methods of applying compression for managing acute hand burn edema. The results of this study demonstrate that in minor burn patients, a spiral application of Coban to the fingers and figure-of-eight application to the hand and forearm (Figure 1) and a cylinder application of Coban to the fingers and spiral application to the hand (Figure 2) result in superior edema reduction compared to a generic compression glove. A retrospective cohort study of 42 patients with hand burn injury was performed by Park et al.41 Of the cohort, 22 patients received a modified hand compression bandaging in addition to standard care and conventional physical therapy and were compared to 20 patients receiving standard care and physical therapy only for a 4-week period postburn. The modified hand compression was applied 6 days per week during the 4-week period and was applied using 1-inch bandage gauze, wrapped from the wrist to all five fingers, which was then bandaged over using short stretch bandage. There was a significant reduction in hand circumference, skin thickness measured using ultrasonography, and pain at 4 weeks with the use of the modified compression bandaging.42–45 In a study investigating edema in acute burn injury, intermittent compression was compared to one cohort treated with immobilization in soft compression and elevation and to standard dressing with active exercise and elevation in patients presenting within 24 hours of upper extremity burn injury.46 Immobilization and soft compression significantly reduced wrist circumference only. Elevation and active exercise had no effect on hand circumferences. Intermittent compression resulted in significantly reduced hand, wrist, and finger circumferences and was significantly better than the elevation and active exercise that patients with bilateral injury received on the contralateral limb. Intermittent compression, however, prevents the patient from using the hand normally or performing active ROM, which has been shown to facilitate edema resorption.29 The number of days postinjury in this study was a significant covariate in the analysis, and the compression × days postinjury interaction was significant. This is consistent with the pathophysiology of an acute burn injury, where previous research has demonstrated that edema begins to resolve at 24 hours, with complete resolution within 6 days.47 Of the 100 patients recruited to this study, only 5 required surgery for their injuries. Partial-thickness burn injury has been shown to result in greater increases in edema when compared to deep-partial and full-thickness injuries, due to a combination of greater vascular perfusion in partial-thickness injury, and greater compromise of vascular and lymphatic structures with increased severity of injury reducing edema resorption in deeper injury.4,48 Range of movement measures were shown to improve between sessions and reflect improvements associated with reduction in edema, decreased pain, and as a result of education to continue with active ROM and provision and practice of a home exercise program. Statistically significant improvements in hand composite finger flexion, hand span, and wrist flexion were demonstrated with all compression methods. A minimum detectable difference of more than 1 cm for linear measures of hand composite flexion and hand span was shown to be a real change in these measures,38 which indicates that edema did not affect these hand ROM outcomes in a clinically meaningful way. Similarly, the changes in wrist ROM measures between sessions in this study were less than the minimum detectable difference of at least 9° as reported by Edgar et al.38 The improvements in ROM may also be associated with patient confidence and knowledge of importance of maintaining movement, which was part of the education provided to the patients in the initial treatment session. This supports the practice in the author’s burn unit of combining compression and active movement for the proactive management of edema.21,23 Hand and wrist ROM measures were assessed with compression in situ and repeated when the compression was removed. Significant reductions in ROM for all measures, except hand CFF, were recorded for the spiral application of Coban with compression in situ (Table 5). Differences in finger ROM have been demonstrated using spiral and cylindrical applications of Coban in healthy populations.20 The cylindrical application of Coban was similarly restrictive, except that hand span was not significantly reduced. Hand span and wrist extension were reduced with the glove in situ. These findings are postulated to reflect the impact of the resistance to active movement due to different levels of compression imparted by these methods of compression, with higher levels of compression hypothesized to be more restrictive to movement. This increased compression associated with spiral application of Coban potentially requires that the patient activates the muscles more strongly against the compression to achieve active ROM. As a result, there is a potential secondary benefit, with improved ROM for the spiral Coban group once the dressings are removed (Table 3). Similar reductions in ROM with both cylindrical and spiral applications, when compared to baseline measures for finger and thumb joint measures, were reported in a study in healthy individuals, where spiral Coban applied to the fingers was more restrictive than cylindrical Coban.20 Functional movement and full active ROM were encouraged while wearing the compression to facilitate edema reduction, so while the reduction in ROM is statistically significant, it is not likely to be clinically important given that this compression is temporary during the acute burn period, to facilitate acute edema reduction. Interface pressure measurement between the skin and compression is measured using either pneumatic pressure transducers or resistive piezoelectric sensors.49,50 A limitation of this study is that the level of compression provided by each method investigated was not able to be measured and represents future studies in compression for the management of acute burn edema. Lymphatic clearance has been shown to rapidly increase with an external applied pressure of 30 mmHg to 45 mmHg compared to uncompressed tissues in animal models.24 Application of Coban to the lower leg resulted in mean pressures of 22.8 mmHg in a resting elevated position, which was comparable to other cohesive bandages, as well as noncohesive, nonstretch bandages.28 CONCLUSIONS This study found that there was no evidence of a clinically meaningful advantage between spiral or cylindrical application of a Coban glove to manage acute edema following hand burn injury. In contrast, both methods of applying Coban were superior to a generic compression glove for decreasing hand burn edema. Hand ROM improved between sessions, associated with reduced edema, education, and a home exercise program provided to encourage functional use of the hand. Funding: D.O.E.’s part-time research salary (Chevron Fellowship) is supported by the Fiona Wood Foundation, Western Australia. The products and equipment used in this study are those available in the author’s jurisdiction and are not exclusively endorsed as the only equipment necessary to reproduce this study. Conflicts of interest statement. There are no conflicts of interest to be reported. ACKNOWLEDGEMENTS The PhD research of lead author D.O.E. is supported by the Australian Government Research Training Program Scholarship. The Fiona Wood Foundation and Chevron are also acknowledged for their financial contribution to the research salary of D.O.E. REFERENCES 1. Hettiaratchy S , Dziewulski P. 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TI - Randomized Controlled Trial of Compression Interventions for Managing Hand Burn Edema, as Measured by Bioimpedance Spectroscopy
JF - Journal of Burn Care & Research
DO - 10.1093/jbcr/iraa104
DA - 2020-09-23
UR - https://www.deepdyve.com/lp/oxford-university-press/randomized-controlled-trial-of-compression-interventions-for-managing-eW0N0xqOF2
SP - 992
EP - 999
VL - 41
IS - 5
DP - DeepDyve
ER -