Vita TU, Occupational Therapist and Project Manager
Sunshine Social Welfare Foundation
Pressure therapy can help control scar proliferation and improve scar pliability. However, achieving uniform and effective pressure over shoulder scars often falls short of expectations. When we try to compensate for pressure therapy limitations in the shoulder area without understanding their cause and effect, not only does this fail to address the problem, but this can even lead to undesired side effects. This article aims to shed light on what are the challenges for pressure therapy for shoulder burn scars and what side effects commonly occur.
Reasons why pressure therapy for shoulder burn scars is challenging
Three-dimensional shoulder structure: The shoulder connects the upper limb to the torso and has a complex, three-dimensional structure. Designing a 2D pressure garment pattern to fit this 3D shape requires precise calculations. However, over-reliance on seams to create a 3D effect may concentrate the seams on the shoulder area, reducing comfort.
Complex shoulder contours: The shoulder has multiple curved surfaces, including the acromion, scapula, and underarm. There are also concave areas, such as the supraclavicular region and armpit. Moreover, the cross-section of the entire area where the shoulder is connected to the trunk is an ellipse, with the front and back sides being flat or concave, and the left and right sides protruding. These characteristics make it difficult to distribute pressure evenly. Protruding areas will receive more pressure, while concave areas will receive little to no pressure.
Wide range of shoulder movement: The shoulder can move in multiple directions, including flexion/extension, adduction/abduction, and internal/external rotation. As the foundation for upper limb movements, the shoulder is constantly in motion, making it hard to maintain stable pressure. For example, it’s hard to keep pressure inserts exactly in place because the shoulder is in constant movement
As its name implies, pressure therapy uses the application of pressure to control scar proliferation. When scars aren’t well-controlled, many people will often assume that increasing pressure will improve outcomes. However, higher pressure doesn't guarantee better outcomes, and excessive pressure on the shoulder—a complex, curved, and mobile area—will not only fail to enhance scar control but also lead to side effects.
Common side effects of excessive pressure over the shoulder area and tips to prevent or solve these problems
Below are common side effects of excessive pressure over the shoulder area, as well as simple tips to prevent side effects from happening, or to address these side effects when they have already occurred.
Posture problems: Due to its anatomical structure, the shoulder is an area where pressure therapy is often less effective, in the sense that some areas receive more pressure, and some areas receive less to no pressure. Tightening the pressure garment in the front chest area excessively is not only ineffective to increase pressure for the shoulder area (slightly concave areas like the anterior shoulder still won’t receive enough pressure), but it can also lead to a rounded shoulder posture.
Prevention tip: Verify that pressure garments are designed with proper fit and alignment to avoid forcing the shoulders into a rounded position.
Resolution tip: It’s important to identify the cause of poor posture. Scar contracture on the chest, pain from scars on the chest or an ill-fitting pressure garment shirt can contribute to developing round shoulder posture, so the main contributing factor to this problem needs to be clearly identified.
Restricted range of motion: A pressure garment that is too tight can limit shoulder movement, preventing users from performing daily activities smoothly and impacting functionality. Over time, this may lead to joint stiffness or even contractures. Scar control is important, but it cannot come at the cost of range of motion and should not cause upper extremity functional performance limitation.
Prevention tip: Customizing the garment design with stretchable fabrics in high-mobility areas (ex: axilla) can help reduce movement limitation.
Resolution tip: Check the patient’s shoulder range of motion with and without pressure garments. If the patient performs better without the pressure garment, we can suspect that some of the range of motion restriction comes from the garment itself.
Breathing difficulties: Excessive pressure not only restricts shoulder movement but also limits chest wall expansion during breathing, causing shortness of breath or a sensation of chest tightness.
Prevention tip: During measurement, chest expansion for breathing should be taken into consideration. Also, during the initial fitting of the pressure garment shirt, test the garment for comfort during deep breathing exercises.
Resolution tip: If the patient’s garment restricts breathing, verify the area where tightness causes the most limitation and arrange for the garment to be loosened. If the garment cannot be modified, a new one may be necessary.
Skin injuries: Tight garments are more likely to cause friction injuries, particularly in the front or back of the underarm, where shoulder movements cause the garment to rub against the skin.
Prevention tip: Use soft, seamless fabric or apply soft lining or padding inside the garment in high-friction areas like the underarm. Check for any signs of irritation or breakdown during regular garment adjustments.
Resolution tip: Loosen the garment in the affected area to reduce pressure and friction. Add protection by using soft, seamless fabric or apply padding inside the garment to minimize further irritation. Also, protect the injured skin by covering it with non-woven gauze to prevent infection and promote healing.
Conclusion
The above-mentioned physical side effects of pressure therapy on the shoulder area can lead to significant psychological distress, ultimately affecting patient compliance. Garments that are too tight, restrict breathing or movement, or cause discomfort are less likely to be worn consistently, jeopardizing the therapy's effectiveness. Patients may skip the recommended 23-hour wear schedule or abandon the garment altogether.
Moreover, garments that cause wounds add to patient frustration. These wounds are not only painful but also require time and effort for care, often delaying other essential rehabilitation activities.
While pressure therapy in the shoulder region presents unique challenges, therapists who understand its limitations and common pitfalls are better equipped to prevent side effects and optimize outcomes. Thoughtful garment design, regular monitoring, and a patient-centered approach can make pressure therapy more effective and tolerable for those undergoing treatment.
To learn more about how burns affect the shoulder, and how to manage post-burn shoulder issues, check out our courses Rehabilitation of the Burned Shoulder: Introduction and Basic Concepts and Rehabilitation of the Burned Shoulder: Evaluation and Interventions.
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