INFLAMASI DAN PENYEMBUHAN PADA KULIT AKIBAT LUKA

INFLAMASI
Reaksi jaringan mudah diamati melalui kulit jika terjadi cedera. Inflamasi meskipun nyeri tetapi membantu proses penyembuhan jaringan akibat luka Inflamasi juga mencegah masuknya penyakit pada tubuh. Inflamasi tergantung dari kondisi kesehatan dan sistem kekebalan tubuh (immun system)

KAUSA ATAU PENYEBAB INFLAMASI

Fisik : burns, extreme cold, trauma, gigitan nyamuk) Kimia : racun, senyawa asam, organisme lain Infeksi : bakteri , virus, jamur, parasit Immunologi dan sekitarnya seperti vaskuler maupun hormonal. Jadi penting diketahui bahwa inflamasi tidak selalu infeksi. Kondisi yang mengalami inflamasi disebut dg tambahan itis atau suffic.

CARDINAL SIGNS OF INFLAMMATION

Mesikpun kausa inflamasi berbeda tetapi reaksi tubuh sama, yaitu cardinal signs inflammation, including redness, heat, swelling, pain, and loss of function. Redness, krn dilatasi pembuluh darah. Heat, akumulasi darah . Swelling, cairan keluar dari dinding sel krn meningkatnya permiabilitas membran sel. Pain, substansi cairan dalam sel yg keluar mengandung bahan kimia yg dapat menstimulasi nyeri. Loss of function, akibat pain.

PERAN SEL DARAH PUTIH

Margination or pavementing, segera setelah terjadi kerusakan jaringan sel darah putih ngumpul di dinding pembuluh darah. Emigration, tertarik oleh substansi kimia yang dilepaskan jaringan yg rusak sel darah putih mendekati sel yg rusak. Chemotaxis, gerakan sel darah putih tsb. Phagocytosis, darah putih menghancurkan benda asing atau jaringan yg rusak. Neutrophils dan monocytes, merupakan darah putih yang mampu phagocytosis.

 Benda asing dan jaringan yg telah dipaghocytosis tersebut dibentuk phagosome dan dibawa ke cytoplasma atau cairan sell. Lysosome (enzym pencerna) yang ada di cytoplasma kemudian menghancurkan phagosome tsb.

VASCULAR CHANGES IN ACUT INFLAMATION

CHEMICAL MEDIATORS
Meskipun inflamasi terjadi diawali dengan rusaknya jaringan, tetapi diiringi dengan timbulnya signs and symptom akibat dilepaskannya bahan kimia yang disebut chemical mediators. Diantara chemical mediator tsb termasuk histamines, prostaglandins, leukotrienes, bradykinin, tumor necrosis factor, and complement fractions.

SYMPTOMS ACCOMPANYING INFLAMMATION

Apapun penyebab terjadinya inflamasi akan dibarengi gejala sebagai berikut : Fever, loss of appetite, lethargy, and sleepiness are some symptoms that you may have noticed. These responses are mainly a result of the chemical mediators. An increased number of white blood cells, an increased liver activity, and a decreased iron level in the blood (which results in anemia) are some unseen responses that occur during the inflammatory process. Amino acids, the building blocks of protein, are used up to make new cells and form collagen forrepair. This increase in energy usage, along with loss of appetite, is responsible for weight loss often seen with inflammation

RESOLUTION OF INFLAMMATION
Inflammation can resolve in three ways: (1) it can slowly disappear, with the tissue appearing normal or close to normal (heal); (2) it can progress, with much fluid collecting in the area (exudative inflammation); or, (3) it can become chronic.

EXUDATIVE INFLAMMATION
Fluid collecting outside the cells in the injured area. This fluid is called an exudate. Exudates vary in composition of protein, fluid, and cell content. This blister is filled with a clear exudate,which indicates low protein content. This is known as serous exudate. When this type of inflammation resolves, increased adhesion and scar tissue often occurs in the area. This exudate is known as fibrinous exudate.

 Inflammation may result in a membranous exudate, in which a membrane or sheet is formed on tissue surface. The membrane is a result of dead tissue caught up in the fibrous secretions.

CHRONIC INFLAMMATION
An inflammation is considered chronic when it persists over a long period. In some cases, it may persist for months and years. As a general rule, however, a chronic inflammation is one that lasts for longer than six weeks. Medically, inflammation is considered chronic if the area is infiltrated by many lymphocytes and macrophages, if growth of new capillaries occurs, and if there is an abundance of fibroblasts in the area. Usually inflammation becomes chronic when the initial injury or irritant persists. For example, people working with asbestos can have chronic inflammation in the lungs resulting from inhaled asbestos, a condition called asbestosis. Chronic inflammation may present as fibrosis, ulcer, sinus, or fistula.

FIBROSIS, ULCER, SINUS OR FISTULA

Fibrosis is a reaction caused by fibroblasts that produce collagen and fibrous tissue. Fibrosis results in the formation of scar tissue and adhesions. An ulcer is formed when an organ or tissue surface is lost as a result of the death of cells and is replaced by inflammatory tissue. Usually, ulcers are found in the gut and the skin.

 A sinus is a tract leading from a cavity to the surface. For example, sinuses may be associated with osteomyelitis, in which, as the bone cells die, they form an artificial tract leading from the bone to the surface of the skin through which the dead tissue exudes A fistula is a tract that is open at both ends and through which abnormal communication is established between two surfaces. For example, when cells die while receiving radiotherapy for treatment of cervical cancer, a fistula may develop between the bladder and the vagina

HEALING AND REPAIR

Repair and healing depend on the properties of the cells in the tissue. The cells of the body can be divided into three groups, based on their capacity to regeneratelabile cells, stable cells, and permanent cells. Cells with the capacity to regenerate throughout life quickly multiply and produce new cells to take the place of injured or dead tissue. These are known as labile cells. Examples are epidermal cell geniatourinary tract cells, cells lining the gut (perut), hair follicle cells, and epithelial cells of ducts.

 Another groups of cells, known as stable cells, have a low rate of division, but are able to regenerate if injured. Examples are liver cells, pancreatic cells, fibroblasts, and endothelial cells. Cells of the nervous system, cardiac muscle, and skeletal muscle are referred to as permanent cells. These cells cannot divide, and the injured and dead cells are replaced by fibrous tissue and scar formation.

Keloids and Scars

A keloid, an abnormal nodular mass formed at the site of skin injury, is a result of excessive collagen synthesis. A scar is a mass of collagen that is the end result of repair by fibrosis.

Dermatitis and Cellulitis

Dermatitis is an inflammation of the skin that involves the dermis. There are many forms of dermatitis, such as contact dermatitis and eczema. If the inflammation spreads along the connective tissue of the skin, it is known as cellulitis.

ALBINISM, VITILIGO, FRECKLES

Albinism is caused by a congenital inability to synthesize melanin as a result of genetic defects in the biochemical pathway that manufactures melanin. Vitiligo is a result of melanin loss in patchy areas of the skin. It develops after birth and is progressive. Freckles are small, pigmented spots on the skin, inwhich the melanocytes in the area have produced more than normal levels of melanin pigment

PSORIASIS
This condition, the cause of which is unknown, characteristically presents as scaly (bersisik) patches on the skin. The thickened, scaly patches are a result of the increased rate at which keratinocytes migrate from the stratum germinativum to the surface.

BURNS AND DEHYDRATION

When the epidermis of the skin is damaged by a burn injury, water from the interstitial fluid can be more easily lost by evaporation and dehydration can quickly ensue. The loss of the protective barrier makes the person more vulnerable to invasion by pathogens. Dehydration and infection are the major complications of burn injury.

SHINGLES
Shingles is a viral infection that infects the dorsal root ganglia; it tends to affect one or more dermatomes and produces a painful rash (rasa gatal, exzema, kudis) along its distribution. Massage is contraindicated when rashes are present

SHOCK
Circulatory shock is more pronounced in people with elevated temperature resulting from the dilation of cutaneous blood vessels. People in shock should, therefore, not be warmed to the extent of increasing their body temperature because this can worsen the situation.

KELOID AND SCARS

A keloid, an abnormal nodular mass formed at the site of skin injury, is a result of excessive collagen synthesis. A scar is a mass of collagen that is the end result of repair by fibrosis.

Effects of Aging on the Integumentary System

Semua komponen system integumen akan mengalami penuaan, dan perubahan ini harus menjadi pertimbangan program terapi. Epidermis menjadi lebih tipis akibat penurunan aktivitas stratum germinativum, ini cenderung mudah luka, infeksi dan delay healing. Jumlah sel Langerhan menurun akan meningkatkan resiko infeksi.

 Penurunan produksi vitamin D mengakibatkan penurunan absorbsi calsium dan phosphat dari lambung akibatnya tulang mudah patah. Menurunnya jumlah melanocytes mengakibatkan perubahan warna kulit yang disebut senile lentigo, dan tidak tahan terhadap sinar matahari.

 Lapisan dermis juga menipis, karena jumlah serabut elastin menurun. Ground substance cenderung menjadi dehydrasi. Karena itu kulit orang tua menjadi lemah, cenderung wrinkel atau sag. Ikatan epidermis dan dermis cenderung menurun shg mudah terjadi blester. Aktivitas kelenjar menurun shg dehydrasi, dan jaringan adipose kehilangan lemak, akan menggangu regulasi suhu tubuh.

 Menurunnya pembentukan rambut dan hilangnya melanocytes menyebakan ranbut rontok dan berubah warna menjadi putih. Tetapi bulu di hidung dan telinga pada laki tumbuh lebih banyak. Kuku juga berubah menjadi lebih kaku dan kering

MECHANISME HEALING OF SKIN WOUND

Study of the mechanisms involved in the healing of skin wounds gives insight into healing in general. Figures 2.9 and 2.10 show the mechanism involved in the healing of superficial (healing by first or primary intention) and deep (healing by second intention) skin wounds

FACTORS THAT AFFECT HEALING

Salah satu cara mempercepat penyembuhan adalah dengan membuang material asing dan membersihkan luka. Penyembuhan akan cepat jika luka dijahit sehingga merapatkan kedua batas luka. Tetapi jahitan akan melukai jika tidak diangkat, karena itu harus diangkat beberapa hari setelah operasi, atau dibuat dari bahan mudah terserap jaringan. Untuk mencegah infeksi dignakan cream antibiotic atau cairan antibiotgic untuk membersihkan luka. Jika luka lebar perlu dengan skin graft.

FIG. 2.9 Healing of Skin Wounds by First Intention

FIG.2.10 MECHANISME HEALING OF SKIN WOUND IN SECOND INTENTION

MASSAGE TECHNIQUES AND THE EFFECTS ON THE BODY

The mechanical, reflex, physiologic, psychological, and psychoneuroimmunologic effects of massage are related to the technique used. Mechanical effects are those caused by physically moving the tissues (e.g., compression, stretch, etc.) Reflex effects are changes in function caused by the nervous system.

 Physiologic effects involve changes in body processes caused by nerves, hormones, and chemicals. Psychological effects are emotional or behavioral changes. Psychoneuroimmunologic effects are those that alter hormone levels and function through stimulation of the neurohormonal system.

The techniques used can be categorized as:

Superficial reflex techniques Superficial fluid techniques Neuromuscular techniques Connective tissue techniques Passive movement techniques

SUPERFICIAL REFLEX TECHNIQUES

When superficial reflex techniques are used, the reflexes produce changes . No mechanical effects are produced. Therefore, the direction of the stroke is unimportant. These techniques primarily affect the level of arousal, perception of pain, or autonomic balance and have been shown to have positive effects on the physiologic and psychological development of premature infants. Examples of superficial reflextechniques include static contact, superficial stroking, and fine vibration.

NEUROMUSCULAR TECHNIQUES
Neuromuscular techniques include broad contact compression (compression, pressure, pressing), petrissage (kneading), stripping (stripping massage, deep stroking massage), and specific compression (focal compression, ischemic compression, digital compression, digital pressure, direct pressure, static friction, and deep touch). These techniques affect both superficial and deeper tissues, such as muscle. Broad contact compression has been shown to increase blood and lymph flow.6 It may increase or decrease muscle resting tension and have a stimulating or sedative effect, depending on the rate and pressure of strokes. Hence, it is commonly used in sports massage

CONNECTIVE TISSUE TECHNIQUE

Connective tissue technique uses palpation to help remodel and lengthen connective tissue. Friction (circular friction, transverse friction, deep friction, deep transverse friction, cross-fiber friction, and Cyriax friction), skin rolling (tissue rolling, rolling), myofascial release (myofascial stretching), and direct fascial techniques (connective tissue technique, bindegewebsmassage, myofascial massage, deep tissue massage, deep stroking, strumming, ironing, myofascial manipulation, and soft-tissue mobilization) are some of the methods used. This technique is accompanied by reactive hyperemia and local increase in temperature

PASSIVE MOVEMENT TECHNIQUES

Passive movement techniques use passive motion to treat various conditions. They include shaking (muscle shaking, course vibration, rolling friction, and jostling), rhythmic mobilization, and rocking (pelvic rocking, rocking vibration). These techniques have greater effects on muscles and joints. They produce sedation (possibly by stimulating vestibular reflexes) and decrease anxiety and pain perception

PERCUSSIVE TECHNIQUES
Percussive techniques alternatively deform and release tissue at varying rhythms and pressure. Clapping or cupping, tapping, hacking, pounding, and tapotement are some examples. These strokes result in initial skin blanching as a result of contraction of arterioles from mechanical stimulation. Blanching is followed by redness brought about by vasodilation from overstimulation. The effects of this technique on muscle tone and alertness vary with the rate, vigor, and duration of strokes.

EFFECT OF HEAT ON SKIN

When heat is applied for a short period, it causes peripheral vasodilatation, redness of skin, general and local muscular relaxation, increase in pulse rate and respiratory rate, shallow respiration, decrease in blood pressure, and diminished heat production. It stimulates the circulation, speeds removal of inflammation waste products and, thereby, relieves pain, swelling, and spasm.

HEAT DISTRIBUTION
One thing is certain: when heat is applied to the body it is distributed to adjacent parts according to heat flow and blood flow. The distribution of heat depends on: the size of the heated area the depth of absorption of specific radiation the duration and intensity of heating the method by which it is applied.

METABOLIC RATE
What physiotherapists do is often aimed at speeding up or slowing down the metabolism within a cell or group of cells. Metabolic rate increases by 13% fo every 1 degree Celsius rise in temperature. This means that the cells require more oxygen and nutrients, and accordingly there is an increased production of metabolites or waste products. Generally speaking, irreversible tissue damage occurs at approximately 45C.

Key point
In many situations a warm moist towel giving a wet heat, as opposed to a dry heat, is preferred, giving soothing penetrating warmth which can provide comfort and pain relief. A recent study examined the possible anti-inflammatory mechanism of action of the application of a hot mud pack. The elevation in temperature to about 47C for 20 minutes appeared to inhibit the expression of one of the plasma cytokines, IL-6, which is often associated with inflammation.

EFFECT OF COLD ON SKIN

The rate of skin cooling is faster than the rate of rewarming, implying that a shorter period of cold application suffices to cool the skin. The depth of cold penetration depends on the duration and the area of application. Areas of the body containing more adipose tissue take a longer time to change temperature.

 If deeper structures are to be cooled, the duration of application is increased. When cold, in the form of water, is applied locally, it results in peripheral vasoconstriction and pallor. The vasoconstriction, in turn, results in a decrease in skin temperature and reduction of edema, muscle spasm, and further hemorrhage.

 Analgesic effects begin when skin temperature is lowered to approximately 13.6C (56.5F). Analgesia is produced by the reduction in nerve conduction velocity by cold. Systemic reactions, such as increase in heart rate, respiratory rate, blood pressure, and shivering (gemetar), may be produced. Soon after cold application has ended, peripheral vasodilatation may occur, with redness of skin, feeling of warmth, slowing of pulse and respiratory rates, and relaxation. This reaction may last for 2030 minutes. For therapeutic purposes, both types of reactions may be desirable and cold and hot applications may be alternated.

Reducing the local temperature

Reducing the local temperature has the effect of decreasing blood flow in the area and consequently will reduce the symptoms of inflammation associated with changes in blood flow, such as swelling. In addition, recent electrophysiological studies have demonstrated that reducing the temperature from 31C to 14C inhibited the activity of spinal neurons. This helps to explain both the pain relief and reduction in inflammation caused by strong cooling of the skin. Another consequence of a decrease in temperature is the localised decrease in metabolic demands, a useful effect which limits the hypoxic effects of vasoconstriction and oedema.

WATER AND SKIN

The special properties of water make it a good medium for heat and cold application. The application of water for therapeutic purposes is termed hydrotherapy. Water is referred to as a flexible therapeutic agent because of its unique chemical and physical properties. It can be used as a liquid, solid (ice), or gas (steam). Water transports heat by convection as it easily circulates. Conversely, a lot of heat is liberated when water is cooled

 Water is frequently used as a medium for applying thermal stimuli. Table 2.1 gives an arbitrary classification of temperatures and adjectives used for describing temperature. It should be noted that the results of hydrotherapy vary with age, weight, and general physical condition. Therefore, care must be taken when treating young persons, elderly persons, those in a poor state of nutrition, and those suffering from chronic vascular diseases

Mechanical Manipulation
It has also been recognised for many years that exposure to such forces is essential for tissue homeostasis and, importantly, for the healing of damaged areas. Numerous studies have indicated how the application of mechanical stress is vital to the differentiation of certain cell types involved in the healing process.

 Research is continuing into whether cells respond differently to externally applied as opposed to internally applied forces. Meanwhile (sementara), some form of mechanical manipulation is often used successfully by physiotherapists to advance the healing process. A number of techniques have been developed relevant to the particular organ, structure or tissue to be treated. An example is deep transverse friction (DTF).

ELECTROTHERAPY
The application of electrotherapy for wound healing has been found to increase the rate of healing by more than 50%. However, despite a number of clinical studies demonstrating the beneficial impact of electrotherapy, the optimal delivery techniques have yet to be fully determined.

Ultrasound Therapy
The thermal effects as a result of the production of continuous waves are proportional to the amount of collagen in the tissue, so maximal effects may be seen at the junctions of bone with tendons. Additional effects may be increased blood flow, cell permeability and protein synthesis.

UsCONT
Pulsed US has been shown to act on some cellular reactions involved in each phase of the healing process, such as the inflammatory reaction, angiogenesis, chondrogenesis, intramembranous ossification, endochondral ossification, and bone remodelling. Together, stable cavitation and cellular streaming are thought to provide the means whereby the activity at the cell membrane is altered (Williams 1983). Thermal doses of US are thought to promote softtissue healing by enhancing cell metabolism (Dyson 1995).

US CONT
As well as increasing the amount of collagen secretion, US appears to encourage alignment of collagen into stronger bundles than haphazard strands that can sometimes occur in other words, US can make scar tissue stronger. Da Cunha et al. (2001) showed increased organisation and aggregation of collagen bundles within the Achilles tendon of the rat following application of pulsed US (Figure 19.5). US may also interact with mast cells, platelets and macrophages to accelerate tissue repair.

USCONT
Acoustic streaming causes release of serotonin from platelets. US causes mast cells to release histamine into the sur-rounding tissues (probably by increasing permeability of the mast cell membrane to calcium ions). US also reduces sodium/potassium ATP-ase pump activity which may decrease neural transmission accounting possibly for the analgesic properties of US.

EFFECT US ON SCAR

US..CONT
The most common uses of US are in the management of soft-tissue injuries, rheumatic complaints, and lesions of tendons and ligaments. There is still a need for thorough adequately controlled studies and, indeed, some recent studies have indicated that low-intensity US may facilitate fracture healing, particularly during the late phases.

Drug Therapy
Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs are among the most commonly used medi- cines, being prescribed largely for their anti-inflamma-tory, antipyretic and analgesic properties. The classic example of this type of agent is aspirin (acetylsalicylic acid) which acts to prevent the production of prostaglandins and thromboxanes, which are powerful pro-inflammatory lipid mediators.

DRUG CONT
There are, however, a multitude of other agents which act in the same way: ibuprofen, naproxen, mefenamic acid, flufenamic acid, piroxicam, and others. An unfortunate side-effect of NSAIDs arises from their intrinsic toxicity to the gastrointestinal mucosa. They can cause complications ranging from dyspepsia (chronic indigestion) to life-threatening gastrointestinal ulcers. This limits their use, although some (e.g.ibuprofen) carry considerably less risk of these complications than others (e.g. azapropazone).

DRUG .CONT
Synthetic glucocorticoids are among the most effective anti-inflammatory drugs available; examples include prednisolone, dexamethasone, methylcortisone and methylprednisolone. They are able to affect the immune system in a number of ways which help to contribute to their powerful antiinflammatory action.

DRUG..CONT
In addition to this action, Corticosteroids have a number of other actions which wilL contribute to their anti-inflammatory effectiveness. These actions are not fully clear but may include: reducing the production of adhesion molecules (so preventing cells from leaving the circulation and entering the target area) suppressing activated macrophages stabilising membranes (so decreasing the ability of cells to present antigen) slowing down cell division (so possibly influencing the overall size of the lymphocyte pool) altering the distribution of T lymphocytes (such that the number circulating around the body have been considerably decreased).

DRUGCONT
These actions can prevent the production of antibodies and lymphocyte-mediated destruction of agents recognised as foreign, and consequently prevent an effective mounting of an immune response. Anti-histamines :
as first-generation H1 antagonists and they have the sideeffect of causing decreased alertness, slowed reaction times and sleepiness. Second-genera-tion H2 antagonists such as terfenadine, astemizole and loratadine have the advantage that they are not sedat-ing as they do not cross the blood-brain barrie

DRUG..CONT
Gold Gold-based therapies such as auranofin (oral administration), aurothiomalate and aurothioglucose (both given by intramuscular injection) have been used for many years because of their ability to slow the progression of rheumatoid arthritis, along with reducing the symptoms and possibly also decreasing bone/articular cartilage destruction.

SKIN LESIONS AND BODYWORKERS

All bodyworkers must be able to distinguish different lesions on the surface of the skin and to determine whether it is infectious. Many lesions may appear in-fectious but may not actually be infectious, such as some types of psoriasis, severe acne, or vitiligo. Touch therapy may be of great help to those clients who are often isolated from society because of their appearance. Figure 2.11 indicates the appearance of common skin lesions or skin signs. It is important for all bodyworkers to avoid infected, acutely inflamed, or irritable skin lesions.

PRIMARY LESSION

SECONDARY LESSION

VASCULAR LESSION

BODY WRAPS AND SKIN

Some relaxing or therapeutic treatments use herbs, clay (lempung, tanah liat), mud, or paraffin. They may be used to treat muscle and joint disorders, as well as to beautify and smooth the skin. Sheets, towels, or cheesecloth bags containing herbs are placed in a steaming vat and, once impregnated with the herb, drained and used to wrap the body or body part.

 A warm blanket and a plastic sheet are used to retain heat. In a mud wrap, the body is coated with heated mineralized mud. Muscle relaxation, increased circulation, and lymph drainage are some of the observed effects. Temporary weight loss may be observed as a result of increased loss of water by perspiration. Other beneficial wraps include a mixture of volcanic as hand paraffin and seaweed wraps TERIMA KASIH