Cool Under Pressure

Burn patients are advised to wear pressure garments 23 hours a day, for one to two years, to reduce scars. Now a consortium of organizations has developed a new compression fabric to make these garments more comfortable to wear.

With 60 percent of his body burned at the water park explosion accident in June 2015, Lin You-xuan is now well on his way to recovery. But he still needs to wear compression garments to reduce his scars. Here he is wearing the latest-version compression garment developed by DA.AI Technology and partners.

On the evening of June 27, 2015, throngs of young people flocked to the Formosa Fun Coast water park in Bali, New Taipei City, for a “Color Play Asia” party. Colored corn starch powder was sprayed into the air during the event to add to the excitement, but the good times instantly turned to tragedy when the powder exploded. Fifteen people died, and almost 500 people were burned. Most of the victims were between 18 and 29 years of age.

The number of fatalities was much lower than experts had predicted, thanks to the skill and dedication of countless medical caregivers, but the survivors nevertheless faced a daunting, painful, and long road to recovery.

After the initial period of urgent care—wound cleaning, skin transplantation, and infection control—patients entered a period of rehabilitation for the restoration of function. Pain and itching were their constant companions.

Along with daily massage and physical therapy, they also had their dressings changed every day and they had to wear compression garments to minimize the development of scars. Their most unbearable torture during this time was itchiness. New skin is extremely delicate; it is tender, sensitive, and itchy. The patient cannot scratch the itches since he must not break the skin and run the risk of infections.

Master Cheng Yen met many victims of the water park explosion and their families during her regular tour of Tzu Chi facilities around Taiwan in September 2015. She noticed that the victims, who were trying hard to keep still to show their respect, could not stop scratching or slapping their wounds. They appeared miserable. The Master really felt for them.

Upon her return to Hualien, she asked the DA.AI Technology Company, a social enterprise founded by some entrepreneurs who share Tzu Chi ideals, to look into ways to improve the material used in compression garments so that they would be cooler, more breathable, and more comfortable to wear.

On behalf of their respective organizations, Wu Zhong-yong (second from left), chairman of Gwo Jyh Warp Knitting, Lee Kuei-chi (third from left), president of the Taiwan Textile Research Institute, and Walter Huang (黃華德, fourth from right), chairman of DA.AI Technology, donate 2,000 yards of compression fabric to the Sunshine Social Welfare Foundation. Ma Hai-hsia (fourth from left), chairperson of the Sunshine Foundation, received the fabric on behalf of her foundation.  Courtesy of DA.AI Technology Company


Mission impossible

In October 2015, Li Ding-ming (李鼎銘), the executive director of DA.AI Technology, and a few of his coworkers visited the Master at the Jing Si Abode, the Tzu Chi headquarters in Hualien. They had come with their minds made up to tell the Master that their company could not possibly comply with her request on technical grounds.

They explained to her that most pressure garments are made of nylon, entirely outside of their company’s area of expertise, which is making fibers from recycled PET bottles. They did not have what it took to make, much less improve, compression fabric.

After listening to their explanations, the Master said, “Try to look at this matter from the perspective of the young victims. If they were members of your own family, wouldn’t you do your utmost to try?”

Who could argue with that reasoning? The Master’s compassion moved Li and his team. DA.AI Technology subsequently decided to commit the necessary funds and personnel to the improvement of compression garments.

Lin Zheng-xiong (林正雄), who worked at DA.AI Technology, was assigned to lead the project. He had once worked at Academia Sinica, the foremost academic institution in Taiwan, which supports research activities in a broad variety of disciplines. His expertise was in biomedical sciences. After Lin received the assignment, one of the first things he did was visit the Sunshine Social Welfare Foundation, which has worked with burn patients since the 1980s, to better understand the material used in compression fabric.

First, Lin wanted to solve the heat-trapping problem of the material. He searched for fine, cool yarn to use, and he found it. Since warp-knitted fabric is typically used in making compression garments, he visited the Gwo Jyh Warp Knitting Industry Company in Longtan, northern Taiwan, and talked to its chairman, Wu Zhong-yong
(吳中庸), about the project. Impressed by the Master’s compassion, Wu promised to do all he could to help with the project.

DA.AI Technology and Gwo Jyh thus began their collaboration. Lin and his team at DA.AI researched how compression fabric was to be woven and spelled out the product specifications, which Gwo Jyh followed. They succeeded in producing cloth that was cool and highly breathable.

But then Lin came upon some important information when he was researching pressure garments: This kind of garment must provide compression of 25 mmHg or higher to effectively flatten and improve the appearance of scars.

Lin asked the Sunshine Social Welfare Founda-tion and several Taiwanese manufacturers of compression garments, but he found that none of them possessed an instrument to measure the force of compression for pressure garments. Eventually he found a maker of compression socks that owned the needed instrument. He asked the maker to measure the fabric they had produced and found that it was capable of delivering only 12 mmHg.

Lin bought a compression measuring instrument from Australia and purchased fabrics domestically and from abroad to study. Finally, after testing eight fabrics, he found one that produced the required pressure and had good breathability.

Lin studied this fabric in great detail and went to Gwo Jyh frequently to bounce ideas around. His energy and enthusiasm turned He Jia-mou
(何佳謀), Gwo Jyh’s plant manager, into an active supporter of the project.

Lin realized he had to start with the yarn to boost the therapeutic efficacy of the resulting compression garment. For this, the Formosa Chemicals & Fibre Corporation (FCFC), which had long worked with Gwo Jyh in the textile industry, was enlisted to help. The corporation helped develop a customized cool yarn for the project, which was then woven into fabric by Gwo Jyh.

The fabric the team produced was cool, breathable, and comfortable to wear. Most importantly, it met the 25 mmHg requirement.

Compression garments must provide a pressure of 25 mmHg or higher to effectively reduce scars.


The 25 mmHg challenge

Why is that number so important?

The heart contracts to circulate blood rich with oxygen and nutrients to the body. The blood starts out at a high pressure, but that diminishes as the blood travels farther away from the heart. The pressure drops to about 25 mmHg by the time the blood reaches the terminal capillaries just under the skin—where most burn scars are located.

If no external pressure is applied to restrict the blood flow, then oxygen and other nutrients reach the scar tissues. As a result, the scars grow, become more pinkish, and protrude. The bumpy and unsightly scar tissue often causes victims to withdraw from social interactions.

Compression garments that deliver 25 mmHg of pressure to the skin keep blood from reaching burn scars and thus deprive them of the opportunity to grow. The scar tissues starve, wither, and shrink, which in turn makes the skin smoother.

It took Lin seven months to research all the fabrics, from all that they had purchased to their own design. With each fabric, he made a tight sleeve for his own arm and then measured the force the sleeve exerted on his arm. He came to the conclusion that the tensile force of a fabric had to reach 3.8 pounds to deliver the goal of 25mmHg pressure. He also concluded that the longitudinal and latitudinal tensile force of the fabric had to be vastly different: 4.0 pounds and 0.6 pound respectively. The greater tension was necessary to efficiently suppress scar growth and the lesser tension to allow free bodily movement for the wearer.

Lin also made adjustments to the typical pattern for making a compression garment so that the tension a garment exerts on the skin is tailored to local needs. A physical therapist usually needs to feel the fit of a typical compression garment on the patient, and then he either takes in a quarter of an inch here or loosens a half inch there to reach the desired compression at as many locations as possible. Lin’s compression garment has such adjustments largely built in.

Lin addressed another issue: Whether or not the wearer notices it, garments and skin rub against each other. Such rubbing becomes a problem for the ultra-sensitive skin of burn patients. Lin worked with Gwo Jyh in designing their fabric so that the skin-touching side would create a lot less friction than a traditional fabric and be smoother on the skin.

Before testing their compression fabric with humans on a greater scale, DA.AI Technology recruited five burn patients with the help of the Sunshine Social Welfare Foundation to do preliminary testing. One of the testers was once a competitive swimmer. The right sleeve of his test garment was made with traditional fabric; the left sleeve was constructed of DA.AI fabric. He underwent physical therapy diligently every day. The frequent motions caused the right sleeve to slacken and lose compression so that the team had to take in the sleeve almost every week to keep it taut on his right arm. Eventually, the sleeve lost its elasticity altogether. On the other hand—or shall we say, “on the other arm,” (pun intended)—the left sleeve, made of the new fabric, received high marks from the swimmer for both maneuverability and compression.

Though the new fabric worked very well, some testers complained that its flesh color was downright ugly. That took Lin by surprise. It never occurred to him that this would be an issue. “What color they wear matters to these young people,” Lin said, “For them, even compression garments must have a sense of fashion.”

Listening to this feedback, he and the Gwo Jyh team got busy again. Gwo Jyh carefully chose a non-toxic dye that would not hurt the skin. Then they subjected it to allergy reaction tests. After much work, they were successful in producing the new compression fabric in black.

Measuring the color of a scar provides a scientific way of understanding the efficacy of a compression garment. Courtesy of DA.AI Technology Company

Efficacy by the numbers

The compression fabric developed by DA.AI and its partners began formal testing on June 2, 2016. Twenty-nine burn patients were recruited to participate in the testing. After drawing lots, some testers wore regular compression fabric on their upper body and the DA.AI fabric on their lower body; some wore the opposite; and some wore the new fabric for both upper and lower bodies.

DA.AI Technology purchased a device that could measure changes in the color of the testers’ scars. Tzu Chi volunteers were recruited to help do the measuring. To prepare for this assignment, more than 70 volunteers learned from DA.AI R&D staffers Wang Yan-wen (王妍文) and Huang Yu-jin (黃毓瑾) how to use the instrument. The two staffers also taught the volunteers how to measure the pressure applied by a compression garment. In addition, the volunteers learned about burn scars from Song You-li (宋有礪), deputy director of the Taipei rehabilitation center of the Sunshine Social Welfare Foundation. Then the volunteers gathered at a Tzu Chi office to try on compression garments so that they would know how to better help burn victims put on or take off the garments.

Many of the volunteers were already familiar with burn injuries. Most of them had helped care for victims of the water park explosion. For the garment test, the volunteers measured and recorded garment pressure and scar color twice a week for a month, and then once a week for the remaining five months of the experiment.

Volunteers also took the opportunity to massage the burn scars of the victims to help soften or loosen them. Volunteer Lin Chun-jin (林春金) visited the New Taipei rehabilitation center of the Sunshine Foundation every week to work with the compression garment testers. She said of the young people under her care, “I can’t bear to see them so badly injured, so I do as much as I can to help them.” She knew that the parents of the testers had already worked exceedingly hard to care for their children after they were burned, so she wanted to take some of the load off their shoulders, if only for a little while. She gave shiatsu massages to the victims’ burn scars, focusing on each scar for about three minutes. It took her one to two hours to massage all the scars for just one patient, and the patient often enjoyed it so much that he or she would fall asleep. Some even exclaimed, “This feels really good!”

The relief had come to them free, but at a cost to Lin: Her hands or arms often hurt from overexertion. Like the other volunteers, though, she did not think much of her own pain. “Some of the children came in here on tiptoes because the scars on the backs of their knees were so tight that they couldn’t put their feet flat on the ground,” she said. “But after we massaged them for two hours, they were able to walk out of here normally. That gave us such a great sense of accomplishment that no words could ever adequately describe it.”

Six months of measuring, recording, and caring passed and the test came to an end. The test participants were asked to rate the volunteers who had cared for them, and every one of them gave a perfect score.

The measurement logs that the volunteers had kept were jam-packed with useful numbers, which, after being analyzed, proved that the compression garments used in the test were indeed effective. “The redness of the scars decreased to about 60 percent of what it was at the outset of the test,” said Lin, the project leader.


Lin Zheng-xiong (right) often visited Gwo Jyh Warp Knitting during the compression fabric project. He has become very good partners with two Gwo Jyh employees, He Jia-mou (left) and Jian Jin-cheng (簡進成).

A newer version

Besides the data that was collected, the volunteers also provided Lin lots of information that they had acquired from the test participants while working with them. It included the following: The garment tended to slip downwards during workouts, which made the fabric pile up; the threads in the fabric tended to break after the garment had been altered and sewn multiple times; and extended wearing of compression masks might lead to folliculitis, an infection in the hair follicles.

The feedback led Lin and Gwo Jyh to critically review their fabric, including the flexibility and range of motion it allowed its wearer. They revised the patternmaking and manufacturing process and created a newer, improved version.

Compression garments made of this fabric have received good marks from people who have tried them on. Lin You-xuan (林佑軒) wore the older version for half a year, but now he has moved on to the latest. “The new version has kept the good characteristics of the old one, like good breathability, the cooling effect, and the high compression. But it has improvements too, including being less tight and more durable. It’s really comfortable to wear.”

User feedback like this was music to the ears of the developers. The participants in the project—DA.AI Technology, Gwo Jyh, the Sunshine Foundation, and FCFC—had spent 21 months to get this far and receive such positive feedback.

On June 23, 2017, the project team held a presentation of the product at the Taiwan Textile Research Institute (TTRI). Lee Kuei-chi (李貴琪), president of TTRI, piled accolades on the fabric, whose success he attributed to the close collaboration of the project participants. His talk was followed by a donation: Gwo Jyh, TTRI, and DA.AI jointly gave 2,000 yards of the latest compression fabric to the Sunshine Foundation to be made into a thousand compression garments. The finished garments would be given to 500 burn victims, each receiving two garments so they could have a change of clothes.

Ma Hai-hsia (馬海霞), the chairperson of the Sunshine Foundation, thanked the three parties for their donation and promised to keep improving the foundation’s services so that burn victims could be more comfortable during their rehabilitation.

Shu Ching-hsien (舒靜嫻), Sunshine CEO, observed that the explosion at the Formosa Fun Coast water park, though most unfortunate, had brought out the most beautiful scenes in the world—people working together to relieve the suffering of the victims.

DA.AI Technology obtained two patents in May 2017, one for a compression garment and the other for a highly elastic, breathable, warp-knitted fabric. The patents signify that the DA.AI expertise in this area has won affirmation and surpassed its competition. Lin pointed out that the market for compression garments is very small, limiting the size of the profit. As a result, little effort had been devoted to developing them. He attributed the successful development of their new fabric to the desire on the part of the participating organizations to do something for burn victims. The partners in the project did not do it for profit, so costs were of little concern. The Sunshine Foundation helped recruit burn patients to try on the garments and provide feedback, which led to modifications that resulted in a successful product.

Lin is also proud that the project team has captured the detailed steps of making such a fabric and can tailor the garments in standardized and scientific models that can be applied repeatedly to produce the same satisfactory product. He sincerely hopes that their compression fabric will ease and shorten burn patients’ journey to recovery.

Gwo Jyh keeps an old machine that can make highly elastic compression fabric. Though there is no profit in the project, the company doesn’t mind at all.




January 2018