The role of physical therapy in wound care has evolved since the inception of the Reconstruction Aide in the 1850s, which occurred primarily in response to the emerging polio epidemic when massage and aquatic type exercises were used, acknowledged Sharon Lucich, PT, CWS, a physical therapist at Indiana University Health in Indianapolis, IN.
"Our involvement in wound care seemed to have begun during World War I, where physiotherapists provided whirlpool and massage therapy to the soldiers who survived their injuries on the field," she explained. "In World War II, the soldiers' injuries were more complex, often including amputations, burns and cold injuries. Besides whirlpool, we began to use other modalities, such as heat, cold and electrical stimulation."
It wasn't until later that the profession began calling themselves physical therapists and focused on the management of many other types of disabling conditions.
"Once again, whirlpool was one of the main interventions used in treating chronic wounds. However, there was a great deal of interest in other modalities and many investigational studies were initiated," noted Lucich. Because of this, today there are many interventions available to the physical therapist in order to improve the wound healing outcomes in the chronic and complex acute wound.
The Physical Therapist's Role
For all patient populations, physical therapists perform an examination, which includes obtaining a history, reviewing the musculoskeletal, neuromuscular, cardiovascular, pulmonary and integumentary systems, and performing tests and measures to determine the overall functional ability of the patient, noted Lucich.
"We then evaluate the data and determine a physical therapy diagnosis, which drives our plan of care. When the patient is being treated for a wound, this same process occurs. Often, it may be noted that the patient has limited mobility, strength or range of motion, all unrelated to the wound," she said. "The physical therapist is able to provide interventions to rehabilitate this dysfunction. Even more specific to the wound patient, however, is when there is a dysfunction that is directly related to the wound."
Physical therapists can make a critical difference in wound healing since scar tissue, tendon or bone may often be involved. Deciding whether to mobilize or immobilize the area can make a profound impact in the patient's functional ability long after the wound has been closed.
Peter Deziel, PT, evaluates and treats wounds based upon their location and any irritation that may result, and helps educate patients on some precautions.
"A therapist's primary role is to make sure the wound is properly treated to prevent contamination, while still allowing the patient to perform essential daily functions," said the vice-president of therapy services for Concentra, covering Arkansas, Alabama, Florida, Georgia, North Carolina, South Carolina and Tennessee.
Deziel works alongside a treating physician to establish a treatment plan, and continued management and healing of wounds. Many of the patients he sees are treated for wound management resulting from burns that occurred either at work or at home.
Many patients with open wounds fail to heal within a predictable time frame, remarked Jennifer Eingle, PT, DPT, CWS, a physical therapist at Indiana University Health.
"These wounds become chronic in nature and demonstrate a prolonged progression through the phases of healing, most often the inflammatory phase. This failure to heal may be multi-factorial in nature, including systemic and local factors, presence of infection, wound characteristics and inappropriate wound management," she said.
Physical therapists can play a crucial role in eliminating barriers to healing or using specific interventions to enhance healing and outcomes, such as:
Debridement-the first step in wound bed preparation, used for the removal of nonviable or devitalized tissue, callouses or foreign objects from the wound bed or periwound. Debridement can either be selective or nonselective. Selective debridement includes the forms of sharp, enzymatic, and autolytic debridement. Nonselective or mechanical debridement is another category of debridement in which force is used to remove devitalized tissue either with dressing choices, whirlpool treatment or scrubbing of the wound.
Whirlpool-one of the oldest forms of wound care, although rarely used today. Whirlpool is indicated for use on infected, heavily-draining wounds, wounds with foreign matter embedded in the base, wounds that require rehydration or have thick necrotic tissue. "Unfortunately, the inappropriate use of whirlpool when not indicated can prolong wound healing or closure," noted Dr. Eingle.
Pulse lavage with concurrent suction-a form of wound irrigation that has become the standard of care for wound irrigation. Using a gun-shaped device, saline flows through, delivering a constant irrigant to the wound bed as a negative pressure removes the irrigant into an external canister. This form of irrigation is simple and effective, promotes circulation and can be done at the bedside.
Contact, high-frequency ultrasound-an intervention that can assist in reducing inflammation, stimulating granulation tissue formation, collagen remodeling and improving tensile strength. Contact ultrasound can be used either to the periwound, with the injured area submerged in water, or directly over the wound with a barrier to improve healing.
Noncontact, low-frequency ultrasound-a more recent modality specific to wound healing. "The probe does not actively touch the wound, so there is very little pain felt by the patient," said Dr. Eingle. "In addition, the medium used is saline which also serves to gently cleanse the wound during treatment." This form of ultrasound is portable, can be used in any setting and does not require dependent positioning.
Contact, low-frequency ultrasound-a modality gaining popularity in wound clinics. Using saline as a medium, the probe comes into contact with the wound bed, and through the use of sharp debridement, removes nonviable tissue.
Negative pressure wound therapy (NPWT)-increases perfusion and blood flow, thereby increasing granulation tissue formation while helping to approximate wound edges. In addition, NPWT helps to reduce wound and periwound edema and offer improved control of heavy exudates while maintaining a warm, moist healing environment with few adverse effects.
Electrical stimulation (E-stim)-enhances wound healing mostly through the use of high-volt pulsed current parameters. Electrical current stimulates cells, improves blood flow, and enhances growth of different cell types important in each phase of healing. In addition, e-stim assists in reduction of bioburden at the wound base.
UVC or ultraviolet light-an adjunct used to manage chronic wounds. "It has been noted that UVC has a bactericidal effect, most notable with patients that present with pseudomonas," stated Dr. Eingle.
Total contact casting (TCC)-considered a gold standard in the treatment of neuropathic ulcers and used frequently by physical therapists. The application of a cast works to disperse weight-bearing forces over a larger area of the foot, reducing contact pressure at the site of the wound to facilitate healing and immobilize the ankle joint to reduce shearing.
"Appropriate dressing selection based on the wound characteristics is probably one of the more important interventions. Dressings, when chosen appropriately, can also assist with moving the wound through different phases of healing and improve the outcomes of the above mentioned modalities," said Dr. Eingle.
The dressing should donate moisture when dry, absorb moisture when wet, treat infection if present, and fit with the patient's lifestyle and needs. "Lastly, as an integral part of the multidisciplinary team, the treating physical therapist will need to work together with other health professionals to achieve the best outcome," concluded Dr. Eingle.
Beth Puliti is a frequent contributor to ADVANCE.
ADVANCE spoke with Paul J. Haydu, MD, CWSP, FACCWS, medical director at the Tri City Medical Center, Centers for Wound Care and Hyperbaric Medicine, Oceanside, CA, about the role hyperbaric oxygen therapy can play in wound care.
ADVANCE: What is hyperbaric oxygen (HBO)
Dr. Haydu: It means to treat someone not only with 100 percent oxygen (which can be done with a face mask), but to immerse them in pure oxygen under pressure. It's like scuba diving to 33 feet.
ADVANCE: How does hyperbaric oxygen
Dr. Haydu: Because oxygen is administered in pure form and under pressure, not only does the patient's red blood cell hemoglobin get fully oxygenated, but their blood serum becomes saturated as well. The result is that oxygen-starved tissues get much more life-giving oxygen, which helps greatly with the healing process. Hyperbaric oxygen also helps destroy bacteria that need to live in low-oxygen environments and enhances the functioning of white blood cells in killing bacteria.
ADVANCE: What types of wounds can HBO treatments help?
Dr. Haydu: Hyperbaric oxygen therapy is very helpful in healing diabetic wounds of the legs and feet. It's also very helpful for patients who have received prior radiation therapy, and have a non-healing wound in the area of prior irradiation. It can also be used for patients with severe peripheral arterial disease, when they've already had angioplasty or bypass and nothing further surgical can be done. After surgery, if a patient has a tissue flap that is in danger, these characteristically improve with HBO treatment.
ADVANCE: What do treatments consist of?
Dr. Haydu: Patients are placed in a clear chamber for two hours per treatment, five days a week. Fifteen minutes brings them "to depth" at 2 atmospheres, the equivalent of diving under 33 feet of seawater. Patients stay at "treatment depth" for 90 minutes and then are decompressed and "brought to the surface" over 15 minutes' time. That's two hours per visit.
ADVANCE: Who is a candidate for hyperbaric oxygen therapy?
Dr. Haydu: Anyone with a non-healing chronic wound due to diabetes, prior radiation treatment or low tissue oxygen due to arterial disease is a candidate. And anyone with damage to internal organs from prior irradiation treatments can be helped with their symptoms. Patients with trouble clearing their ears (as when you fly) will need to receive over-the-counter medicine to help them clear their ears. In rare cases, a visit to an ENT doctor is needed. People who have difficulty with claustrophobia find that once they're showed the cheerful, clear chamber they are fine. In occasional cases, a little anti-anxiety medicine will help for the first few treatments.
Beth Puliti is a frequent contributor to ADVANCE.