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In the multidisciplinary puzzle that astute clinicians know must be pieced together for an effective wound care program, physical therapy plays a unique role, and one that is growing in importance.
To begin with, physical therapists are trained in the care, healing, treatment, and management of soft-tissue injuries, and what is a wound if not a soft-tissue injury, says Bonnie Sparks, PT, president of the Wound Management Special Interest Group of the American Physical Therapy Association in Alexandria, VA. (For details of this group, see story, p. 111.)
Many people are surprised that physical therapists have such a great interest in wound care, adds Carrie Sussman, PT, president of Sussman Physical Therapy in Torrance, CA. "A lot of medical people don’t connect the dots. If you think about it, though, you will realize that there is a connection between the various types of tissue trauma. Any break in the skin can be accompanied by complicating factors that need to be addressed. We’ve been using physical therapy technologies for many years to treat soft-tissue trauma, including open wounds."
During their standard educational curriculum, physical therapists are required to learn about the wound healing process, which necessitates a detailed knowledge of the musculoskeletal system and the skin.
Augmenting this fundamental training in the treatment of soft-tissue injury are a number of modalities not typically relied on by other specialists, such as electrical stimulation and ultrasound. It is perhaps these and other devices that most distinguish a physical therapist’s approach to wound care.
Following is a summary of a few of the modalities commonly used by physical therapists to treat patients, including those with chronic wounds:
• Electrical stimulation.
Delivering a pulsed electric current to the site of soft- and hard-tissue injury has been a mainstay of physical therapists. The electrical current is supplied by coupling an electrode with a wet capacitive coupled contact, Sussman explains.
"We put a moist dressing over the wound, cover it with an electrode made of aluminum, carbon, or another metal, and hook it up to the unit that delivers the current," she says.
Depending on the system in use, the electrical current can be DC, AC, or pulsed direct current. The most widely used now is a high-voltage pulsed DC current, say Sussman and other physical therapists.
During treatment, the patient feels no pain but may experience a slight tingling at the site of the electrode. Patients and family members can be taught to administer electrical stimulation at home. The smallest portable units are about the size of an electronic beeper.
While the Health Care Financing Administration (HCFA) recently discontinued Medicare reimbursement for electrical stimulation (see story, p. 112), Sussman says the modality can have a noticeable effect on healing. "I’ve seen wounds that were necrotic and chronically inflamed convert to acute wound healing. In my experience, the mean healing time for wounds treated with electrical stimulation ranges from eight to 16 weeks," says Sussman.
She likes to apply electrical stimulation on a daily basis. Some therapists prefer twice-a-day applications, but a single daily treatment means fewer disruptions of the wound dressing and is less labor intensive, she says. (For more on theories about electrical stimulation and wound care, see story, p. 113.)
Unlike electrical stimulation, ultrasound should be administered by a health care professional because misuse can cause tissue damage. The therapy is most effective during the inflammatory phase of wound repair, says Sussman. If proponents of the technology are correct, the very high energy frequencies delivered by ultrasound stimulate cellular responses that result in greater oxygen perfusion to tissue.
Sussman notes that ultrasound is used more often for closed wounds than for open wounds and that recent study results are most favorable in closed wounds. She adds, however, that she has used ultrasound to resolve hematomas in open wounds after four or five treatments.
A typical treatment session lasts no more than 10 minutes, regardless of wound size. To transmit the energy to tissue, a conductor, such as gel, lotion, or water must be applied to the wound. For deep wounds, the spaces in the "tunneled" areas act as gaps that impede the transmission of ultrasound, since the energy does not travel through air. One solution is to treat the wound while it is immersed in water, a technique most easily accomplished with foot wounds.
Ultrasound waves cause no sensation, but the pressure of the ultrasound transducer, which must be placed directly against the wound, certainly can cause pain.
"It’s sometimes difficult to persuade patients to go through the initial pain phase," Sussman adds.
• Pulsed radio frequency stimulation.
Delivering radio waves to an ulcer theoretically induces an increase in the electric current flowing through injured tissue and increases blood circulation and cell permeability, explains Sussman. As opposed to electrical stimulation and ultrasound, pulsed radio stimulation can be delivered without the need for direct tissue contact between the device and skin and, therefore, precludes the need to remove dressings.
"For patients who can’t tolerate direct contact because of pain, this would be very effective," says Sussman.
Pulsed radio frequency helps to restart the inflammatory phase of healing, which is beneficial in those wounds in which inflammation has ceased.
An array of devices is certainly not the only claim physical therapists have on wound care. Those who deal with chronic wounds often go to great lengths to learn about the plethora of wound dressings on the market, adds Pamela G. Unger, PT, clinical director and partner at the Center for Advanced Wound care in Wyomissing, PA.
Physical therapists cover all of the basic aspects of wound care, including patient screening for risk of skin breakdown, functional losses from breakdown, wound assessment, positioning and weight-bearing issues, and facilitation of wound repair, Sparks adds. She also notes that in many parts of the United States, physical therapists are the only non-physician professionals who can perform sharp wound debridement without having post-graduate education.
"This is because physical therapists are trained in sharp debridement during their education," she says.
But no one discipline can be totally successful alone, she warns. "If a true team approach is utilized, then the result will be dynamic, and most often the outcome will be positive," Sparks says.
Wound care knowledge is eminently useful in the larger picture for physical therapists because it has a direct impact on more common aspects of their practices. Chronic wounds often limit the ability of therapists to continue with primary rehabilitation programs.
"A lot of therapists in home care, nursing homes, subacute care facilities, and hospitals have become involved in wound care because wounds limit the ability to rehabilitate the patient further," Sparks says. "Sometimes the wound care program becomes the primary focus of the therapy because until it has begun healing, there isn’t a lot of rehab that can be completed with a patient. You might be able to initiate exercise and range of motion, but a lot of times the process is stifled by a chronic wound."