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PHYSICAL THERAPY AND WOUND CARE:
Not An Oxymoron
Disclosures
Key Opinion Leader: Urgo Medical
HISTORY
❖1917: WORLD WAR I
❖BRITISH AND AMERICAN ARMIES
•RECONSTRUCTION AIDES❖PHYSICAL THERAPY ROLES:
• HYDORTHERAPY• ELECTROTHERAPY• MECHANOTHERAPY• ACTIVE EXERCISE• INDOOR AND OUTDOOR GAMES• MASSAGE
PHYSICAL THERAPY PRACTICES
PAST
• HYDROTHERAPY
• ELECTROTHERAPY
• MECHANOTHERAPY
• INDOOR/OUTDOOR GAMES
• MASSAGE
PRESENT• CONSERVATIVE SHARP DEBRIDEMENT
• GAIT/BALANCE
• THERAPEUTIC EXERCISE
• ELECTRICAL STIMULATION
• ULTRASOUND
• DRESSING MANAGEMENT
• ORTHOTIC
• ASSISTIVE DEVICES
• PATIENT EDUCATION
• COMPRESSION WRAPPING
• TOTAL CONTACT CASTING
• ULTRAVIOLET THERAPY
• MONOCHROMATIC INFRARED ENERGY
• SCAR MANAGEMENT/MASSAGE
• MOBILITY: FUNCTIONAL TRAINING
• SEATING POSITIONING
• CONTRACTURES/SENSATION
WHAT ARE WE??Physical Therapists…”are healthcare professionals who
maintain, restore, and improve movement, activity and health, enabling individuals of all ages to have
optimal functioning and quality of life. “
AVILES, Frank Jr.; Examining the Increased Role of the Physical Therapist Within the Wound Care Industry; Today’s Wound Clinic, May 2014, Vol 8 issue 4.
According to the American Physical Therapy Association’s (APTA’s) Guide to Physical Therapist Practice:
…the PT provides “application of therapeutic procedures and modalities that are intended to enhance…
• wound perfusion
• manage scar
• promote an optimal wound environment
• remove excess exudate from a wound complex
• eliminate nonviable tissue from a wound bed…
Procedures and modalities may include: sharp debridement; dressings; orthotic, protective, and supportive devices; physical agents and mechanical and electrotherapeutic modalities; and topical agents.”
BUT THAT IS NOT ALL WE DO!!!
WHAT WE DO…..DO
GAIT
BALANCE
THERAPEUTIC EXERCISE
DRESSING MANAGEMENT
ORTHOTICS
ASSISTIVE DEVICES
SCAR MANAGEMENT/MASSAGE
MOBILITY: FUNCTIONAL TRAINING
PATIENT EDUCATION
CONSERVATIVE SHARP DEBRIDEMENT
SEATING POSITIONING
CONTRACTURE MANAGEMENT
MODALILTIES
COMPRESSION THERAPY
TOTAL CONTACT CASTING
LYMPHEDEMA MANAGEMENT
BESIDES “WOUND CARE”
GAIT
BALANCE
THERAPEUTIC EXERCISE
DRESSING MANAGEMENT
ORTHOTICS
ASSISTIVE DEVICES
SCAR MANAGEMENT/MASSAGE
MOBILITY: FUNCTIONAL TRAINING
PATIENT EDUCATION
CONSERVATIVE SHARP DEBRIDEMENT
SEATING POSITIONING
CONTRACTURE MANAGEMENT
MODALILTIES
COMPRESSION THERAPY
TOTAL CONTACT CASTING
LYMPHEDEMA MANAGEMENT
WHY WOULD A WOUND PATIENT NEED PT?
Functional Limitations:
1. Reduction in strength/ROM
2. Needs an assistive device to be safe
3. Can’t transfer safely
4. Edema
5. Has a TCC
6. Poorly accountable
7. Needs compression hose
8. Needs orthotics
9. Needs pressure relief…………………….ETC
BRIDGE THE GAP!!
Recognize outliers
Embrace the TEAM
Focus on outcomes for the patient
Fine the value in improving mobility/function
ULCER
RE-ULCERATION
DIABETIC FOOT ULCERWOUND CLINIC
PHYSICIAN PROVIDER:
✓ESTABLISH PLAN OF CARE
✓SHARP DEBRIDEMENT
✓TCC APPLICATION
✓TISSUE/ADVANCED TREATMENT
NURSE:
✓IMPLEMENT TREATMENT PER PROVIDER
✓DRESSINGS
✓PATIENT EDUCATION
PHYSICAL THERAPY DEPARTMENT
✓GAIT
✓SAFE FUNCTIONAL MOBILITY
✓ORTHOTIC/CUSTOM SHOE FIT
✓EDEMA MANAGEMENT
✓THERAPEUTIC EXERCISE
✓BALANCE
✓PATIENT EDUCATION
✓ASSISTIVE DEVICES
✓TOTAL CONTACT CASTING
To advance the care of people with and at risk for wounds.
Safe ambulation
Balance
Assistive device management
Shoe gear
Efficient functional movement
VENOUS ULCERWOUND CLINIC
PHYSICIAN PROVIDER:
✓ ESTABLISH PLAN OF CARE
✓DEBRIDEMENT
✓TISSUE/ADVANCED THERAPIES
✓DIAGNOSTICS/INTERVENTIONS
NURSE:
✓IMPLEMENT TREATMENT PER PROVIDER
✓COMPRESSION THERAPY
✓PATIENT EDUCATION
PHYSICAL THERAPY DEPARTMENT
✓THERAPEUTIC EXERCISE
✓GAIT TRAINING
✓COMPRESSION MANAGEMENT
✓FUNCTIONAL ACTIVITY INDEPENDENCE
✓EXTREME ELEVATION
✓HOME EXERCISE PROGRAM
✓ENDURANCE
✓LYMPHEDEMA
ABNORMAL GAIT
➢POOR POSTURE➢SLOWER GAIT
➢SHORTER STEP AND STRIDE LENGTHS➢LONGER STANCE PHASE➢WIDER BASE OF SUPPORT
➢DECREASED MOBILITY AND STRENGTH➢IMPAIRED STATIC AND BALANCE ➢ABNORMAL PLANTAR PRESSURES
Brach JS1, Talkowski JB, Strotmeyer ES, Newman AB. Diabetes mellitus and gait dysfunction: possible explanatory factors. Phys Ther. 2008Nov;88(11):1365-74. doi: 10.2522/ptj.20080016. Pub 2008 Sep 18.
Sawacha Z, Gabriella G, Cristoferi G, Guiotto A, Avogaro A, Cobelli C.Clin Biomech (Bristol, Avon). Diabetic gait and posture abnormalities:biomechanical investigation through three dimensional gait analysis. 2009 Nov;24(9):722-8. doi: 10.1016/j.clinbiomech.2009.07.007.Epub 2009 Aug 21.
EXERCISE, EXERCISE, EXERCISE
“AN UNSUPERVISED RANGE OF MOTION EXERCISE PROGRAM CAN SIGNIFICANTLY REDUCE PEAK PLANTAR PRESSURE IN DIABETIC SUBJECTS WITH IN A RELATIVELY SHORT PERIOD OF TIME.”
Goldsmith,JR; The effects of Range of Motion therapy on the plantar pressure of patient with diabetes mellitus; J Am Podiatr Med Assoc. 2002 Oct;92(9):483-90
BENEFITS OF EXERCISE➢GAIT TRAININGImprove/Modify the Gait Cycle
➢STRENGTHENINGImprove Calf Pump
Improve Hip strength
➢STRETCHING-IMPROVE ANKLE RANGE OF MOTION AND STRENGTH
Sartor CD, et al; effect of a combined strengthening, stretching and functional training program versus usual-care on gait biomechanics and foot function for diabetic neuropathy: a randomized controlled trial,; BMC musculoskeletal disorders, 2012, vol 13 ,page 36
WOUND HEALING BENEFITS OF EXERCISE
➢EXERCISE EFFECTS THE INFLAMMATORY PHASE-inhibits the expression of pro-inflammatory factors and increases the expression of anti-inflammatory factors
➢EXERCISE IMPROVES TISSUE OXYGENATION
Mahoney, E: Incorporating Exercise as an Integral Part of Wound Management; Todays wound Clinic; Volume 8 Issue 5 - June/July 2014
CHALLENGES
✓STAFFING/REFFERING
✓REIMBURSEMENT
✓CLINIC SET UP
✓PHYSICAL THERAPIST INTEREST
“Insanity is doing the same thing over and
over again and expecting different
results.”- Albert Einstein
CURRENT REOCCURRANCE RATES
DFU: From 1-3 years: 40%-65%CVI ulcer: 63-79%
BIBLIOGRAPHY
1. AVILES, Frank Jr.; Examining the Increased Role of the Physical Therapist Within the Wound Care Industry; Today’s Wound Clinic, May 2014, Vol 8 issue 4.
2. Sartor CD, et al; effect of a combined strengthening, stretching and functional training program versus usual-care on gait biomechanics and foot function for diabetic neuropathy: a randomized controlled trial,; BMC musculoskeletal disorders, 2012, vol 13 ,page 36
3. Mahoney, E: Incorporating Exercise as an Integral Part of Wound Management; Todays wound Clinic; Volume 8 Issue 5 - June/July 2014
4. Goldsmith,JR; The effects of Range of Motion therapy on the plantar pressure of patient with diabetes mellitus; J Am Podiatr Med Assoc. 2002 Oct;92(9):483-90
5. Sawacha Z, Gabriella G, Cristoferi G, Guiotto A, Avogaro A, Cobelli C.Clin Biomech (Bristol, Avon). Diabetic gait and posture abnormalities: a biomechanical investigation through three dimensional gait analysis. 2009 Nov;24(9):722-8. doi: 10.1016/j.clinbiomech.2009.07.007. Epub 2009 Aug 21.
6. Brach JS1, Talkowski JB, Strotmeyer ES, Newman AB. Diabetes mellitus and gait dysfunction: possible explanatory factors. Phys Ther. 2008 Nov;88(11):1365-74. doi: 10.2522/ptj.20080016. Epub 2008 Sep 18.
7. Zhou, K., Krug, K., & Brogan, M. S. (2015). Physical Therapy in Wound Care: A Cost-Effectiveness Analysis. Medicine, 94(49), e2202. http://doi.org/10.1097/MD.0000000000002202
8. Hart J; Inflammation. 1: Its role in the healing of acute wounds.J Wound Care. 2002 Jun;11(6):205-9.