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.