By DR. NILMA ELIAS SANTIAGO
The growing prevalence and incidence of acute and chronic wounds in the United States is a major concern for the healthcare system. One wound alone can cost the system up to $28 billion. Therefore, patients with wounds must be managed by the best clinicians to achieve the best possible outcomes.
Wound management should involve an interdisciplinary team with each member providing their area of expertise collaboratively to benefit the patient and facilitate positive results. Physicians, nurses, dietitians, pharmacists, the patient as an active member of his/her care, caregivers, occupational therapists, and physical therapists must be part of this team.
Physical therapists are healthcare providers who diagnose and treat individuals with medical conditions that impact their mobility and functional independence. The American Physical Therapy Association indicates that “PTs examine each individual and develop a plan, using treatment techniques, to promote the ability to move, reduce pain, restore function, and prevent disability.”
Most healthcare practitioners know the role of the PT in rehabilitation and pain management. However, the PT’s scope of practice involves other areas, including wound management. Patients with acute and chronic wounds often present with pain, edema, inflammation, among other impairments causing limitations in the ability of the individual to perform daily tasks. Aside from the medical complications an open wound can cause, lack of social participation, inability to work, need for a caregiver and increased burden of care can arise due to this integumentary compromise.
The PT can assess a wound, establish an adequate plan of care, provide interventions to facilitate healing, and manage the functional limitations associated with having the wound. Hence, PTs are an important member of the interdisciplinary team for wound management. Self-care, ambulation, transfers, etc., are just a few of the problems a patient with an open wound may present that a PT can treat. In addition, PTs engage in education, health promotion, and wellness, facilitating primary, secondary and tertiary prevention to decrease the risk for individuals to develop wounds.
Wounds undergo four physiological phases of healing: hemostasis, inflammation, proliferation, and remodeling. Local and systemic factors can affect the normal progression of these stages affecting the closure of a wound. Impaired oxygenation, infection, and venous insufficiency are examples of local factors that affect the characteristics of the wound itself. Smoking, alcohol abuse, diabetes, age, obesity, and stress among others are examples of systemic factors, which involve the overall health of the individual and their ability to heal. PTs provide patient education to manage these systemic factors affecting wound healing. Nevertheless, PTs can also manage local factors with specialized interventions and modalities to facilitate wound healing. These interventions include but are not limited to sharp debridement, pulse lavage, specialty dressings to facilitate moist wound healing, compression therapy, electrical stimulation, low-frequency ultrasound, and low-level laser therapy.
Upon assessment of the wound, the PT can determine which interventions are more appropriate to assist the wound to progress to the next stage, not to mention the comprehensive functional evaluation to assess how the wound affects the patient’s ability to perform his/her activities of daily living and/or instrumental activities. For example, an elderly patient presents with an acute wound from a skin tear. He/she benefits from the expertise of the PT who will not only examine the wound and provide the most appropriate intervention but also determine how to prevent another one by providing education and treatment on how to care for the skin, issue arm/leg sleeves to decrease friction forces that breakdown the skin, and teach proper mobility techniques to prevent falls, skin trauma, etc. Another example would be a patient with a diabetic foot ulcer.
The PT can assess the wound and evaluate the patient’s strength, range of motion, sensation, deep tendon reflexes, balance, gait, assess the shoewear and provide education on off-loading, diabetes, foot care, daily skin inspection, etc. to facilitate wound healing and prevent further skin breakdown. Nonetheless, it is important to remark that should the wound present with characteristics requiring interventions outside of the PT’s scope of practice, the therapist has the competence and obligation to make a referral to the appropriate practitioner. One example would be a wound demonstrating upon assessment 100 percent of eschar or slough that requires surgical debridement, the patient will be referred to a general surgeon.
Physical therapists can provide wound management across different practice settings such as acute/intensive care, outpatient, rehabilitation, home health, skilled nursing, and sports medicine. Since wound management needs may vary among patients and clinical settings, examination, evaluation, interventions, and goals are adjusted to the individual patient needs in each setting.
As mentioned above, physical therapists are important members of the wound management interdisciplinary team because of their expertise in functional mobility and how this is affected by an acute or chronic wound. In addition, PTs can pursue board specialized certifications in wound management demonstrating a high level of training. Consequently, for a patient with a wound to reach his/her functional goals along with wound healing, the physical therapist is, without a doubt, a crucial member in the wound management interdisciplinary team. In the words of Dr. Carrie Sussman, a pioneer physical therapist in the field of wound management and a member of the Academy of Clinical Electrophysiology and Wound Management: “Treat the whole patient, not just the hole in the patient.”
Dr. Nilma Elias Santiago, PT, DPT, WCC, CLT, OMS, is the owner and Physical Therapist at Integumentary Physiotherapy Clinic. She is Board Certified in Wound Care, Ostomy Management and Certified in Lymphedema Management. She can be reached at nilma@integumentarypt.com. Also visit http://www.integumentarypt.com
