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Sources: With permission from J Cuzell, D Krasner. Wound Dressings. In PP Gogia (ed). Clinical Wound Management. Thorofare, NJ: Slack, 1995;)5 Feedar. Clinical Managemenr of Chronic Wounds. In LC Kloth, KH Miller (eds). Wound Healing: Alrernatives in Managemenr. Philadelphia: FA Davis. 1995; ML Levin, LW O'Neal, JH Bower (cds), The Diabetic Foot (4th ed). St. Louis: Mosby. 1993; JC Lawrence. Dressings and wound infection. Am J Surg 1994; 167( I A):21 j and CT Hess. When to usc hydrocolloid dressings. Adv Skin Wound Care 2000;13:63.

BURNS AND WOUNDS

493

treat the chronic, nonhealing ulcer. Frequently a patient may have

been receiving treatment for a wound before hospitalization for an

acute medical condition and the therapist may be continuing or may

need to recommend alternative healing agents. Platelet-derived

growth {actor promotes cellular migration of leukocytes and macrophages and stimulates fibroblasts to produce collagen. An example of platelet-derived growth factor is Regranex gel (becaplermin).83

Another possible solution is skill substitutes (e.g., Dermagraft),

which consist of fibroblasts from a newborn foreskin donor, placed

on a polygalactic acid mesh. The fibroblasts multiply, attach to the

mesh, and release growth factors,S! Living skin equivalent (e.g.,

graftskin IApligrafJ) consists of bovine type I collagen that is acid dissociated and added to a culture system. Human fibroblasts are then added.B'

These are typically fairly expensive treatments and are reserved for

nonhealing foot ulcers that have not responded to other topical agents

and treatments.

Physical Therapy Intervention in Wound Care

The responsibility and autonomy of the physical therapist in the treatment of wounds vary greatly among facilities. The physical therapist can and should play a key role in the patient'S clinical course of preventing a wound, initiating wound carc, or both. The physical therapist in the acute care setting can also be responsible for making recommendations abour wound care on discharge from the hospital.

Unless the wound is superficial and caused by trauma, wound closure

is not likely to occur during the acute care phase. Therefore, the ultimate long-term goal of complete wound closure, which may occur over many months, occurs at a different level of care, usually outpatient or home care.

The following are the primary goals of phy sical therapy for wound

treatment in the acute care scrring:

•

To promote wound healing through wound assessment, dressing

choice and application, wound cleansing, and debridement

•

To educate patienrs and families about wound care and prevention of furrher breakdown and future wounds

494 AC1JTE CARE HANDBOOK FOR PHYSICAL THERAI)ISTS

Table 7-14. Physical Therapy Considerations for Wound Care

Physical Therapy

lnrervention

Consideration

Pain manage

Coordinate physical therapy session with pain premediment

cation to reduce acute cyclic and noncyclic pain.

Consider the use of positioning, relaxation techniques,

deep breathing, exercise, or modalities to relieve pain.

Modify wound treatmenr techniques as able to eliminate

the source of pain.

Range of morion,

Adequate range of motion is necessary for proper

strength, and

positioning and minimizing the risk of pressure ulcer

functional

formation.

mobility

Care should be taken with manual contacts with fragile

skin, and care should be taken not to disturb dressings

during exercise.

Adequate strength is necessary for weight shifting and

functional mobility with the maintenance of weightbearing precautions.

Edema

Depending on the etiology, exercise, compression

managemenr

therapy, lymphatic drainage. limb elevation (used with

caution in the patient with cardiac dysfunction), or a

combination of these can be used to manage edema.

Prevention

Education (e.g. , dressing application. infection control,

wound inspection, the etiology of wounds)

Positioning (e.g., splines, turning schedule)

Skin care and hygiene (e.g., dressing removal)

Pressure reduction surfaces (e.g., air mattress, wheelchair

cushion)

Footwear adaptations (e.g., orthotics, inserts, extradepth shoes)

•

To maximize patient mobility and function while accommodating needs for wound healing (e.g., maintaining non-weight-bcaring status)

•

To minimize pain

•

To provide recommendations for interdisciplinary acute care

•

To provide recommendations and referrals for follow up care

BURNS AND WOUNDS

495

To fulfill these responsibilities, the therapist must consider all

information gathered during the evaluation process and establish

appropriate goals and time frames. The etiology of the wound, risk

factors, and other data guide the therapist toward the proper intervention. Objective, measurable, and functional goals are as important in wound care as in any other aspect of physical therapy.

Patients with wounds typically have many other medical complications and needs that a physical therapist cannot address alone. To provide optimal care, the physical therapist should function as a part

of an interdisciplinary team that may include a physician, nurse, specialized skin and wound care nurse (referred to as an ellterostomai therapist), dietitian, and others. The physical therapist should be

aware of and make proper recommendations to the appropriate pers onnel for all of the patient's needs for healing.

Specific considerations for physical therapy intervention with a

patient who has a wound include pain management, ROM, strengthening, functional mobility, edema management, and wound prevention. Table 7-14 describes these considerations.

References

1. Williams WG, Phillips LG. Pathophysiology of the Burn Wound. In DN

Herndon (ed), Total Burn Care. London: Saunders, 1996;63.

2. Falke! jE. Anatomy and Physiology of the Skin. [n RI Richard, Mj Staley (eds), Burn Care Rehabilitation Principles and Practice. Philadelphia: FA Davis, 1994; I O.

3. Totora Gj, Grabowski SR (eds). Principles of Anatomy and Physiology

(7th ed). New York: Harper-Collins College, 1989;126.

4. \Varden GD, Heimback DM. Burns. In 51 Schwartz (cd), Principles of

Surgery, Vol. I (7th cd). New York: McGraw-Hili, 1999;223-262.

5. johnson C. Pathologic Manifestations of Burn Injury. In RI Richard, Mj

Staley (eds), Burn Care and Rehabilitation Principles and Practice. Philadelphia: FA Davis, 1994;29.

6. Rai J. Jeschke MG, Barrow RE, Herndon DN. Electrical injuries: a 30-

year review. j Trauma 1999;46(5):933-936.

7. High-Tension Electrical Burns. In RH Oemling, C laLonde (cds), Burn

Trauma. New York: Thieme, J989j223.

8. Winfree J, Barillo OJ. Burn management. Nomhermal injuries. Nurs

Clin North Am [997;32(2):275-296.