REHABILITATING THE
PATIENT WITH WOUNDS:
APPROACHES FOR THE
NON-WOUND CARE PT
STEPHANIE WOELFEL-DYESS
PT, MPT, CWS, FACCWS
GENESIS REHAB SERVICES
OBJECTIVES
• Upon completion of this course, you will be
able to:
• Describe effective therapeutic interventions for
treating wounds of various etiologies.
• Apply compensatory strategies that may be
utilized by patients with wounds involving muscle
and deeper tissues.
• Describe and implement therapeutic
interventions specific to patients with surgical
wounds.
• Implement effective physical therapist
involvement on a facility wound team.
WARNING!!
GUIDE TO PHYSICAL
THERAPIST PRACTICE
• Integumentary Practice Pattern
• 7A: Primary Prevention/Risk Reduction for
Integumentary Disorders
• 7B: Impaired Integumentary Integrity Associated
with Superficial Skin Involvement
• 7C: Impaired Integumentary Integrity Associated
with Partial-Thickness Skin Involvement and Scar
Formation
• 7D: Impaired Integumentary Integrity Associated
with Full-Thickness Skin Involvement and Scar
Formation
• 7E: Impaired Integumentary Integrity Associated
with Skin Involvement Extending into Fascia,
Muscle or Bone and Scar Formation
7A: PRIMARY PREVENTION/RISK
REDUCTION
• Procedural interventions focus on
therapeutic exercise for:
• Aerobic capacity/endurance conditioning or
reconditioning
• Balance, coordination and agility training
• Body mechanics and postural stabilization
• Strength, power and endurance training for head,
neck limb, pelvic-floor, trunk and ventilatory
muscles
7A: PRIMARY PREVENTION/RISK
REDUCTION
• Patient education
re: risk factors and
pathology/
pathophysiology
• Prescription,
application and, as
appropriate,
fabrication of
devices and
equipment
• Adaptive/assistive
devices
• Orthotics/prosthetics
• Supportive
devices/garments
7B: SUPERFICIAL SKIN
INVOLVEMENT
• Procedural interventions focus on
therapeutic exercise for:
• Aerobic capacity/endurance conditioning or
reconditioning
• Body mechanics and postural stabilization
• Flexibility exercises
• Strength, power and endurance training for head,
neck limb, pelvic-floor, trunk and ventilatory
muscles
• Pain management
7B: SUPERFICIAL SKIN INVOLVEMENT
• Procedural interventions focus on manual
therapy techniques for:
• Manual lymphatic drainage
• Therapeutic massage
• Prescription, application and, as
appropriate, fabrication of devices and
equipment
• Adaptive/assistive devices (including beds)
• Orthotics/prosthetics
• Supportive devices/garments
7B: SUPERFICIAL SKIN INVOLVEMENT
• Procedural
interventions focus
on integumentary
repair and
protection
techniques
regarding:
• Dressings
• Topical agents
• Procedural
interventions focus
on mechanical
techniques:
• Compression therapy
7B: SUPERFICIAL SKIN INVOLVEMENT
• Procedural interventions focus on
biophysical technologies:
• Electrotherapy -• Electrical muscle stimulation
• High volt pulsed current (HVPC)
• Transcutaneous electrical nerve stimulation (TENS)
• Hydrotherapy
• Light agents – Ultraviolet
• Sound agents
• Phonophoresis
• Ultrasound
7C: PARTIAL-THICKNESS SKIN
INVOLVEMENT & SCAR FORMATION
• Procedural interventions focus on
therapeutic exercise for:
Balance, coordination and agility training
Body mechanics and postural stabilization
Flexibility exercises
Gait and locomotion training
Strength, power and endurance training for head,
neck limb, pelvic-floor, trunk and ventilatory
muscles
• Pain management
•
•
•
•
•
7C: PARTIAL-THICKNESS SKIN
INVOLVEMENT & SCAR FORMATION
• Procedural interventions focus on manual
therapy techniques for:
• Manual lymphatic drainage
• Therapeutic massage
• Prescription, application and, as
appropriate, fabrication of devices and
equipment
• Adaptive/assistive devices (including beds)
• Orthotics/prosthetics
• Supportive devices/garments
7C: PARTIAL-THICKNESS SKIN
INVOLVEMENT & SCAR FORMATION
• Procedural
interventions focus on
integumentary repair
and protection
techniques
regarding:
• Debridement –
selective & nonselective
• Dressings
• Oxygen therapy
• Topical agents
• Procedural
interventions focus on
mechanical
techniques:
• Compression therapy
• Including
vasopneumatic devices
• Taping
• Total contact casting
7C: PARTIAL-THICKNESS SKIN
INVOLVEMENT & SCAR FORMATION
• Procedural interventions focus on
biophysical technologies:
• Electrotherapy -• Electrical muscle stimulation
• High volt pulsed current (HVPC)
• Transcutaneous electrical nerve stimulation (TENS)
•
•
•
•
Hydrotherapy – including PLWS
Light agents – Ultraviolet, laser
Sound agents – Phonophoresis, ultrasound
Thermotherapy
7D: FULL -THICKNESS SKIN
INVOLVEMENT & SCAR FORMATION
• Procedural interventions focus on
therapeutic exercise for:
Balance, coordination and agility training
Body mechanics and postural stabilization
Flexibility exercises
Gait and locomotion training
Strength, power and endurance training for head,
neck limb, pelvic-floor, trunk and ventilatory
muscles
• Pain management
•
•
•
•
•
7D: FULL -THICKNESS SKIN
INVOLVEMENT & SCAR FORMATION
• Procedural interventions focus on manual
therapy techniques for:
•
•
•
•
Manual lymphatic drainage
Therapeutic massage
Connective tissue massage
Soft tissue mobilization/manipulation
• Prescription, application and, as
appropriate, fabrication of devices and
equipment
• Adaptive/assistive devices (including beds &
environmental controls)
• Orthotics/prosthetics
• Supportive devices/garments
7D: FULL -THICKNESS SKIN
INVOLVEMENT & SCAR FORMATION
• Procedural
interventions focus on
integumentary repair
and protection
techniques regarding:
• Debridement – selective
& non-selective
• Dressings (including
NPWT)
• Oxygen therapy
• Topical agents
• Procedural
interventions focus on
mechanical
techniques:
• Compression therapy
• Including vasopneumatic
devices
• Taping
• Total contact casting
• Gravity-assisted
compression via tilt table
• CPM’s
7D: FULL -THICKNESS SKIN
INVOLVEMENT & SCAR FORMATION
• Procedural interventions focus on
biophysical technologies:
• Electrotherapy -• Electrical muscle stimulation
• High volt pulsed current (HVPC)
• Transcutaneous electrical nerve stimulation (TENS)
•
•
•
•
Hydrotherapy – including PLWS
Light agents – Ultraviolet, laser
Sound agents – Phonophoresis, ultrasound
Thermotherapy
7E: SKIN INVOLVEMENT INTO FASCIA,
MUSCLE, OR BONE & SCAR FORMATION
• Procedural interventions focus on
therapeutic exercise for:
Balance, coordination and agility training
Body mechanics and postural stabilization
Flexibility exercises
Gait and locomotion training
Strength, power and endurance training for head,
neck limb, pelvic-floor, trunk and ventilatory
muscles
• Pain management
•
•
•
•
•
7E: SKIN INVOLVEMENT INTO FASCIA,
MUSCLE, OR BONE & SCAR FORMATION
• Procedural interventions focus on manual
therapy techniques for:
•
•
•
•
Manual lymphatic drainage
Therapeutic massage
Connective tissue massage
Soft tissue mobilization/manipulation
• Prescription, application and, as
appropriate, fabrication of devices and
equipment
• Adaptive/assistive devices (including beds &
environmental controls)
• Orthotics/prosthetics
• Supportive devices/garments
7E: SKIN INVOLVEMENT INTO FASCIA,
MUSCLE, OR BONE & SCAR FORMATION
• Procedural
interventions focus on
integumentary repair
and protection
techniques regarding:
• Debridement – selective
& non-selective
• Dressings (including
NPWT)
• Oxygen therapy
• Topical agents
• Procedural
interventions focus on
mechanical
techniques:
• Compression therapy
• Including vasopneumatic
devices
• Taping
• Total contact casting
• Gravity-assisted
compression via tilt table
• CPM’s
7E: SKIN INVOLVEMENT INTO FASCIA,
MUSCLE, OR BONE & SCAR FORMATION
• Procedural interventions focus on
biophysical technologies:
• Electrotherapy -• Electrical muscle stimulation
• High volt pulsed current (HVPC)
• Transcutaneous electrical nerve stimulation (TENS)
•
•
•
•
Hydrotherapy – including PLWS
Light agents – Ultraviolet, laser
Sound agents – Phonophoresis, ultrasound
Thermotherapy
INTEGUMENTARY PRACTICE
PATTERN IN PRACTICE
• Integumentary
Practice Pattern
focuses on level of
tissue involvement
and is therefore
applicable across
wound etiologies
• Combining practice
pattern guidance
with information on
wound etiology
allows for patientspecific
interventions and
more targeted care
WOUND ETIOLOGY
• In order to appropriately treat any wound,
you must determine the underlying cause –
if this is not addressed and corrected, no
treatment will be effective
• Many “traditional” physical therapy
interventions positively impact the healing
process for various types of wounds
WOUND ETIOLOGY -- PRESSURE
• Pressure
• Typically located over bony prominences
• Prolonged pressure, friction, shear (or any
combination of these forces) causes
ischemia and eventual cell death
• Classified using “Stages” to describe
amount of tissue destruction
RISK FACTORS FOR PRESSURE
ULCER DEVELOPMENT
• Impaired circulation
• Decreased mobility
• Predisposing illness
• Diminished mental capacity
• Incontinence
• Poor nutrition/dehydration
• Past history of pressure ulcers
• Poorly fitting splints/braces
PRESSURE ULCERS – STAGE I
• Intact skin with nonblanchable redness
of a localized area
usually over a bony
prominence. Darkly
pigmented skin may
not have visual
blanching; its color
may differ from
surrounding area.
STAGE I PRESSURE ULCER IN
DARKER SKIN
PRESSURE ULCERS – STAGE II
• Partial thickness loss
of dermis presenting
as a shallow open
ulcer with a red pink
wound bed without
slough. May also
present as an intact
or open/ruptured
serum-filled blister.
• Typically painful
STAGE II
PRESSURE ULCERS -- SUSPECTED
DEEP TISSUE INJURY
• Purple or maroon
localized area of
discolored intact
skin or blood-filled
blister due to
damage of
underlying soft
tissue from pressure
and/or shear.
PRESSURE ULCERS – STAGE III
• Full-thickness tissue loss.
Subcutaneous fat may
be visible but bone,
tendon or muscle are
not exposed. Slough
may be present but
does not obscure the
depth of the tissue loss.
May include
undermining and
tunneling.
PRESSURE ULCERS – STAGE IV
• Full-thickness tissue
loss with exposed
bone, tendon or
muscle. Slough or
eschar may be
present on some
parts of the wound
bed. Often include
undermining and
tunneling.
PRESSURE ULCERS -- UNSTAGEABLE
• Full thickness tissue
loss in which the
base of the ulcer is
covered by slough
(yellow, tan, gray,
green or brown)
and/or eschar (tan,
brown or black) in
the wound bed.
WOUND ETIOLOGY – VASCULAR
• Arterial:
• Lack of adequate
perfusion leads to
ischemic skin changes
• Usually found on toes,
feet and distal third of the
leg
• Tend to have very little
drainage, patient has
increased pain with leg
elevation
• Can be partial thickness
or full thickness
depending on extent of
tissue damage
ARTERIAL WOUND
RISK FACTORS FOR ARTERIAL WOUNDS
• Age
• Smoking
• Diabetes mellitus
• Hypertension
• Dyslipidemia
• Family history
• Obesity
• Sedentary
lifestyle
WOUND ETIOLOGY -- VASCULAR
• Venous:
• Incompetent valves lead
to a fluid overload in the
lower extremities –
edema
• Typically found on the
distal, medial third of the
leg
• Heavy amounts of
drainage, elevation helps
symptoms
• Can be partial thickness
or full thickness
depending on extent of
tissue damage
VENOUS WOUND
RISK FACTORS FOR VENOUS ULCERS
• Age
• Obesity
• Previous leg injuries
• Deep venous thrombosis
• Phlebitis
WOUND ETIOLOGY -- NEUROPATHIC
• A.K.A “Diabetic” ulcers
• Various neuropathies
(sensory, motor,
autonomic) contribute to
changes in the foot
which can lead to
ulceration
• Typically found on the
plantar surface of the
foot
• Can also see bony
deformities (Charcot
foot) in patients with
neuropathy
SEVERE CHARCOT DEFORMITY
CHARCOT FOOT – TYPICAL ULCER
PRESENTATION
RISK FACTORS FOR NEUROPATHIC
WOUNDS
Diabetes > 10 years
Male
Poor glucose control
Cardiovascular,
retinal, or renal
complications
• Peripheral
neuropathy with loss
of protective
sensation
•
•
•
•
• Altered biomechanics
• Evidence of increased
pressure
• Erythema, hemorrhage
under a callus
• Bony deformity
• Peripheral vascular
disease
• History of ulcers or
amputation
• Severe nail pathology
CHARACTERISTICS OF LOWER
EXTREMITY ULCERS
Type
Cause
Pain
Location
Appearance
Arterial
Arteriosclerosis
Severe
Toes, feet,
lower third of
leg
Defined borders,
pale base, little
drainage
Venous
Venous
insufficiency
Moderate
Proximal to the
medial
malleolus
Irreg. borders,
pink base, heavy
drainage,
hemosiderin
staining
Neuropathic
Diabetes
Varies
Plantar foot
Pale pink base,
mod. drainage,
callous
(neuropathy)
WOUND ETIOLOGY -- TRAUMATIC
• Describes a wide
variety of causes
(shear forces, GSW,
burns, skin
breakdown due to
incontinence)
WOUND ETIOLOGY -- SURGICAL
• Man-made wounds
due to surgical
procedure,
debridement,
incision and
drainage, etc.
FUNCTIONAL APPROACH TO WOUND
INTERVENTIONS
• Assess wound etiology, location & severity
• How is the wound affecting the patient from a
musculoskeletal standpoint?
• How is this impacting the patient’s function and
mobility?
• Are there additional systems involved?
• What physical therapy interventions are most
appropriate?
“Treat the whole patient,
not the hole in the patient.”
Dr. Carrie Sussman DPT
SURGICAL ABDOMINAL WOUND
MUSCLES IMPACTED
• Rectus Abdominis – spinal flexion, posture,
respiration, increasing intra-abdominal
pressure
• External abdominal oblique – increase intraabdominal pressure, flexion/rotation of
vertebral column, lateral trunk flexion
• Internal abdominal oblique – antagonist to
diaphragm (helping to reduce volume of
thoracic cavity during exhalation), rotation
of vertebral column, lateral trunk flexion
• Transverse abdominis – provides thoracic
and pelvic stability, assists in childbirth
FUNCTION/SYSTEMS IMPACTED
• Feeding
• Grooming
• Bathing
• Dressing
• Toileting
• Bed mobility
• Sitting Balance
• Standing balance
• Respiratory Function
TREATMENT INTERVENTIONS?
• ADL training
• Therapeutic exercise
• Involve respiratory musculature as well
• Therapeutic activity
• Neuromuscular re-education
• Pain management
ANTERIOR-LATERAL LOWER
EXTREMITY
MUSCLES IMPACTED
• Tibialis anterior – dorsiflexion & foot inversion
(open chain); balance of LE and talus on
tarsal bones (closed chain)
• Extensor digitorum longus – toe extension
and ankle dorsiflexion
• Extensor hallucis longus – extends the great
toe and assists in DF; also assists with foot
inversion & eversion
• Peroneus brevis – foot plantarflexion and
eversion
FUNCTION IMPACTED
• Walking
• Running
• Negotiating uneven surfaces
• Stair climbing
• Standing balance
• Activity tolerance
TREATMENT INTERVENTIONS?
• Therapeutic exercise
• Therapeutic activity
• Neuromuscular re-education
• Gait training
• Activity tolerance
• Pain management
ARTERIAL INSUFFICIENCY
INTERVENTIONS
• Exercise to increase arterial blood flow has been
demonstrated to be helpful in long-term
maintenance and arterial ulcer prevention
• Therapeutic exercise is one of the most effective
measures for patients with claudication. It also offers
improvements in glucose metabolism, cholesterol
levels and cardiovascular benefits.
VENOUS INSUFFICIENCY
INTERVENTIONS
• Musculoskeletal changes can not only be a precursor to venous insufficiency but can also
exacerbate venous issues and cause calf muscle
pump disuse atrophy
• Focus interventions on ankle ROM, and activation of
foot and calf muscle pumps
GLUTEAL/HAMSTRING REGION
MUSCLES IMPACTED
• Gluteus maximus – hip ER & extension,
supports knee extension, chief antigravity
muscle in sitting
• Gluteus medius – hip ABD, preventing hip
ADD, internal rotation of hip
• Gluteus minimus -- hip ABD, preventing hip
ADD, internal rotation of hip
• Piriformis – hip external rotation with hip
extension and hip ABD with hip flexion
• Superior & inferior gemellus – hip ER
• Obturator internus – hip ER, hip ABD,
stabilizer of hip during walking
MUSCLES IMPACTED
• Quadratus femoris – hip ER, hip ADD,
stabilizes femoral head in the acetabulum
• Semitendinosus – hip extension, knee flexion,
IR of the tibia on the femur during knee
flexion & IR of femur when hip is extended
• Biceps femoris – knee flexion, ER of tibia on
the femur during knee flexion & hip
extension (long head)
• Adductor magnus & minimus – hip ADD
(based on attachment also ER, IR and ext of
hip)
FUNCTION IMPACTED
• Wheelchair mobility
• Bed mobility
• Standing balance
• Single limb stance activities
• Sit to stand transfers
• Walking
• Stair negotiation
TREATMENT INTERVENTIONS?
• Offload!
• Therapeutic exercise
• Therapeutic activities
• Neuromuscular re-education
• Gait training
• W/C Management
• Pain management
FLAP PROCEDURES
• Flaps –
• Soft tissue and/or muscle are transplanted from
another area of the body (free flap) or rotated
(rotational flap) to close a large wound deficit
ADDITIONAL CONSIDERATIONS – FLAP
PROCEDURES
• Donor location – rotational flap vs. free flap
• Rehabilitation parameters set by surgeon:
•
•
•
•
•
Bedrest
Weight-bearing restrictions
ROM restrictions
Progressive sitting challenge
Transfer method
• Minimize risk for dehiscence
• Avoid friction and shear forces
POSTERIOR SHOULDER/UE
MUSCLES IMPACTED
• Trapezius – scapular movement (rotation,
retraction, elevation, depression) and neck
extension when scapula are stabilized
• Rhomboid – scapular retraction when
trapezius is contracted, assists in downward
rotation of the scapula, scapular
stabilization when other shoulder muscles
are active
MUSCLES IMPACTED
• Supraspinatus – assists in UE ABD and stabilizes
humerus
• Infraspinatus – ER of UE and stabilizes humerus
• Deltoid – shoulder ABD, flexion and extension
• Teres major – IR and ADD of UE, stabilizes
humerus
• Teres minor – ER of UE, ADD of forearm and
stabilizes humerus
• Triceps – elbow extension, shoulder extension
(long head)
FUNCTION IMPACTED
• Feeding
• Grooming
• Bathing
• Dressing
• Toileting
• Wheelchair mobility
• Sit to stand transfers
TREATMENT INTERVENTIONS?
• ADL training
• Wheelchair management
• Therapeutic activity
• Therapeutic exercise (ROM)
• Pain management
NEUROPATHIC ULCER – PLANTAR
FOOT
MUSCLES IMPACTED
• Flexor hallucis brevis – great toe flexion
• Lumbricals – flexion of
metatarsophalangeal joints and
extension of interphalangeal joints
FUNCTION IMPACTED
• Gait
• Balance
• Proprioception
TREATMENT INTERVENTIONS?
• Offload!
• Therapeutic exercise
• Therapeutic activity
• Neuromuscular re-education
• Gait training
• Pain management
SACRAL PRESSURE ULCER
MUSCLES IMPACTED
• Latissimus dorsi – UE ADD, extension and IR
• Gluteus maximus -- hip ER & extension,
supports knee extension, chief antigravity
muscle in sitting
• Gluteus medius – hip IR & ABD, preventing
hip ADD
• Erector spinae (Iliocostalis lumborum,
Longissimus thoracis, Iliocostalis thoracis) –
spinal extension
• Multifidus – vertebral stabilization during
local movements
FUNCTION IMPACTED
• Feeding
• Grooming
• Bathing
• Dressing
• Toileting
• W/C mobility
• Sitting balance
• Standing balance
• Sit to stand transfers
• Walking
• Stair-climbing
TREATMENT INTERVENTIONS?
• Offload!
• Therapeutic exercise
• Therapeutic activity
• Neuromuscular re-education
• W/C management
• Pain management
PHYSICAL THERAPIST ROLE IN
WOUND ROUNDS
• We are the experts in anatomy and
functional mobility
• May be helpful to use a systems review
approach
•
•
•
•
•
Integumentary
Musculoskeletal
Neuromuscular
Cardiovascular/Pulmonary
GI/Genitourinary
POTENTIAL INTERVENTIONS –
THE GUIDE IS BACK!
• Positioning
• Support surfaces –
bed & seating
• Adaptive/assistive
devices
• Orthotics/
prosthetics
• Support garments
• Compression
therapy
• Transfer method
• Compensatory
strategies
• Biophysical
technologies
• RNP strategies
• Referrals to
additional
disciplines
THANK YOU!
EMBRACE
YOUR
PRACTICE!
REFERENCES
• Collins L, Seraj S. Diagnosis and treatment of venous
ulcers. Am fam physician. 2010 Apr 15;81(8):989-996.
• Hess, CT. Arterial ulcer checklist. Advances in skin
and wound care. 23(9):432, September 2010.
• Hopf HW et al.; Wound repair and regeneration.
14(6): 693-710, Nov-Dec 2006.
• Orsted HL et al.; Ostomy wound management.
47(10): 18-20, 22-4. Oct 2001.
• Interactive Guide to Physical Therapist Practice by
American Physical Therapy Association. 2003.