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Physical therapist intervention for disorders of the vascular, lymphatic, and/or integumentary systems should include a variety of techniques to address the problems identified during the examination. It is common for patients with disorders in these systems to present with multiple factors contributing to the primary diagnosis. The intervention plan should reflect a holistic view of the patient. For example, an individual with signs and symptoms of venous disease may also present with poor ankle ROM, an LE wound, and lymphedema. The wound must be cleansed and dressed but the limb should also receive compression for optimum healing. Ankle ROM must be improved because ambulation will enhance calf pump function. Another example of the need to view patients holistically would be an individual with signs and symptoms of arterial disease who also presents with decreased LE strength, diabetes, and peripheral neuropathy. Exercise is important for this person, but it must be carefully coordinated to address arterial health, diabetes management, and skin protection.
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A natural component of viewing patients holistically is to be able to identify the need for interdisciplinary care. This concept may be more important for individuals with disorders of the vascular, lymphatic, or integumentary systems for the very reasons listed in the previous paragraph: these populations present with complicated, multisystem problems that are often best addressed using a team approach. Integrated care facilitates an exchange of information among all the health professionals that are involved in the care of the patient. This model of care might be delivered by a team of individuals who work together every day or it might be coordinated by a physical therapist who pulls together certain professionals for a particular patient's needs.
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Coordination, Communication, and Documentation
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In keeping with practice standards, the physical therapist coordinates intervention efforts to ensure the patient receives the highest quality of care. Critical to this goal is open communication among the health care team, patient, family, and caregivers. The team will most likely include a physician, nurse, physical therapist, occupational therapist, dietitian, and social worker. Referrals to other health care professionals (e.g., podiatrist) who can support the patient can also be made. Meticulous documentation will have a significant impact on issues such as continuity of care, receiving adequate number of visits for procedures, and a stronger working relationship with referring practitioners. Photographs, special forms for data collection, and body graphs are very effective tools to enhance communication and documentation. Appendix 14.C provides an example of an examination form that might be used to document data collected for a patient with a disorder of the vascular, lymphatic, or integumentary system.
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Patient/Client-Related Instruction
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Disorders of the vascular, lymphatic, and integumentary systems represent major health events for patients and their families and require life-long management strategies. Patients and families often react with anger, despair, or at least confusion when learning about a condition that may be permanent. The value of patient and family education cannot be underestimated. Patient education will be the key to preparing individuals to manage their symptoms, prevent recurrence, and remain vigilant about their condition. Information should be provided that is appropriate to the patient/family/caregiver's educational level with provisions for follow-up and repetition. Motivational strategies are important to ensure adherence to self-management. For many chronic disorders, high-quality patient education has been shown to result in positive changes in health behaviors, QOL perceptions, and adherence to home programs. Instruction for the patient should include resources, education materials, and a home program.
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Resources
Community services and support groups related to the patient's diagnosis
Counseling services, as needed, especially for assistance with QOL issues
Internet sites (Appendix 14.D lists Web-based resources for clinicians, families, and patients with vascular, lymphatic, and integumentary disorders)
Family member participation in care
Education materials
Instructional materials, multimedia tools
Self-management strategies
Available resources include Wound Care by Sussman107 and Living Well with Lymphedema by Ehrlich, Vinje-Harrewijn, and McMahon108
Home program
Skin and/or wound care; prevention practices; scar management
Compression garment or bandage wear and care
Exercise
Edema control
Pressure-redistributing devices
Foot care for patients with diabetes (see Appendix 14.A for a foot care guide)
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Outpatient or home therapy may be required for some patients. Follow-up visits at regularly scheduled intervals may be the best way to facilitate adherence to the home program and to prevent recurrence or exacerbation of symptoms.
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Procedural Interventions
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This section has been organized in the order in which a physical therapist would provide patient care. Within each section, information has been organized from most invasive/least selective (nonspecific) to least invasive/most selective (highly specific). In developing the POC, a physical therapist should select interventions that are least invasive/most selective, always trying to create an environment that is conducive to healing. The ultimate goal should be to optimize the body's opportunity to heal. Despite tremendous gains in the management of vascular, lymphatic, and integumentary disorders, there are still an alarming number of practitioners using outdated and often harmful methods to treat these disorders. Overused agents such as povidone-iodine, wet-to-dry dressings, whirlpool, and compression pumps have been replaced for at least a decade with more advanced, biocompatible, and cost-effective methods of treatment. The use of inappropriate agents can delay healing and may cause harm. Supporting literature abounds for the clinician seeking evidence-based practice. Elements of skin and wound care that are often overlooked or underestimated for their impact include PRDs, positioning, exercise, patient education, compression, and orthotics.
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The therapist treating a patient with a wound should strive to establish an ideal wound environment. The choices made about intervention should be guided by the goal of achieving this ideal environment, described as moist, free from necrotic tissue, free from exudate, warm, protected from trauma, and protected from infection. Physical therapists may manage wound care in a primary care role, or in consultation with a physician and/or other providers. Interventions involving pharmaceuticals will always require physician consultation for a prescription. "Although practice may change based on new evidence, the search for healing in the most humane way and fastest time possible persists as the goal."109, p. S1
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Wound cleansing is differentiated from wound débridement, which follows in the next section. The wound cleansing method should be selected based on its ability to support or return a wound bed to homeostasis. Chemical and mechanical trauma should be minimized even in the presence of infection. A decision to cleanse should be made carefully, because many wounds do not need to be cleansed at every dressing change. Often the negative effects to the wound from cleansing outweigh the positives. Not only is there a potential loss of endogenous fluids from the wound surface but also there is significant slowing of cellular activity for up to 3 hours after wound cleansing.110
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Since whirlpool can be classified as a means of cleansing and mechanical débridement, it is discussed in both categories of intervention. Despite at least a decade of investigation, with little evidence to support its use, whirlpool is still used for both nonselective mechanical débridement and for wound cleansing. However, many clinicians involved in wound care have decreased their use of whirlpool significantly in response to the evolution of wound care and subsequent publication of the Agency for Health Care Research and Quality (AHRQ) guidelines. Standards have changed with the increased knowledge of the microenvironment in the wound bed and a greater understanding of the chemical mediators necessary for homeostasis.
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The historical rationale for use of whirlpool was based on its use in deodorization, skin and wound cleansing, mechanical nonselective débridement, wound decontamination and infection control, and softening adherent necrotic tissue in preparation for débridement. There is little evidence to support whirlpool as the optimal method for achieving these. If using whirlpool for an infected wound, the AHRQ recommends that whirlpool be discontinued when the ulcer is clean. First issued in 1994, the guidelines are considered to still be current.101 The guidelines include more than 300 references, bibliographic sources, and updates that can be easily obtained.111
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Evidence-based rationale for a decrease in the use of whirlpool is based on a number of factors. There is risk of contamination from waterborne pathogens and from patient cross-contamination. The dependent position can initiate or increase venous congestion and extremity edema. With whirlpool there is loss of endogenous fluids from the wound bed and heat loss affecting core body temperature and the local wound area. Even mild changes in core body temperature (hypothermia) have negative effects on the cells that are important to wound healing. In addition, mechanical disruption of granulation tissue, epithelial cells, and new skin grafts occurs, primarily from the use of water agitation. Immersion in a whirlpool saturates wound tissue and surrounding skin, creating the potential for maceration, skin breakdown, and temporary inactivation of normal skin defenses. Thus, there is the potential to prolong inflammation and delay wound healing. Whirlpool can also increase heart and respiratory rates. Finally, the use of whirlpool is labor intensive and costly in terms of use of water, utilities, linen, and staff.3,112,113,114,115,116
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Based on current standards of care and guidance from the literature, it may be possible to justify the use of whirlpool in some situations. Wounds that need intensive cleansing that cannot be accomplished with other methods might benefit from whirlpool. Minimal agitation of water is recommended with only small body areas treated for short amounts of time (5 to 10 minutes) to limit the negative effects of temperature and pressure changes. Unless infection is confirmed with tissue culture, cytotoxic agents in the water should be avoided (e.g., povidone-iodine, chlorine). Wounds that need softening of loosely adherent tissue before sharp, enzymatic, or autolytic débridement might benefit from whirlpool when other tissue-softening methods are not appropriate. (Note: there is little to no reimbursement for the use of whirlpool to soften tissue before débridement.) Wounds that would benefit from stimulation of peripheral circulation might benefit from whirlpool. Neutral warmth or normothermia (normal body temperature, 98.6°F [37°C]) is recommended.
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Pulsatile Lavage with Suction
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Pulsatile lavage with suction (PLWS, also referred to as forceful irrigation) is a method of wound irrigation combined with suction (Fig. 14.16).117 Pulsed irrigation and simultaneous suction removes the irrigation fluid, wound exudate, and loose debris. In use for over 20 years, this wound cleansing and débridement method has several advantages over whirlpool cleansing. PLWS uses less water, less staff support, and less treatment time and requires less cleanup time. PLWS can be performed bedside and in the home. (Note: family or visitors are not allowed in the room during the procedure owing to aerosolization of microorganisms.)118 This type of cleansing collects wound exudate and debris efficiently and delivers topical antibiotics, antiseptics, and antibacterial solutions efficiently. PLWS speeds healing by rapid removal of contaminants and treats tunneling wounds and undermining wounds using special cannula tips. Risk of periwound maceration and cross-contamination is eliminated with use of disposable equipment.
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Although the advantages are clear, there are disadvantages to using PLWS. These include risk of overuse, especially with clean, granulating wounds, and risk of trauma to newly formed tissue from plastic tips, pulsed irrigant, and/or suction. Treatment may be painful to the patient. PLWS use should be limited to experienced therapists who are well versed in anatomy, especially when irrigating tracts, areas of undermining, or exposed bone, tendon, blood vessels, cavity linings, grafts, or flaps. All staff involved in treatment must wear disposable personal protective equipment (PPE). Compared to other irrigation options, disposable, single-use equipment contributes to landfill burden. There is considerable cost when labor, PPE, and equipment are calculated.
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Nonforceful Irrigation
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As soon as possible, wound cleansing should be accomplished with minimal pressure or force on the wound bed by nonforceful irrigation. This can be accomplished by pouring a solution over a wound, or using a bulb syringe or other device designed to deliver an irrigant to the wound (Fig. 14.17). There are several products that package saline specifically for wound cleansing: Blairex® Wound Wash Saline, manufactured by Blairex Laboratories, Inc., Columbus, IN 47202; and Saljet®, single-dose sterile saline manufactured by Winchester Laboratories, LLC, St. Charles, IL 60174. Several manufacturers produce a spray container that delivers saline or a surfactant at very gentle pressures (Fig. 14.18). Infected wounds can also be effectively cleaned with nonforceful irrigation. Wounds with necrotic tissue or debris, however, may respond best to a few sessions of a more forceful type of cleansing. For wounds that are clean, with new tissue growth, cleansing should be done only to remove excess endogenous fluids or residue left by dressing products.
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Commercial Skin and Wound Cleansers
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There are many skin and wound cleansers designed as topical solutions and marketed to treat acute and chronic wounds. For many years solutions have been used indiscriminately without consideration or measurement of the potential side effects on the new cells trying to proliferate in the wound bed. These topical cleansers may have some antimicrobial effects but most have significant antimitotic (inhibiting mitosis) effects as well.119 This means that cleansers may adversely affect important cells such as fibroblasts and epidermal keratinocytes during tissue repair. The cells most affected are the all-important cells that fill and cover a wound. Information on the toxicity of the most common cleansers has been created to assist health care providers in selecting or rejecting the use of cleansers.119 It is no surprise that acetic acid is extremely cytotoxic to the cells in a wound but of greater concern is the fact that ordinary bath soaps, even moisturizing body washes, are very cytotoxic. A physical therapist utilizing commercial cleansers or ordinary soap must consider the rationale behind the use of each topical agent applied to the wound and weigh the cost to the wound: some contribute to wound healing whereas others contribute to aspects other than wound healing.
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Débridement is defined as the removal of foreign material and dead or damaged tissue. Removal of devitalized or infected tissue is an important intervention to prevent or control bacterial growth, encourage normal cellular activity in the wound bed, and enhance the rate of tissue repair. Nonselective débridement removes all tissue both necrotic and living. Methods in this category may be quick but are often painful and frequently cause damage to nearby healthy tissue. Selective débridement removes necrotic tissue in a controlled method. Selective methods are more comfortable and gentle to the wound bed but may remove tissue more slowly.
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The importance of physical therapist proficiency in sharp débridement is reflected in the Physical Therapist Licensure Examination Content Outline (the content outline can be accessed at www.fsbpt.org/download/CandidateHandbook20110114.pdf), the Commission on Accreditation in Physical Therapy Education (CAPTE) evaluative criteria (the Accreditation Handbook can be accessed at www.capteonline.org/Accreditation Handbook) and the Guide to Physical Therapist Practice.88 In response, most professional-level programs include instruction in sharp débridement within the curriculum. In the majority of states, débridement is included in the scope of practice for physical therapists. Physical therapists should consult their state's practice act to ensure that débridement is within their scope of practice in that state before providing this intervention.
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When choosing a method of débridement, clinicians must consider not only the wound status but also the physiological, emotional, and financial status of the patient. Modern wound management experts avoid débridement techniques that cause the wound to bleed owing to the highly damaging effects to the wound tissues.
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Nonselective Débridement
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Wet-to-Dry Dressings A wet-to-dry (WTD) dressing consists of wet gauze applied to the wound bed and allowed to dry on the wound. Removal of the dry dressing débrides the wound, pulling away any cellular material that has adhered to the gauze. This method of débridement removes necrotic tissue, as well as rich endogenous fluids, fibrin, and other cells critical to wound healing. It is also frequently uncomfortable for the patient, often causing bleeding and trauma to the wound bed. There is literature to describe the use of WTD dressings for débridement, but the efficacy of the procedure has not been demonstrated.120,121 Wound management experts have agreed for over two decades with a multidisciplinary panel: "One of the most routinely and inappropriately used forms of non-selective mechanical débridement is the wet-to-dry dressing."122, p. 28 Once believed to be less costly than other dressing options, it has been shown that WTD gauze dressings are actually more costly than advanced dressings. Evidence for the many negative aspects of WTD dressings is summarized in Box 14.1 Evidence Summary.
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Box 14.1 Evidence Summary Outcome Studies Using Wet-to-Dry (WTD) Dressings as Part of Wound Care
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Since WTD dressings can be classified as a tool for mechanical débridement and/or a primary wound dressing, the procedure has been discussed here and in the section on dressings.
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Surgical Débridement Surgical débridement provides rapid results when treating life-threatening necrosis, large wounds, tunneling wounds, and necrotic or infected bone. Wide excision, removing viable and nonviable tissue, is usually done in the operating room with anesthesia. Laser débridement, another form of surgical débridement, may be appropriate when an individual is not a candidate for operating room procedures. Surgical débridement is not within the scope of practice of a physical therapist.
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Pulsatile Lavage with Suction PLWS will provide nonselective débridement while cleansing a wound. Refer to the detailed discussion of PLWS in the previous section on Cleansing.
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Whirlpool Whirlpool can be used for mechanical débridement through its feature of water agitation. It can also be used to soften necrotic tissue in preparation for sharp, enzymatic, or autolytic débridement. There are, however, often better methods of preparing tissue for débridement than whirlpool. See discussion in the previous section on Cleansing.
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Selective Débridement
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Sharp Sharp débridement is defined as the removal of dead or necrotic tissue or foreign material from and around a wound using sterile instruments such as a scalpel, scissors, and/or forceps (Fig. 14.19). Considered the gold standard of methods for removal of necrotic tissue, sharp débridement is a minor, tissue-sparing procedure that is performed bedside or in a procedure room. In the vast majority of U. S. states, it is within the scope of practice for a physical therapist to perform sharp débridement. It is incumbent on the therapist to be aware of his or her state practice act regarding regulations. The American Physical Therapy Association (APTA) position statement indicates that sharp débridement should be performed exclusively by physical therapists, not other personnel. For a full copy of this statement, go to www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/ProceduralInterventions.pdf. Additional information can be found in the Guide to Physical Therapist Practice.88 To maintain current standards, a physical therapist should not débride except in the presence of necrotic tissue.
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Even though sharp débridement is effective for all types of necrotic tissue, there are situations where this form of débridement is not appropriate. It is contraindicated for vascular wounds with limited blood flow where eschar may be serving as a cap or cover for a chronic open wound. Without adequate perfusion in this scenario, there is little hope of wound closure. Sharp débridement is not appropriate for wounds with tunneling (when the wound bed cannot be seen) or areas affected by dry gangrene. Patients with low platelet counts, on anticoagulants, or with other conditions that inhibit clotting are not suitable candidates. It is also contraindicated for pressure ulcers on the heels covered with dry eschar. (Note: Some experts maintain that in this scenario, eschar provides protection as long as there is no infection present; others maintain that eschar must be removed because it inhibits epithelial cell growth.)
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Chemical or Enzymatic Enzymatic débridement is a type of selective débridement that includes the application of a topical agent containing enzymes that act by dissolving necrotic tissue. There are several types and brands of enzymatic agents, each designed to affect a certain type of necrotic tissue. Advantages for this type of treatment are that débridement is selective, patient discomfort is minimal, and application procedures are simple. Disadvantages include the potential development of dermatitis of the intact periwound skin, frequent dressing changes disrupting the wound bed, and the need to crosshatch existing eschar with a scalpel so that the enzyme can penetrate the wound. Enzymatic débridement agents do not have an impact on pathogen levels in the wound bed and should not be considered antimicrobial. Some enzymatic débridement preparations contain the protein papain. Topical drug products containing papain were taken off the market in the United States in November 2008 because they have not been approved by the Food and Drug Administration (FDA); for more information on this issue go to www.fda.gov/papain. When utilizing other types of enzymatic agents still on the market, a referral for treatment and a prescription for the enzymatic agent are currently required in most regions of North America.
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Biosurgery Biosurgery as a form of selective débridement is also referred to as maggot débridement therapy (MDT), or maggot or larval therapy (Fig 14.20). Although it has been in use in the Western world for over 150 years, its popularity declined with the advent of antibiotics. Biosurgery is now generating new interest owing to the rise of multidrug-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA). Sterile, newly hatched larvae are placed on chronic wounds and held in place with dressings or a biobag for 2 to 5 days before removal. Biosurgery has been shown to remove devitalized tissue, decrease the risk of infection, and improve wound healing without side effects in a wide variety of wound types. Biosurgery is recommended for osteomyelitis and deep wound infections that remain unresponsive to more conventional antibiotic and surgical therapy. Although moist wound healing is compatible with biosurgery, a very wet wound environment has an adverse effect on larval survival. Certain types of moisture-retentive wound dressings are more compatible with larval survival than others.134,135,136,137,138,139,140,141
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The use of medical-grade honey as a wound dressing has been shown to enhance débridement and healing. Honey dressings are available in hydrocolloid, alginate, and liquid categories. They have been shown to facilitate autolytic débridement, decrease or eliminate wound odor, prevent biofilm (thin layer of bacteria) formation, and soften necrotic tissue.142,143,144,145
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Autolytic débridement uses the endogenous enzymes on the wound bed to digest devitalized tissue and promote granulation tissue formation. In practice, the body's natural fluids are held in contact with the wound base with a moisture-retentive dressing for 3 to 7 days. By increasing the moisture content of slough and necrotic tissue with enzyme-rich body fluids, autolytic activity is facilitated. Although this method is the least invasive/most selective, as well as inexpensive, painless, and biocompatible, each patient is examined to determine if this type of débridement is best for the existing wound. The type of moisture-retentive dressing selected to promote autolytic débridement will be based on the health of the periwound tissues and the level of fungal or bacterial loads. The presence of infection does not rule out the use of occlusive dressings, as described earlier in the discussion on moist wound healing.
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Current standards for chronic wound care have decreased the use of topical agents even in the presence of infection. In the literature these agents may be referred to as antiseptics, disinfectants, and/or antimicrobials. Other topical agent categories include antibiotics and analgesics. Guidelines reveal that almost all human-made products are cytotoxic to WBCs even when diluted.101 Many agents once thought to be safe are now known to be unsafe to healing tissue, causing adverse reactions at any concentration. Many agents once thought to be effective as antibacterial or decontaminating agents are now known to be ineffective. When striving for wound bed homeostasis, preserving cellular life in endogenous fluids is almost always more desirable than destroying it with additives. Many physicians and wound management experts use the following adage to guide in the decision making process: "It is desirable never to put anything in the wound that cannot be tolerated comfortably in the conjunctival sac."15, p. 179 In plain terms, "If you can't put it in your eyes don't put it in the wound." Even under Direct Access, in most states physical therapists are not permitted to prescribe medications, even over-the-counter products, for wound care. If, during the examination or intervention, a physical therapist determines that a topical agent may be indicated, the patient's physician should be contacted and the findings discussed. Consideration of topical agents should always include the risks and benefits of the topical agent in relation to potential cytotoxicity, biocompatibility, safety, and efficacy.
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Povidone-Iodine Povidone-iodine (PVI) is a combination of iodine plus a polymer that provides bactericidal effects. One commonly known product name is Betadine (Purdue Products LP, Stamford, CT 06901). Used indiscriminately for many years on acute and chronic wounds, it is now recommended mainly for wounds infected with Staphylococcus aureus. The AHRQ guidelines published in 1994 state: "Do not clean ulcer wounds with skin cleansers or antiseptic agents (e.g., povidone-iodine, iodophor, sodium hypochlorite solution [Dakin's solution], hydrogen peroxide, acetic acid)."101, p. 15 Although the guidelines address pressure ulcers, the wound-healing evidence is applicable to all wound treatments. This evidence implies that the use of PVI, as well as other antiseptics, is inconsistent with practice standards. In rare instances when such agents are recommended by a physician and are indeed appropriate, clinicians should document sound reasoning behind the use of these products because they will be held accountable to these published and respected guidelines. An example of a situation such as this would be when other, less cytotoxic treatments have failed to reduce the bacterial load in an infected wound. The literature does not provide adequate clinical or legal reasons to use PVI for managing wounds.146 In addition, the FDA has not approved the use of PVI solution or PVI surgical scrub solution for wounds. PVI has been shown to reduce bacterial counts in infected wounds, and currently there is no antimicrobial resistance to PVI.147 Its use is contraindicated for the noninfected wound.101
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Sodium Hypochlorite Solutions: Dakin's Solution (Bleach and Boric Acid), Sodium Hypochlorite (Household Bleach) Sodium hypochlorite is cytotoxic even at very dilute concentrations. It damages fibroblasts and endothelial cells and causes cellular damage to granulation tissue. It is irritating to the skin and can initiate severe reactions in some individuals. It is used in the management of wounds with purulent exudate. Treatment should be discontinued when the wound is clean. Its use is contraindicated for the noninfected wound.101
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Acetic Acid Solution Acetic acid is traditionally used to inhibit bacterial infections; however, the solution has been found to be more damaging to fibroblasts than to bacteria. A common form of acetic acid is found in vinegar. It is corrosive and cytotoxic at any dilution. Most recently, it has been used to manage contamination by Pseudomonas aeruginosa. Its use is contraindicated for the noninfected wound.101
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Oxidizing Agents: Hydrogen Peroxide Solution When this solution comes in contact with tissue, there is a release of oxygen and temporary antimicrobial activity. Its bubbling action is used for nonselective débridement to loosen small debris. It is cytotoxic unless diluted to a very weak concentration. Its use is contraindicated in-wounds that are noninfected, tunneling, or granulating.101
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This section includes a sample of commonly used topical antimicrobials, antibiotics, and antibacterials. Each of these topical agents is effective against a variety of bacteria and is selected by the physician based on the species cultured for an individual patient. All share a risk of similar side effects such as burning, itching, contact dermatitis, and/or allergic sensitivity. There is little evidence in the literature to show levels of cytotoxicity in these topical agents. Examples include the following:
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Bacitracin/Baciguent: associated with allergic reactions.
Neosporin/neomycin sulfate: causes greatest incidence of allergic reactions.
Silvadene/silver sulfadiazine: primarily for thermal injuries, silver is selectively toxic to bacteria but may inactivate topical proteolytic enzymes.148
Furacin/nitrofurazone: cytotoxic in animal studies.149
Sulfamylon/mafenide acetate: diffuses easily through eschar, primarily for thermal injuries.
Bactroban/mupirocin ointment: currently effective against all species of staphylococcus.
Gentamicin/Geramycin: currently effective against all species of staphylococcus and streptococcus.
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Owing to the paucity of information on cytotoxicity, the risk of side effects, and the growing incidence of antibiotic-resistant bacteria, use of these products for chronic wounds should be considered carefully and is usually contraindicated for the noninfected wound.
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Creams and Ointments (Over-the-Counter) Some antibacterial ointments and creams such as Bacitracin and Neosporin can be purchased without a prescription. These are minimally bacteriostatic owing to their dilution. Once they lose their antibacterial strength, the ointments may trap bacteria and encourage bacterial growth from surface contamination. If ointments or creams are used, the wound should be cleansed regularly to remove potential contamination; however, frequent cleansing may disrupt the healing process. These preparations can be used to provide moisture to a dry wound, but they may create a greasy wound bed, making early epithelial cell migration difficult. A more biocompatible ointment that will provide moisture to a healing wound is Aquaphor® (Beiersdorf Inc., Wilton, CT 06897).
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The use of topical anesthetics to control wound pain is controversial in the literature. Conflicting reports and the lack of substantial research have led to concerns about the impact of anesthetics on the wound bed. This issue is further complicated by the broad profile of patients with wounds, their etiologies, and co-morbidities. The more common agents used topically are lidocaine and EMLA (eutectic mixture of local anesthetics) cream, which is a mixture of lidocaine and prilocaine (AstraZeneca, Wilmington, DE 19850). Amitriptyline, a tricyclic antidepressant, has local anesthetic properties and has shown promise as an option for treating wound pain.150 While topical anesthetics may be under scrutiny for their effects, vasoconstriction in particular, there is a need for more investigation since pain is a major issue for most patients with wounds.
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Endogenous growth factors normally abound in the fluids of a wound. In most chronic wounds the normal timetable for healing has been delayed or stopped. Growth factors that are decreased or absent can be added topically to the wound bed. Increasing strength of evidence supports the practice of adding growth factors to a wound to facilitate healing. The application of exogenous growth factors in conjunction with good wound care increases wound healing outcomes and can convert a chronic wound into a healed wound.19,151,152,153,154,155,156 Growth factors can be isolated from an individual's own tissue, added to a liquid formula in a laboratory, and then applied to the wound. An example of an autologous growth factor product with a name familiar to many clinicians is AutoloGel™ System (Cytomedix Inc., Gaithersburg, MD 20877).157 Recombinant DNA technology has resulted in other products such as becaplermin gel, trade name Regranex® Gel (Ortho-McNeil-Janssen Pharmaceuticals, Inc., Titusville, NJ 08560). Reimbursement for application of growth factors varies and should be checked before use. For example, becaplermin gel is FDA approved for the treatment of LE diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond but currently not approved for the treatment of pressure, venous, or other nondiabetic-related wounds.
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Topical Agents and Acute Wounds
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The use of antiseptics and antibiotics to reduce bacterial levels in acute, traumatic wounds follows a different rationale from that of chronic wounds. For wounds resulting from trauma or thermal injury, the risk for contamination is high. It is accepted practice to use cytotoxic products such as povidone-iodine or Silvadene® (silver sulfadiazine) in the early management of acute traumatic wounds. The goal is to discontinue use of cytotoxic agents as soon as the wounds are clean and able to produce and support endogenous fluids.
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Mechanical Modalities
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Procedures for use of modalities vary based on unique patient characteristics and individual patient response. A useful place to begin is with protocols recommended in comprehensive wound management texts such as Wound Healing: Evidence-Based Management by McCulloch and Kloth158 and Wound Care: A Collaborative Practice Manual for Health Professionals by Sussman and Bates-Jensen.159 Owing to the ever-changing rules of reimbursement, it is prudent to check current reimbursement and documentation guidelines when billing for these services. The decision to use mechanical modalities rests in the hands of the physical therapist unless physician authorization is required in order to receive reimbursement. The reimbursement requirement may vary from state to state and sometimes between payers in the same state. In some cases, individual physicians may develop their own protocols that require physical therapists to contact them before changing a POC.
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Therapeutic ultrasound (US) application for wound management differs from its use as a modality to treat pain. Ultrasound stimulates cell activity, accelerating processes such as inflammation. Once thought to target only the sluggish wound in the inflammatory stage, evidence now demonstrates that the effects can be seen throughout all wound-healing phases. Basic science evidence and clinical research have established that skin repair and wound contraction can be accelerated, collagen secretion can be stimulated, and elastin properties can be affected to strengthen scar tissue. Standard procedure for the treatment is to cover the wound with a sheet of hydrogel or an application of amorphous hydrogel. US is then delivered with a handheld applicator (Fig. 14.21). Another option for treatment is to apply US transmission gel to the periwound area and treat from this region in addition to or instead of the wound bed.160,161,162,163,164 Another option for delivery of US is to use a system that provides noncontact, nonthermal, low-frequency ultrasound (Fig. 14.22). A mist of sterile saline is propelled toward the wound and the ultrasound is transferred from the device to the patient without contact or pain. Studies have provided evidence that this type of US treatment reduces bacterial quantity in a wound and promotes healing, especially in wounds that have been slow to heal.84,165,166,167,168,169
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Electrical Stimulation
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The use of electrical stimulation (ES) to treat chronic and, more recently, acute wounds is well documented. Electrical stimulation is recommended to eliminate bacterial load, promote granulation, decrease inflammation, reduce edema, reduce wound-related pain, and augment blood flow. Human skin, wounds, and the cells that facilitate wound healing all have measurable electrical currents. Electrical stimulation affects various types of cells and their activities by supporting, altering, or providing electrical currents to accelerate wound healing. A clear understanding of medical electricity will assist the clinician in applying an appropriate ES treatment. The available literature is diverse and instructive.170,171,172,173,174,175,176,177 There are a variety of options for treatment setup depending on the goals of treatment, the type of wound, and the condition of the patient. Standard equipment for the direct method of application will include an ES unit, treatment and non-treatment electrodes, and a substance such as saline-soaked gauze or a hydrogel dressing applied to the wound bed or cavity to enhance electrical conductivity under the treatment electrode (Fig. 14.23). For the indirect method, gel electrodes straddle the wound and interface with the periwound skin. Clinical decisions related to voltage, electrode placement, dosage, and other variables must be made on a case-by-case basis. Information about treatment protocols, strength of evidence, and guidelines for treatment can be found in detailed wound care texts.178,179
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Thermal and Nonthermal Diathermy
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Pulsed shortwave diathermy (PSWD), continuous shortwave diathermy (CSWD), and nonthermal pulsed radiofrequency stimulation (PRFS) have been used successfully to treat chronic open wounds, facilitating progress from one phase of wound healing to the next. These diathermy treatments utilize radio waves to provide thermal and nonthermal effects, respectively. All models transmit radiation from an applicator head to the target tissues. PSWD heats superficial and deep tissues. CSWD heats deep muscle and joint tissues. PRFS is nonthermal and can influence tissue at the cellular level. Individuals with arterial insufficiency are not good candidates for PSWD or CSWD because their tissues are not able to dissipate heat well enough to avoid burns. Wound sites treated with diathermy have demonstrated increased fibroblast proliferation, collagen formation, tissue perfusion, and metabolic rate. Although the number of clinical studies is smaller than that of other modalities, the evidence is mounting for the role diathermy plays in wound healing. Physical therapists are using diathermy more often since the publication of a number of studies regarding the nonthermal effects of pulsed diathermy and the production of smaller, more portable, user-friendly diathermy units.180,181,182 Equipment needed for treatment includes a diathermy unit/electronic console and one or two applicator heads. Treatment is usually delivered without touching the skin. Wounds should be carefully prepared before treatment according to guidelines provided by the distributor. With newer units such as the Provant® Therapy System (Regenesis® Biomedical Inc., Scottsdale, AZ 85257), the pad can be placed over wound dressings, compression garments, and casts. Because the effects of heat may continue after the treatment, patients should be observed carefully and protocol guidelines should be followed closely (Fig. 14.24).
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Ultraviolet Radiation
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Ultraviolet (UV) radiation energy is a form of radiation between x-ray and visible light on the electromagnetic spectrum.183 UV wavelengths have been divided into wavelengths and bands. The three bands most useful for their effects on human skin are UVA, UVB, and UVC. UV has cutaneous and bactericidal effects that include increased blood flow, enhanced granulation tissue formation, destruction of bacteria, stimulation of vitamin D production, and thickening of the stratum corneum. The varied physiological effects make this treatment appropriate for a variety of skin diseases, as well as acute and chronic wounds.160 The effects of UV radiation on antibiotic-resistant bacteria make it a potentially effective tool in wound care; however, there are only a few up-to-date, well-controlled clinical studies emerging at this time.184,185 Early supporting literature is now quite dated, leaving room for new clinical studies to provide evidence of the efficacy of the intervention. UVC in particular has been found to be effective in the treatment of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and, more recently, some strains of Pseudomonas aeruginosa.186,187 The treatment is typically delivered to a clean wound with dressings removed, using a UVB or UVC lamp. Treatment distance, dosage, frequency, and subsequent clinical outcomes will vary based on the goals of the treatment and the status of the wound. Due to manufacturing challenges in North America, portable, handheld UV units to treat wounds are not readily available at this time. Physical therapists planning to utilize UV for wound care might partner with a wound care team, a resourceful vendor, and the latest evidence to devise a treatment plan.
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Hyperbaric Oxygen Therapy
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Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen to an individual resting inside a sealed chamber. The oxygen is delivered at a pressure greater than the atmosphere. This systemic treatment increases the amount of oxygen available for cell metabolism, improving oxygen delivery to hypoxic tissue. Systemic HBOT is, however, associated with risks related to oxygen toxicity. The literature demonstrates positive responses to this treatment when used as an adjunct to other forms of wound care but few controlled, randomized trials have been completed.160,188,189,190,191 Chambers to deliver topical oxygen have been available for at least a decade. These smaller chambers enclose a limb or a segment of the body instead of requiring coverage of the entire body.
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Following physician referral, a physical therapist may assist or coordinate a systemic or topical treatment. Often, a trained technician will manage the equipment controls and the delivery chamber. Wound care may occur before or after the HBOT or the topical HBOT depending on the preferences of the physician and the protocol of the facility. Discussion among investigators comparing the effects of systemic versus topical oxygen is ongoing. In some studies, topical oxygen is also referred to as topical hyperbaric oxygen (THBO) and O2 therapy.13,192,193 Instead of the full-body chamber used for HBOT, THBO is portable and is delivered in a localized limb chamber.13,192 THBO has been combined with electrical stimulation and also with cold laser for the treatment of pressure ulcers and neuropathic foot wounds.193,194 Topical O2 therapy has enhanced the effects of growth factors in investigations within the last few years.12 Renewed interest by investigators has led to more refined protocols and improved strength of evidence in the field. If investigations continue to provide positive results, the use of topical O2 in wound care could result in more cost-effective and efficient care, fewer risks, and applicability to a wider population as compared to systemic O2.
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Negative Pressure Wound Therapy
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Negative pressure wound therapy (NPWT) is used as an adjunct to wound healing to facilitate wound closure in acute surgical wounds, as well as with more challenging, slow-to-heal wounds. The procedure is known by several terms but the most well known is vacuum-assisted closure or VAC® (Kinetic Concepts, Inc., San Antonio, TX 78265). An open cell foam dressing is placed in the wound and a suction tube is connected from the foam to a portable pump. An airtight seal is created over the foam and the suction tube with a clear, occlusive film (Fig. 14.25). A controlled amount of negative (subatmospheric) pressure is applied through the foam to the entire wound bed. Typically, for the first few days (48 hours) the negative pressure is applied continuously via the portable pump system. After a significant amount of excess wound fluid has been withdrawn, the pump is programmed to apply pressure intermittently. The foam dressing is changed every 12 hours (infected wounds) to 48 hours or longer (clean wounds). The strength of evidence is mounting as basic research explores the effects of this treatment. NPWT has been shown to enhance granulation tissue formation, promote wound edge approximation, remove edema from wounds, and improve oxygen levels in the wound.195,196,197,198,199,200,201 Studies have also shown that with the use of NPWT, the healing time for selected wounds decreased in comparison to standard wound care.202,203 One claim that is still under investigation is the ability of the VAC to remove bacteria from the wound bed. Although a physician must order this type of therapy, many are unaware of this intervention and would be responsive to an appropriate recommendation by the therapist. In different environments, physical therapists, nurses, or other clinical staff may perform administration of the technique.
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Cold laser is also referred to in the literature as low-level cold laser, low-level infrared laser, or monochromatic infrared photo energy (MIRE). Low-energy laser treatment uses light in the infrared spectrum. This therapy has been promoted for augmenting wound healing204 and reversing the symptoms of peripheral neuropathy in individuals with diabetes.205,206 It is thought that the effects of laser increase circulation and reduce pain by increasing the release of nitric oxide into the micro-circulation. Although supportive, peer-reviewed literature is modest at this point, published studies citing success with this treatment are mounting while debates continue.207,208,209,210 Despite the term cold laser, light in the infrared spectrum can also be used to deliver heat as a treatment modality. Owing to the perceived lack of adequate evidence, some third-party payers do not cover cold laser treatment except when used as a heat modality. This may soon change as the strength of evidence increases for its use to treat peripheral neuropathy. The most well-known product on the market is called Anodyne® Therapy System (Anodyne® Therapy, LLC, Tampa, FL 33626). Figure 14.26 depicts use of a special foot pad to deliver infrared photo energy.
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The type of wound dressings selected for a wound may have a profound effect on healing time. There are hundreds of choices for the discerning clinician. Information on indications, contraindications, and expected outcomes can be obtained from individual vendors listed in Appendix 14.E, as well as from texts devoted entirely to wound care.158,159 Physical therapists who are monitoring a wound on a regular basis and are knowledgeable about dressing alternatives are often the most appropriate clinicians to make the decision about dressing selections. This chapter includes introductory information necessary to make clinical decisions about dressings: the characteristics of the dressing categories and the effects of the dressings on the wound bed. Refer to Appendix 14.F for a listing of dressings categorized by treatment goal (purpose) or type of wound (indication).
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Choosing or recommending appropriate dressings should be directed by the characteristics of the wound and periwound tissues, not by what is available in the supply closet. A product that preserves wound hydration and limits fluid loss is usually ideal. In addition to following the principles of moist wound healing in most dressing selections, the following list identifies wound characteristics and the corresponding action that a dressing should perform:
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Infection: absent or present; prevent or treat
Necrosis: remove or not; autolytic or mechanical
Drainage: dry (no drainage), adequate (moist) or excessive (too wet); restore, retain, or remove
Granulation tissue: present or absent; protect, facilitate formation
Epithelialization: present or absent; facilitate formation
Periwound area: intact, at risk or macerated; protect or absorb
Incontinence: present or absent; protect or absorb
Cavities and tunneling: present or absent; fill and protect
Friction: present, some risk, significant risk; cushion, protect, or prevent
Odor: minimal or needs reduction; ignore or add odor-reducing dressings
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The dressing that is applied directly to the wound is referred to as the primary dressing. The dressing that is applied over the primary dressing is referred to as the secondary dressing. Some advanced dressings serve as the primary and secondary, including adhesive and absorptive qualities in the same dressing.
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Gauze dressings (Fig. 14.27) are considered by many wound management experts to be outside the description of modern wound dressings.120 Used and misused for decades, there are more reasons not to use gauze than there are indications for use. As a primary dressing, gauze leaves contaminating fibers in the wound, contributes to desiccation, is permeable to bacteria, can be adherent to the wound, releases excessive amounts of bacteria into the air on removal, causes a loss of normothermia, and is painful on removal if it adheres to the wound surface. Once thought to be cost-effective, it has been shown in more than one study to be more costly than other dressing choices (see Box 14.1 Evidence Summary). Gauze ribbon can be used to maintain an opening for drainage in a tunneling wound. It can also be used successfully to gently support a cavity wound but should not be used to aggressively pack any shape of wound. It was once thought that cavity wounds should be packed very full but it has since been established that granulation tissue and epithelial cells do not flourish with aggressive gauze packing. The additional pressure from a tightly packed wound will impede the flow of oxygen and nutrients to the granulating wound bed. Gauze can be an effective secondary dressing, especially if the dressings will be changed frequently or if exudate is heavy. Gauze 4 × 4s and a roll of gauze are typically used to create a WTD dressing. WTD dressings were previously discussed under the section on débridement because of their nonselective removal of tissue during dressing changes. Because WTD dressings can be classified as a tool for mechanical débridement or as a primary wound dressing, they are discussed in both categories. Refer to that section of the chapter for more details.
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Designed to be less adherent, this category includes products made of tightly meshed synthetic fibers or woven products such as cellulose acetate. Fiber materials are impregnated with a petroleum emulsion such as Vaseline®, intended to prevent the gauze from sticking to the wound surface. Used as a primary dressing this choice is minimally absorptive, provides minimal protection, does not enhance a moist environment, and may create a greasy wound bed. One of its more appropriate uses is as a primary dressing over new sutures to prevent them from catching or sticking in a gauze secondary dressing.
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Films are made of a transparent membrane with an acrylic adhesive layer (Fig. 14.28). Transparent films do not allow bacteria or moisture into the wound. They facilitate a moist wound environment, trapping endogenous fluids in the wound bed to assist with autolytic débridement, wound bed homeostasis, and angiogenesis. Films assist in protecting skin from the effects of shearing, friction, and the contaminating effects of incontinence. Removal of a film dressing must be done with great caution because this can cause skin tears, especially with fragile or aging skin. Currently, few films have absorptive qualities and cannot be used on highly exuding wounds.
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Foams are highly absorbent pads, sheets, or ropes of polyurethane available in many sizes with many features (Fig. 14.29). They are available with or without adhesive backing so that they can be used as a primary and/or a secondary dressing. Foam dressings are highly absorptive but also help to create an occlusive environment for moist wound healing. They should not be used alone on a dry wound but could serve as a secondary dressing if the primary dressing was a gel product.
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Hydrogels are categorized as amorphous, referring to a liquid-like gel, or as sheets, consisting of a thin, flexible sheet of polymer containing at least 90% water (Fig. 14.30). Both types are used to increase moisture in a dry wound bed, soften necrotic tissue, and support autolytic débridement. Both have some absorptive qualities and will swell slightly until they are saturated. The amorphous gel (Fig. 14.31) must be contained in the wound with a secondary dressing. The flexible sheets usually require a secondary dressing but are available through some vendors with tape attached to the borders. Patient response is usually very positive to the soothing sensation of the hydrogel application.
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Considered the most occlusive of the moisture-retentive dressings, hydrocolloids are also available in less occlusive or semipermeable styles as well. As with foams, these dressings come in a variety of styles and shapes including pastes, granules, powder, and sheets. They typically consist of an absorbent colloidal material combined with a film or foam backing (Fig. 14.32). Hydrocolloid dressings work best on mild to moderate exudating wounds. When wound exudate combines with the colloidal polymer, a soft, gelatinous, often yellow, and malodorous mass is formed. Patients, families, caregivers, and other health care providers must be informed about this harmless reaction so that infection is not assumed. Hydrocolloids have been used successfully as occlusive dressings over infected wounds without fulmination of existing bacteria. They are also the dressing of choice to cover and protect larvae during maggot débridement therapy.
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This dressing category is also known as calcium alginate because the dressings are manufactured using the calcium salts of alginic acid derived from marine algae and kelp (seaweed). The raw material is woven and then converted into flat sheets, ropes, or ribbon shapes (Fig. 14.33). Alginates absorb 20 to 30 times their own weight, are gentle to apply and remove, and are biocompatible with the wound bed. A chemical reaction between the dressing and wound exudate creates a gel substance that helps to maintain a moist wound environment while absorbing excess exudate. Because they are permeable, alginates do not provide a barrier against bacteria. This characteristic makes them an effective choice when an infected wound cannot be covered with an occlusive dressing. Most alginates currently require a secondary dressing to hold them in place. Several manufacturers are combining alginates with other products, such as hydrocolloids, to maximize their effectiveness. There is growing interest in the use of silver in advanced dressings to combine the antimicrobial action of silver with the absorptive qualities of alginates. Long-term effects remain unclear. There is a need for more clinical trials and longer follow-up times to look at the long-term effects on healing.211 An example of this type of dressing is SILVERCEL® (Johnson & Johnson Wound Management, ETHICON, Inc., Somerville, NJ 08876).
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Hydrofiber or hydroactive dressings are designed to have a selective absorptive capacity. They have the combined positive characteristics of alginate, foam, and gel dressings. When in contact with the wound, the synthetic fibers absorb exudate and align themselves perpendicular to the wound surface. This vertical wicking process keeps debris and wound fluid contained within the dressing.212 There is considerably less pain on removal of a hydrofiber dressing because the fibers do not stick to the wound or dry out.212,213 The dressing properties allow growth factors and other peptides to survive on the wound bed. Aquacel® is a spun Hydrofiber® dressing that readily absorbs moisture (Fig. 14.34). Aquacel® Ag adds ionic silver to the absorbent dressing (ConvaTec, Skillman, NJ 08558).
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Considered by some to be topical applications and by others to be dressings, human skin equivalents and bioengineered tissues are finding their place in the wound care arena. Skin substitutes are created using a variety of techniques and substances. Cells are derived from sources such as neonatal male foreskin and porcine (pig) dermal collagen. The products are produced in laboratories, shipped either frozen or cooled, and then applied to the patient's wound by a member of the wound care team. Although a physician would prescribe the use of a skin substitute, other health care professionals can apply the product to the wound based on individual facility protocol. Skin substitutes consist of living skin applications that resemble skin structure and function and may include epidermal and dermal layers. They are useful as temporary coverage, providing skin protection for the wound bed. Some have been shown to stimulate endogenous cell activity. Most are marketed to use on wounds that have not responded to conventional therapy such as chronic diabetic foot ulcers, venous leg ulcers, and deep burn wounds.214 Examples to look for when investigating skin substitutes are Apligraf (Novartis, East Hanover, NJ 07936), Dermagraft and Transcyte (Advanced Biohealing, LaJolla, CA 92037), and Biobrane (UDL Laboratories, Rockford, IL 61103).
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New products are entering the market yearly as research and development continue to grow and expand in the area of wound care. Too many to mention all, categories include options such as polysaccharide dressings, absorptive fillers, hydrophilic fiber, composite dressings, collagen, and biological products. Hyalofill-F (ConvaTec, Skillman, NJ 08558) is a hyaluronic acid derivative dressing that is applied directly to the wound. Hyaluronic acid is important for its role in cell proliferation. It is useful in helping a chronic wound to move through the stages of healing. First used on neuropathic foot ulcers, it has been used successfully in clinical trials for venous leg ulcers.215,216
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Manual Lymphatic Drainage
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MLD is a specialized manual therapy technique that affects primarily superficial lymphatic circulation. It is considered to be one of the five elements of an effective treatment intervention for lymphedema and many types of edema. This manual therapy provides a gentle stretch to the skin that enhances lymph capillary activity. MLD will increase the frequency of lymphangion contractions; improve lymph transport capacity; redirect lymph flow toward collateral vessels, anastomoses, and uninvolved lymph regions; and mobilize excess lymph fluid that has overwhelmed a body segment or region.74,217,218 The techniques of MLD are gentle and specific, requiring specialized education to be performed accurately (Fig. 14.35). To obtain contact information for training facilities that provide specialized education in MLD as a part of CDT, refer to the special section in Appendix 14.D for contact information. The benefits of this treatment are not limited to the population with lymphedema. MLD is used successfully for edema from CVI, sports injury, neurological injury, and post-operative swelling, but there is a need for more well-designed randomized controlled trials to provide high-ranking evidence.219,220 The use of MLD is contraindicated for treating cardiac-, pulmonary-, or renal-related edema because the amount of fluid that will be mobilized may overwhelm one or all of those systems when disease is present.221
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Controlling edema or lymphedema is critical to all stages of healing. Edema not only inhibits wound healing by affecting perfusion of tissues, but also inactivates the ability of the skin to manage bacteria.222 Unless there are red flags, compression should be part of every treatment for individuals with lymphedema, edema, and CVI. Compression therapy should be introduced as soon as clinical signs of swelling or fibrosis appear. A physical therapist may find indications for compression therapy during the examination or later, during the intervention. In most situations the therapist will decide what type and/or style of compression should be applied. Physician authorization, however, may be necessary for reimbursement. When leg wounds are present, compression is essential for timely wound healing. For the individual with mixed arterial and venous disease, an ABI test is indicated to provide information about the safety of using compression on the LE. A greater understanding of how the lymphatic system functions has created a paradigm shift in the way intervention for all types of swelling is planned and delivered. Aggressive compression techniques were once used to "milk" the fluid out of a limb. It is now understood that deep pressure and mechanical "milking" techniques are counterproductive and harmful to the superficial capillary network that filters lymph and interstitial fluids.4
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Elevation is used as a means of controlling some types of swelling and is often a precursor to compression therapy. Mild, acute swelling of the extremities may be relieved temporarily with elevation. Active ROM exercises (e.g., ankle pumps) can be added to elevation to facilitate blood flow in the extremities. Patients should be educated about how to elevate safely, paying attention to positioning so that optimal venous and lymphatic circulation is facilitated. Elevation should be viewed as a temporary or complementary measure while other means of controlling swelling are employed.
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Compression for the LE with a venous wound can be applied using zinc paste–impregnated gauze or Unna's boot (Fig. 14.36). Examples of conveniently packaged products are Medicopaste (Graham-Field Inc., Bay Shore, NY 11706), Unna-FLEX (ConvaTec, Skillman, NJ 08558), and Gelo-Cast (BSN-JOBST, Charlotte, NC 28209). There is little information in the literature to support the topical application of zinc for wound healing. The success of this treatment application is most likely owing to the compression. It is an inexpensive means of covering a wound, providing compression and supporting the calf pump to empty venous blood from the LE. Unna's boot is not appropriate for arterial or mixed arterial/venous ulcers. Although the treatment is used frequently, there are other methods for combining compression with wound care to treat venous wounds.223
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Four-Layer Bandage System
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Four-layer bandage systems have been associated with leg ulcer closure. The system includes a wound covering with modest absorptive qualities and several layers of compression. The bandage system has been shown to be comfortable and cost-effective.224 An example of a well-known system is Profore™ (Fig. 14.37) (Smith & Nephew, Inc., Largo, FL 33773). For the appropriate patient, a four-layer bandage system can be left in place for up to a week.
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Long-Stretch and Short-Stretch Bandages
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Both long-stretch and short-stretch bandages are used to control edema and to supply therapeutic levels of compression to support the venous and lymphatic systems. Long-stretch bandages such as Ace (3M, St. Paul, MN 55144) bandages provide a high resting pressure, which means that they continue to constrict when the wearer is resting. Owing to their extensibility or stretchiness, they do not provide significant working pressure, the ability to resist muscle contraction during activity. Long-stretch bandages are readily available and require minimal training to apply. Short-stretch bandages such as Comprilan (Smith & Nephew, Auckland 1140, NZ) and Rosidal (Lohmann & Rauscher, Topeka, KS 66619) provide low resting pressure and high working pressure (Fig. 14.38). They are less extensible or stretchy, providing a more rigid shell when applied to a limb. This feature makes short-stretch bandages more appropriate for treating edema and lymphedema. Higher working pressures increase the efficiency of the muscle pump during activity whereas lower resting pressures make the bandages more tolerable to wear. Short-stretch bandages require special training to apply. The amount of working and resting pressure delivered to a limb that is bandaged will depend on several important factors: the number of layers of bandage, the age and condition of the bandages, the tension on the bandage when it is applied, and the skill of the clinician.225
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This highly specialized form of bandaging utilizes multiple layers of unique padding materials and short-stretch bandages to create a supportive structure for edematous and lymphedematous body segments. Lymphedema bandaging provides support for tissues that have lost elasticity; facilitates a mild increase in tissue pressure, assisting lymph vessels to empty; prevents refilling of the interstitium between MLD treatments; improves the efficiency of the muscle pump during activity; and provides localized pressure where indicated to soften fibrotic tissue.
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Bandaging protocols include techniques for applying compression to the head and neck, fingers, and hands (Figs. 14.39 and 14.40), UE (Fig. 14.41), and LE (Fig. 14.42). The chest, abdomen, genital area, and back can also receive specialized support from compression products.225
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As with MLD, the benefits of this treatment are not limited to the population with lymphedema. When compression is indicated, standard or modified lymphedema bandaging can be beneficial to the population with edema (e.g., post-operative, CVI, venous ulcers, orthopedic injury).226,227,228,229,230,231 To obtain contact information for training facilities that provide specialized education in bandaging as a part of CDT refer to Appendix 14.D.
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Many patient/client populations use compression garments (Fig. 14.43). Originally designed to assist venous blood flow in the LEs, they are now specifically designed to manage burn and surgical scars, provide support to venous circulation, and prevent reaccumulation of fluid in the lymphedematous limb. There are a variety of garment styles and fabrics, custom and off-the-shelf, to meet the unique needs of different populations. Varying amounts of pressure are woven into the fabric during manufacturing. The amounts of pressure are conveyed as millimeters of mercury (mm Hg). Low pressure would start at 12 to 25 mm Hg and higher pressures go up to 30 to 40 mm Hg. When appropriately selected and fitted by a trained professional and worn correctly by a prepared patient, the garments serve an essential role in managing chronic, life-long conditions such as CVI and lymphedema.225,231
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Garments should not be used as a treatment to remove excess fluids from an extremity. If applied to an extremity that has not been adequately evacuated, the garments will be uncomfortable and may worsen the patient's symptoms.232,233,234 Currently, manufacturers are participating in clinical research supporting the use of silver in compression garments. Juzo Silver (Juzo, Cuyahoga Falls, OH 44223) adds permanently bonded silver to the textile fiber of LE garments to inhibit bacterial growth and reduce odor.
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Limb Containment Systems
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Another option for some individuals is a quilted compression device or limb containment system. These unique compression options may be easier to don and doff, can be worn under short stretch wraps or alone, and can be custom made to any part of the body (Figs. 14.44 and 14.45). This option may be useful for a person who is unable to apply a more fitted support garment independently or whose skin is compromised or fragile. Patients find that these options are useful as part of their home program to retain reductions they have achieved through therapy. These specialized garments can be made to support venous circulation or lymphatic drainage through altering the style and the stitching channels to complement the diagnosis. A physical therapist can consult with the leading manufacturers to get advice on how to integrate the use of this type of compression into the POC or the after-care by contacting www.jovipak.com and/or www.solarismed.com.
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Compression Guidelines
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Compression treatment should be customized to the characteristics of each individual. Relative contraindications for compression should be evaluated, including history of DVT, acute local infection, CHF, cor pulmonale, and acute dermatitis. To assist in clinical decision making, the following is a summary of general guidelines for compression bandaging and garments for edema and lymphedema:
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Arterial wounds: No compression or very light compression with close involvement of the referring practitioner. Long-stretch bandaging or off-the-shelf low compression garment (12 to 25 mm Hg) can be used. Edema will not be great and will evacuate quickly.
Venous wounds: Compression is an essential component of treatment for wound healing and support of the venous system. Short-stretch bandaging with high working pressure and low resting pressure will facilitate the effects of the calf pump during activity. High pressure of 40 mm Hg at the ankle has been suggested.229 Compression garments at pressures of 20 to 30 mm Hg to 30 to 40 mm Hg are used depending on location and severity of swelling, as well as ability of the patient to don and doff garments.
Neuropathic wounds: Compression is contingent on blood flow. Fifteen percent of patients with a neuropathic condition also have an arterial component to their disease and must have an ABI checked before compression is applied. If no arterial involvement, compress with short-stretch wrap. Follow up with compression garments for long-term use at lower compression of 12 to 25 mm Hg up to 20 to 30 mm Hg.
Lymphedema: Short-stretch compression wrap until limb reduction goal reached then moderate to high compression garments at 20 to 30 mm Hg to 30 to 40 mm Hg depending on location and severity of swelling, as well as ability of the patient to don and doff garments.225
Edema: Case studies and reports from the field establish that the compression treatment for lymphedema also works well for edema.230 Short-stretch compression bandages are worn 23 hours/day, graduating to daytime only, decreasing as edema resolves. Off-the-shelf garments at lower levels of compression provide support for skin and help to retain reductions that therapy has achieved.
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Intermittent Pneumatic Compression
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Until the 1990s, intermittent pneumatic compression (IPC) was one of the few clinical interventions used to treat swelling (Fig. 14.46). Since then, new information about the physiology of edema and lymphedema, as well as lymphatic system function, has limited its value in treating some edema and most lymphedema. Intermittent compression pumps can facilitate venous return and may be an important adjunct to other forms of compression for the individual with a venous disorder.3,235 A review of the evidence provided only modest support for the use of IPC for the treatment of venous leg ulcers.236,237,238 Many individuals with long-standing venous insufficiency also have lymphedema. There is even less evidence and more controversy related to the use of IPC for lymphedema.239,240,241,242 If a trial of IPC is indicated, MLD should be delivered before and after each treatment to offset the negative effects of fluid pooling that occurs adjacent to the edge of the limb sleeves. If indicated for treatment, IPC pressure settings must be kept very low to avoid collapse of the superficial lymph capillaries. Each client should be carefully examined by an experienced health care professional before IPC is applied. Blood pressure readings should be taken before each treatment to confirm that IPC will be safe to use. Increasing total peripheral resistance with pneumatic compression will increase the work of the heart, increasing blood pressure. Pneumatic compression treatment is contraindicated for individuals with hypertension or a blood pressure reading greater than 140/90. Other contraindications to intermittent compression include acute inflammation or trauma, local infection, presence of thrombus, cardiac or kidney dysfunction, obstructed lymphatic channels, and impaired cognitive function.
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Sequential Pneumatic Compression with Truncal Component
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Advances in compression systems include more pneumatic chambers that inflate and deflate in a sequential pattern at very low pressures. The newest home use models include truncal decongestion and clearance in preparation for receiving lymph from affected areas. This appliance style mimics the benefits of MLD in the clinic setting (Fig. 14.47). Manual treatments clear the trunk proximally before treating more distal segments of the body. Stretch fabric is incorporated into the appliance design to further mimic the light stretch to the skin that is applied with MLD.74,243,244,245
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Positioning techniques are used to prevent or protect pressure ulcers, as well as other types of wounds, edema, lymphedema, and vascular disorders. This important aspect of intervention, as well as PRDs, should not be overlooked or underestimated during treatment planning. Devices and techniques selected for positioning should be compatible with the individual's health status. It is paramount that a personalized positioning and repositioning schedule be developed and prominently displayed for any patient who cannot position or reposition independently. The standard time intervals used for turning schedules (i.e., every 2 hours) are often too long for individuals who are frail, have fragile skin, or have existing wounds. A turning schedule could be as frequent as every 30 minutes in some cases whereas for other individuals, every 4 hours may be enough. Suggestions for patient positioning programs include the following:246,247,248
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The patient's heels should be protected and elevated off the surface of the bed.
The head of bed should not be elevated past 30° unless medically necessary.
An individualized turning schedule should be provided.
PRDs should be used in conjunction with a turning schedule.
Positioning with weight-bearing directly over the greater trochanter should be avoided.
Positioning with full weight-bearing over an existing wound should be avoided.
Donut-shaped devices for seating solutions should not be used.
Pillows and wedges should be used to separate bony prominences from bed and other body parts.
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Pressure-Redistributing Devices
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Pressure has a direct influence on perfusion or vascularity of a wound site. PRDs should be used to prevent skin breakdown, during the wound healing phase, and during the self-management phase, for life-long protection and prevention (Fig. 14.48). Along with positioning, patients and their caregivers must be educated about pressure redistribution and prevention of pressure-related trauma.249 Advances in support surfaces that redistribute weight have made them more sophisticated and effective (Fig. 14.49). Experts in positioning systems are readily available to advise and instruct clinicians working with special populations.250 Groups such as the Consortium for Spinal Cord Medicine, NPUAP, and HHS have made recommendations and algorithms for positioning and pressure redistributing devices that can be used for intervention planning.76,101,251,252
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The physical therapist should educate patients and promote activities in the POC related to increasing activity levels as appropriate. Too often, exercise is neglected in the intervention plan for individuals with vascular, lymphatic, and integumentary disorders, especially those with wounds or edema. Exercise is indicated for a variety of reasons, including, but not limited to, the following: increase strength and joint ROM, improve quality of movement, increase ADL, improve QOL perceptions, increase blood flow to the extremities, improve calf pump activity, prevent pressure ulcers, and enhance the effects of lymphedema bandaging. Exercise might be contraindicated or planned with caution when medical issues arise such as the need to be non–weight-bearing on a foot wound, unstable cardiopulmonary conditions, or related orthopedic problems that would limit activity.
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Exercise prescription should be customized to the patient's needs and medical status. A walking program can benefit most individuals who are able to ambulate even short distances. Water-based exercise programs can facilitate the transition from bed or chair to land-based exercise. Individuals with wounds can participate in water-based exercise if it is appropriate to cover the wounds with occlusive dressings. The hydrostatic pressure of water contributes to support of edematous and lymphedematous body segments and creates an ideal setting for exercise for most individuals with swelling.
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Patients should be educated about the concept that movement, activity, and formal exercise are all important for long-term management of the conditions listed in this chapter. Physical therapists introduce these concepts, provide expert instruction, and develop appropriate home exercise programs. Patients are guided to accept responsibility for following the exercise prescriptions at home and for making them a part of their everyday lives.
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Patients who are immobile may benefit from resting splints to retain, or dynamic splints to regain, functional ROM. Splinting can also prevent skin breakdown by retaining normal positioning of joints during periods of immobility. Extra precautions (i.e., padding) must be taken to protect aging or fragile skin from breakdown when semi-rigid thermoplastic materials are used for splinting. The use of splinting to manage burn scar is an essential part of the POC for an individual with a thermal injury (see Chapter 24, Burns). Positioning and splinting pointers found there can also be applied to patients with other types of wounds.
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Total Contact Casting
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One method for reduction of weight-bearing stresses on the foot is the application of a total contact cast (TCC). This method can be useful for the individual with a neuropathic ulcer on the plantar surface of the foot. After infection and swelling have been controlled, a plaster cast is applied from the toes to below the knee. A specially trained individual uses plaster, padding techniques, and the placement of a rubber insert on the weight-bearing part of the cast to complete the application. A TCC is usually worn for 7 to 10 days at a time, removed for skin care, and then reapplied. According to a classic article by Salsich et al,253 TCC is effective at healing ulcers initially, but the rate of reulceration once the cast is removed is high.
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A removable ankle-foot orthosis (AFO) can be custom fabricated or ordered prefabricated to provide weight distribution and cushioning for the individual with an insensate foot, a chronic foot ulcer, or Charcot joint (Fig. 14.50). This option is versatile in fit and allows skin checks, dressing changes, and pressure alterations as needed.
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Cast shoes or post-operative (post-op) shoes can be utilized as an inexpensive, temporary alternative for wound off-loading. These shoes, however, do not provide any means of controlling foot motion and little cushioning protection for the chronic wound. This option should be considered temporary. Patients wearing cast shoes for pressure distribution should be monitored closely for signs of complications.
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Extra-depth shoes have a roomy toe box and a deep sole to provide shock absorption and cushion. The shoes should redirect foot pressure away from bony prominences and wounds (Fig. 14.51).254 Available in many styles, they can be purchased from an orthotist or at a specialty shoe store. Individuals with insensate feet, with or without wounds, should strongly consider wearing this type of shoe to support skin protection and ulcer prevention.
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As described earlier in this chapter, scar formation is a component of wound healing.255 After the wound is filled with collagen, the tissue must be remodeled and shaped into the finely structured end product. Contraction of scar tissue can lead to disfigurement and loss of function, especially if the scar tissue is located over a joint surface. Issues of disfigurement and dysfunction are greatest following thermal injury (see Chapter 24, Burns). Currently, the mechanisms by which scar can be controlled are not completely understood. Although some interventions do seem to help, there is room for further investigation into how to achieve optimal control of scar formation. Most scar tissue is managed by a physical therapist using compression garments, stretching exercises, orthotics, positioning, specific types of massage, and the use of topical adjuncts such as silicone gel sheets (Fig. 14.52) and elastomer putty (Fig. 14.53). Topical creams, oils, and ointments have some positive effects on scar but it is not known if the massaging actions used to apply the agents or the agents themselves provide the therapeutic effects. Early and adequate intervention can prevent most of the complications of scarring. Since the process of scar formation usually continues for 6 to 24 months, follow-up care should be part of the intervention plan. Individuals with scar tissue must learn how to safely massage the skin at home because frequent pressure applications have the greatest influence on new connective tissue orientation. When conservative measures of scar management have not controlled scarring, surgical intervention may be indicated. Following surgery, the individual will have a new wound and subsequent new scar to manage.
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