information about wound. physiotherapy management of wound.

1. WOUND HEALING
SHRUTI PUROHIT
MPT IN REHABILITATION

2. • An injury to the tissue can be simply called as
a wound

3.  3 overlapping phase
1. Inflammatory phase
• Characterized by vasodilatation, release of
histamine and stimulation of nociceptive
receptors
• This can be correlated with redness, heat,
swelling and pain

4. 2. Proliferative phase
• Characterized by the formation of granulation
tissue
• Wound contraction starts
• Fibroblast in the wound develops in to
collagen matrix
3. Maturation /remodeling phase
• Remodeling of the new epithelium
• It is an ongoing processes even after wound
closure takes months to years
• Pt intervention starts at this stage

5.  3 tech of wound treatment
• Primary intention- surgically closed
• Secondary intension- close naturally
• Tertiary intention- left open for no. Of days and
then closed if it found to be clean.

7.  History
• It is taken to determine the primary problems
• History should include queries like mechanism
of injury, date of onset, progression
• How long has wound been present
• Treatment history to date
• What types of health-care providers have
been involved in the management of the
wound
• History of previous wounds

8. • Co-morbidities – Patient’s capacity to heal can
be limited by specific disease effects on tissue
like integrity and perfusion, mobility, compliance,
nutrition and risk for infection.
 Diabetes
• abnormal glucose levels are not compatible with
wound healing
• decreased sensation in feet cause high risk
for breakdown

9.  Vascular
• 1. Coronary Artery Disease – decreased
circulating oxygen
• 2. Congestive Heart Failure – edema in
lower extremities
• 3. Peripheral Vascular Disease –
inadequate vascular support
• 4. Peripheral Arterial Disease – inadequate
arterial support

10.  Cancer
• 1. Radiation – high risk or may cause skin
breakdown
• 2. Antineoplastic medications impair wound
healing

11.  Subjective examination
• It is to gather information about the current
symptoms
• He should be questioned about behavior and
characteristics of symptoms (pain associated
with wound or to any extremity, are there any
certain positions which keep symptoms better or
worse)

12.  Objective examination
• Here observation is the important component of
data gathering
• Typically includes-type of lesion (ischemic arterial
ulcer, venous insufficiency ulcer, neuropathic,
rheumatoid ulcer etc)
• Stage of wound (stage 1 to 4)
• Type of drainage- will check the amount, color,
consistency, and odor,serous (clear, watery);
serosanguinous (clear red or reddish brown);
purulent (thick, yellow, cloudy)
• Presence of edema

13. • Simple measurment: with tape, rular like
width×length
• Wound tracing: with pen outline the wound
directly on transperent film
• Scaled photograph: measure with scale on
photograph
• Computerized stereophotogrammetry: 2 pic of
same area taken from diff. positions to produce
a 3 dimentional image for measurement.

14. • Teach the patient self-care of wound
management and identification of signs of
infections
• Provide a moist wound healing environment
• reduces the necrotic tissue at wound site
• Decrease pain associated with wound
• Decrease the risk of infection
• Improve physical functions (if decreased
secondary to wound)

15. • Physical therapy intervention for wound
management includes verity of modalities and
appropriate wound dressing to promote healing
• The intervention plan should have a holistic view
eg: patient with signs and symptoms with venous
disease may also present with poor ankle
ROMs.
• Wound must be cleansed and dressed but
the limb should get compression for optimum
healing.

16.  Ultrasound therapy
• US can increase tissue temperature and it includes-
acceleration of metabolic rate, reduction or control of
pain and muscle spasm, increase circulation and
increase soft tissue extensibility.
• It heats smaller and deeper areas than most superficial
area. US heats tissue with high US absorption
coefficient- tissues with high collagen content like
tendon ligament joint capsule but not for fat with water
content.
• US is not ideal for muscle heating because of low
absorption but very effective in heating scar in muscle
area because of increased collagen content, open
wound

17. • Application of ultrasound stimulates cell activity and it
accelerate inflammatory process.
• The skin repair and wound contraction will be
accelerated.
• US stimulates the collagen secretion and have an affect on
elastin properties which strengthen scar tissue.
• Procedure is done by covering the wound by a hydrogel and
deliver US by a hand held applicator.
• Another option is apply US transmission gel over periwound
areaand treat from this region instead of the wound bed.

18. • The parameters that have been found to be
effective for healing wound is 20% duty cycle,
0.8-1.0 W/cm² intensity, 3MHz frequency, for 5-
10 minutes
• Treatment duration depends on the area of
the wound
• Peri wound tissue 1MHz, continuous mode, 1-
105w/cm2, 2-3 min
• Can be increased by 30sec to max 5 min ,
delivered 3times/wk.

20. .
 Electrical stimulation
• Electrical stimulation has effectiveness in facilitating
healing in both acute and chronic wounds.
• It is used to eliminate bacterial load, promote
granulation, reduce inflamation,edema,reduce wound
related pain
• Electric stimulation has a galvanotoxic effect on the
cells needed for healing
• By using high volt pulsed current (HVPC) directly in the
wound can create these changes –attraction of
neutrophils, macrophages, and epidermal cells which
facilitate debridement and reepithelialization

21.  Method of application
• Direct method of application-it includes an ES unit
treatment and non treatment electrodes and a
saline soaked gauze or hydro gel dressing over
wound bed to enhance electrical conductivity.
• -ve electrode for granulation tissue formation, +ve
gauze wrapped electrode applied over wound &
wrapped with strap or bandage for even pressure,
antimicrobial effect
• -ve electrode equal/ smaller than wound, +ve
electrode equal/larger than wound.
• Indirect method of application-here electrodes are
placed around the peri wound skin using gel.

22.  Stimulating electrode placement:
• Over gauze packing & hold in place with bandage
tape. Connect to stimulator lead
 Dispersive electrode placement:
• Proximal to wound, over soft tissue avoid bony
prominances
• Place wet lint pad under the dispersive electrode
• Pad should be larger than the sum of the areas of
the active electrodes and wound packing.
• Grater spacing, deeper current path for deep
wounds

23.  Dosage
• DC current: 10-50 mA/cm²
• Current applied each day for 45-60min , after
3-4 days when infection is clean, polarity
should be changed.
• HVPS: current intensity should be less than
that which will cause muscle contraction.
100HZ, >100 volts, 20-200micro sec

24.  PEME
• Short burst high freq current
• PD 65 micro sec
• Freq. 400ppm
• Duration 30min
• Electromegnatic energy fires ion molecules,
membrane & cell thus speeding up phagocytic
activity.

25.  Whirlpool bath
• Vasodilatation occur
• Removal of necrotic tissue, debris and topical
agent
• Clean the wound mainly

26.  Ionozone therapy
• Production of ionized steam containing water,
o2, ozone.
• Steam is directed horizontally with proper
position.
• Applied from 75 cm distance , 10-20 min
• Infected wound- daily
• Healing – 2-3 times/day

27.  IR
• Infrared red radiation increases local wound and skin
temperature facilitating metabolic rate and improving
circulation to the wound site.
• This technique is effective in treating chronic wounds even in
the presence of vascular compromise.
• Normothermia can be accomplished by warm up wound
therapy system which includes, delivering moist heat
through a non contact dressing.
• Using a warming card which is placed in a sleeve on top of
the sterile wound cover giving warmth up to 38° C.
• Increase metabolic rate, cutaneous vasodilatation, collagen
extensibility.
• For 10 min

29.  IONTOPHORESIS
• Movt. of ions across a biological membrane by
means of electrical current for theraputic
purpose.
• Wound clean with 1٪ zinc sulphate.
• Surrounding skin should be dried, zinc sulphate
gauze fitted over wound.
• Inactive electrode is attaeched to –ve terminal,
zinc electrode half inch smaller than pad
connected to +ve terminal.

30.  TENS
• 2 mechanism: produce VD via conductor
• Inhibition of sympathatic impulse by activation
of central seronegative systemor release brain
endorphin.
• For 30 min, pulse duration 0.2 ms, freq. 2HZ

31.  Negative pressure wound therapy(NPWT)
• Npwt is a wound healing technique used to facilitate
wound closure in acute surgical and challenging slow
healing wounds.
• VAC or vacuum assisted closure is the device used to
provide negative pressure treatment.
• An open cell foam dressing is placed in the wound and a
suction tube is connected from the foam to the portable
pump, an air tight seal is created over the foam and
suction tube with a film.

32. • A controlled amount of negative pressure (sub
atmospheric) is applied through the foam to the
wound bed.
• For the first few days 48hrs pressure applied
continuously via portable pump, after the
withdrawal of significant amount of wound fluids
it is done intermittently.
• The foam is changed in every 12 hrs(infected
wounds)

35.  Short wave diathermy
• PSWD have been used to treat chronic open wounds
• It provides radio waves to produce thermal and non thermal effect by
facilitating one phase of healing to next.
• PSWD heats superficial tissues and heats deep muscle and
joint tissue
• It increases fibroblast proliferation, collagen formation
and tissue perfusion, reduction of inflammatory process,
increased no. of white cells,fibroblasts in a wound,
improve rate of oedema dispersiton, absorption of
heamatoma
• Treatment is delivered usually with out touching the skin, but with
newer units pad can be placed over the wound dressing,
compression garments etc.
• 25-30w, 20 min, longer pulse duration.

36.  Ultraviolet radiation
• It is divided in to wavelength and bands
• Three bands useful for human skin are UVA,UVB
and UVC
• It has bactericidal effects and it increases blood
flow, enhance granulation tissue formation,
epithelialization, destroy bacteria, minimal
erythmea stimulation of vitamin D
• Procedure is done on a clean wound with dressing
removed using UVB or UVC lamp
• Treatment distance dosage frequency will vary on
the status of the wound

37.  For infected wound:
• Kromayer/water cooled lamp is used
• Uvc 100-280nm used, E4 dose, 2-3 times/wk
until wound is clear of infection.
• Then E1 dose is given to edeges &
surrounding skin to promote healing. Repeated
daily, edeges are coverd with saline gauze.
• It inhibit growth of bacteria, sterilization of
wound

38.  For non infected wound
• UVA/UVB is used
• High pressure mercury vapour lamp used
• Skin around wound protected with petroloeum
gelly
• Dose: E3/E4 used on floor
• E1/E2 used surrounding skin
• Promote granulation tissue, remove slough,
stimulate epidermal growth.

39.  LASER
• Due to wave length of 650,820,840nm
vasodilatation occur & macrophages are
stimulated, improve collagen formation, tissue
healing.
• Gridding tech, used for open wound, stimulate ATP
production, increase immune system
• Single spot method use for small open wound
• dose: wound margins- direct contact, 1-2 cm from
edeges, 4-10j/cm2
• Wound bed: non contact, 1-5j/cm2

40.  Hyperbaric oxygen therapy
• HBO delivers 100% o2 to an individual who rest
inside a sealed chamber at a pressure greater than
atmosphere (full body chamber)
• It increases the amount of o2 available for cell
metabolism, increase o2 in hypoxic tissue, rate
of collagen deposition.
• Topical hyperbaric o2 therapy THBO is used now a
days Instead of full body chamber, localized limb
chambers are used, so THBO delivered o2 directly
to the surface of the wound through a portable unit.
• It is also used in combination therapy along with
stimulation or with cold laser

43.  Compression therapy
• The concept of compression therapy is based on
a simple and efficient mechanical principle
consisting of applying an elastic garment around
an area of the body to control edema
• Edema not only inhibit wound healing by
affecting perfusion of the tissue but also
inactivates the ability of the skin to manage
Bactria
• It should apply as soon as signs of swelling
appears when leg wounds are present

44.  Elevation
• It is not a compression technique but used to
reduce some type of swelling (mild acute swelling)
and is a precursor to compression
• Proper positioning and active ROM exercise should
teach the patient in corporate with other means of
swelling controlling technique like compression etc
 Four layer bandage system
• Four-layer bandaging is a high-compression
bandaging system (sub-bandage pressure 35-
40mmHg at the ankle) that incorporates elastic
layers to achieve a sustained level of compression
over time. Since the development of the four-layer
system over 15 years ago.

45. • The four-layer bandage system is primarily used in the
treatment of venous ulceration and achieves healing in
patients with both deep, superficial and combined venous
incompetence. Four-layer bandaging can also be used to
prevent recurrence in patients who are unable to wear elastic
stockings.
• The short-stretch, elastic effect noted in four-layer
bandaging has made this a useful treatment.
 Indications
 Primary uses
• Treatment of venous ulceration
• Prevention of ulcer recurrence if hosiery is not
tolerated
• Symptomatic relief of superficial thrombophlebitis

46.  Other uses
• Traumatic wounds with local oedema, for example
pretibial lacerations
• Venous/lymphatic disorders
• Ulceration of mixed aetiology with an oedematous
component
 Contraindications
• Patients with heart failure should not receive high-
compression therapy. In this instance high compression
will redistribute blood towards the centre of the body,
thereby increasing the pre-load of the heart and possibly
causing further overload and death

47. • patients with severe obliterative arteriosclerosis
should not receive compression therapy.
 Application
 Layer 1: orthopaedic wool: Orthopaedic wool
provides a layer of padding that protects areas at
risk of high pressure
 Layer 2: crepe bandage: This is the least effective
layer as it simply adds extra absorbency and
smooths down the orthopaedic layer prior to the
application of the two outer compression bandages.

48.  Layer 3: elastic extensible bandage: It is a highly
extensible bandage that provides a sub-bandage
pressure of approximately 17mmHg when
applied at 50% overlap using a figure-of-eight
technique.
 Layer 4: elastic cohesive bandage: A frequent
misconception is that the outer cohesive layer
within the four-layer system is there simply to
maintain the bandage position. In fact, this layer
provides the higher level of compression (sub-
bandage pressure approximately 23mmHg)

50.  Long and short stretch bandages
• This both bandages are used to control edema and
provide compression to support the lymphatic
system
• Long stretch bandages provide a high resting
pressure means they constrict when the wearer is
resting.
• They do not provide significant working pressure.
they are readily available and easy to wear.

51. • Short stretch bandages provide low resting
pressure but provide high working pressure
• They are less stretchy, provide rigid
appearance after application and this make
more appropriate for edema treatment
• Working pressure increases the work of muscle
like pumping activity and lower resting pressure
make bandage more tolerable
• It need special training to apply like no: of
layers, age condition and tension of the
bandage etc.

52.  Lymphedema bandage
• This is highly specialized bandage with
multiple layers of padding materials and
short stretch bandage which provide
support to the lymph edematous body part.
• It provides support to the tissues with elasticity
loss and facilitates a mild tissue pressure to
empty the lymph vessels.
• It is applied to head and neck, chest,
abdomen, genital area and back.

55.  Compression garments
• It is widely used by clients all over the world, it is
designed to venous blood flow in Les.
• Now it is designed to manage burns surgical scars
to provide support to venous circulation ant to
prevent reaccumulation of fluids It is not used as a
treatment to remove excess fluids
• Another one is quilted garment which provide
compression which is used by person who cannot
apply support garment and whose skin is fragile.
• Venous return and lymphatic drainage is attained by
altering the stitching channels

58.  Guidlines for compression bandaging
• Arterial wound- no compression or very light long stretch
bandage in 12-25mmhg is used
• Venous wounds-compression is essential,short stretch
bandage with high working preassure 40mmhg
• Neuropathic wounds-if no arterial involvement compression
with short stretch wrap
• Lymphedema-short stretch compression wrap untle limb
• reduction then modarate to high compression 20-30mmhg 30 -40
mmhg
• Edema-same as lymphedema short stretch
compression 23hours/day.