Physical therapists play a vital role on the multidisciplinary team in the treatment of wounds. It is crucial for PTs to know the scope and limitation of their practice and to communicate effectively with, and make referrals to members of the multidisciplinary team. Physicians should be aware of the progress or deterioration of the wounds being treated. The first step in wound management is the initial wound evaluation, which includes a detailed and comprehensive history and subjective examination. Before the scheduled appointment, review the patient’s medical chart to learn the patient’s sex, age, medical history, and occupation.

PTs should be aware of any pre-existing medical conditions, such as diabetes, hypertension, and peripheral vascular disease that often complicate and delay the normal healing process.¹ Lifestyle, occupation, and activity level may also be crucial factors in planning future treatment processes.

A comprehensive review of diagnostic tests, including pertinent laboratory values, is also necessary. The patient may have had —

• Nutritional tests check for malnutrition
• Vascular exams to show efficiency of blood flow
• Hematological tests to show the patient’s ability to fight infection through his or her individual immune system
• Wound cultures to identify etiogenic agents of an infection
• A culture to rule out the presence of Methycillin-Resistant Staphylococcus Aureus
• Tissue biopsy to rule out malignancy
• MRI and radiographs to rule out the presence of osteomyelitis or any infection

Next, gather the history of the wound: onset of wound, mechanism of injury, and symptoms. The chronological history of occurrence and progression is a very important detail in one’s assessment.

The last part of the evaluation process involves a more specific list of questions, such whether or not the patient uses alcohol, tobacco, and recreational drugs or if the patient is on any medications, including antibiotics or those for allergies. Finally, each patient should be asked about past treatments and whether or not they were effective.

The second part of the initial evaluation is the objective assessment. In this part of the evaluation, a therapist performs an accurate wound assessment before deciding on the course of treatment. The wound assessment should include objective measurements that will allow for constant monitoring of progress towards healing. Clinical measurements are taken first and serve as a point of comparison throughout the healing process. The location is noted as accurately as possible by documenting the exact location in the body. The locations of an ulcer can be one of the first indicators of its cause. When documenting the location of the wound, use anatomical landmarks for clarity. Specify the involved surface area (anterior, posterior, medial, or lateral). Photographs and illustrations can serve as support media for identification purposes and clarity. Describing the peri-wound skin is likewise important. In arterial disease, for instance, lack of hair and shiny skin may indicate poor circulation; a cyanotic appearance will further make a therapist suspect this problem. Trophic changes, such as dry skin, brittle nails, and hair loss, are indicative of poor nutrition to the area.

It is likewise important to identify the type of exudate (drainage) in the wound. Exudate is classified in terms of —

• Type: serous, purulent, sanguineous, or a combination
• Amount: minimal, moderate, or copious,
• Color: clear, red, yellow, white, or green
• Odor: absent, mild, moderate or excessive
• Consistency: thin or thick (otherwise termed purulent or pus-like)

The wound evaluation should include a description and identification of tissue structures. Red wounds are usually clean, healthy and granulating. Beefy red is the ideal description for a healthy granulating wound bed. Yellow wounds may be filled with fibrin or slough (necrotic dead tissue). Slough is a form of necrotic tissue which appears as moist, loose, stringy tissue which cause hypoxia to the wound area thereby inhibiting development of granulation and slows down healing and re-epithelialization.² Black wounds are usually covered with dry eschar. It is also important to note existence of other structures, such as bone, fascia, or tendon. Foreign debris and necrotic tissue should be identified firsthand and be removed as soon as possible to prevent higher risks of infection.

Length and width are used to document and describe the dimensions of wounds. The length of a wound is the longest distance from two points of the wound edges, and the width is the longest perpendicular distance as compared to the length. The depth is the deepest distance to the edge of the wound. In wounds wherein the wound has varying depths in certain points, the depth can be measured from shallowest to deepest points. It is also important to measure the depth in terms of direction or anatomical location. For instance, it can be noted as depth toward the medial or inferior border. Tunneling and undermining are also measured using a cotton swab. When describing tunneling, a therapist must denote the direction of the tunnel in terms of numbers in relation to the hands of the clock. Twelve o’clock to 6:00 indicates the cephalad direction, and 6:00 is the caudal direction. The clock method is also used to measure undermining (a range of rim under intact skin). 

Lastly, girth and temperature are also considered in the objective examination. Girth is measured to quantify the extent of swelling or edema. It can be used as a point of comparison during succeeding appointments to check if edema has resolved or subsided. Temperature is usually tested around the periphery of the wound by palpation to identify the severity of inflammation; it can also be used as an indicator of infection.

A thorough pain history is essential to wound management. There is widespread belief that pain is a major issue for patients suffering from many different wound types.³ A visual pain analog scale can be incorporated into an objective examination. This 0 to 10 scale gives the practitioner an idea of how much pain the patient perceives. Patient comfort is crucial and should be considered before treatment.

Depeding on the location of the wound, several additional tests need to be done. Specifically, for lower extremity wounds, a cutaneous assessment and peripheral arterial/venous assessment are needed before progression of treatment.

A sensory evaluation should always be performed on the involved side and compared to the unaffected side. Use of a cotton tip is the most basic assessment tool for this purpose. The Semmes-Weinstein Monofilament is used to determine cutaneous sensibility. The graded nylon filaments vary in thickness and are designed to bow after a specific force has been applied, thus indicating the cutaneous sensibility of the area tested.⁴ 

For patients with lower leg ulcers, it is very important to differentiate between origins (venous, arterial, or a combination of both). Take pulses (patient should be supine) before any treatment. In clinical practice, the two most important pulses are the dorsalis pedis and posterior tibial. A significant absence or decrease of an arterial pulse may be related to an arterial compromise or occlusion. Pulses are graded 3+ (bounding), 2+ (normal), 1+ (diminished), or 0 (absent).  

The rubor of dependency test is used to determine the adequacy of blood flow in the arterial system by assessing skin color in response to elevation and dependency of the extremity. The patient is positioned in supine with lower limb elevated to 60 degrees for one minute. The skin color during elevation is examined on the plantar aspect of foot. Individuals with normal arterial circulation will exhibit no significant change in skin color. However, in individuals with arterial compromise the foot will turn grayish-white (pallor) when it is elevated, and then will turn bright red (rubor) when the limb is in a dependent position as the arterial system attempts to compensate for tissue hypoxia.⁵ 

After palpating for pulses, using a Doppler ultrasound is effective for further determining vascular status. This is done by taking the objective clinical measurement of the ankle-brachial index. First, a sphygmomanometer cuff is placed around the leg at the malleoli level. The ultrasound probe is held over the dorsalis pedis artery or posterior tibial artery until the audible sound is at its strongest. The sphygmomanometer is inflated until the sound disappears; at this point, it is slowly deflated until the systolic pressure is recorded and the first sound appears. The same technique is done in the arm. The cuff is placed on the upper arm just above the elbow, and the Doppler probe is place on the brachial artery. The systolic pressure is measured. The ankle-brachial index is determined by dividing the dorsalis pedis or posterior tibial systolic pressure by the brachial systolic pressure. A ratio of >0.9 is considered normal. It is crucial to take the ankle-brachial index in patients with suspected venous disease — especially if the clinician is considering using a form of compression, such as an Unna boot.

Wound Treatment

In the clinical setting, wound treatment starts when the clinician cleanses and debrides the wound, decides on the main dressing, and considers other adjunct therapy, such as compression. It is ideal to cleanse wounds with normal saline or sterile water. Topical antiseptics like Betadyne and hydrogen peroxide should be used for wounds that are suspected for local bioburden because most of these agents have been proven to be cytotoxic. Only use topical antiseptics when the local bacterial burden is of greater concern than the stimulation of healing.⁶

After cleansing, debridement is the most likely next step. It involves the removal of nonviable or contaminated tissue, such as slough, fibrin, eschar, and biofilm. Studies have shown that although natural mechanisms exist to promote debridement, the process of debridement accelerates the wound healing process by facilitating the removal of wound debris that yield bacterial bioburden in wounds.⁷ There are five types of debridement:

• Surgical debridement, or sharp debridement, requires a high level of skill and training. Only trained healthcare professionals in approved care settings may remove devitalized tissue. According to the American Physical Therapy Association, sharp debridement, a component of integumentary repair and protection techniques, requires using scissors, scalpel, or forceps/tweezers. Depending on the state practice act, a physical therapist or physical therapist assistant can perform conservative sharp debridement of nonviable tissue alone.
• Autolytic debridement is the process whereby dressings are used to create an environment capable of softening and liquefying slough and promoting granulation tissue at the same time. Autolytic debridement is a selective form of debridement.⁸ In autolytic debridement, wounds’ own fluids containing macrophages and neutrophils digest and soften necrotic tissue.⁹ This is usually used in preparation for sharp debridement. Examples of autolytic dressings are hydrogels, hydrocolloids, transparent films, and alginates.
• Enzymatic debridement is the most selective mode of debridement and relies on the natural enzymes to break down debris. Currently, only Collagenase Santyl is the approved and licensed enzymatic product. Collagenase exists in wounds naturally as a matrix metalloproteinase, where it has been shown to degrade immature collagen in the wound matrix. It is believed that collagenase aides in removal of substrates necessary for bacterial proliferation.¹⁰ Enzymatic debridement appears to be most useful in removal of eschar in large wounds when sharp debridement cannot be used. Before applying the enzymatic agent, use cross-hatching or scoring so the enzymatic ointment can penetrate deeper into the nonviable base.
• Mechanical debridement involves the physical removal of debris from the wound. The simplest method is using the wet-to-dry technique wherein the moist gauze is placed into the wound and is allowed to dry out prior to removal of the gauze on the next dressing change. This process allows the nonviable debris to stick to the gauze and be physically removed from the wound bed. Other methods include pulse lavage and whirlpool therapy.¹¹
• Maggot therapy debridement has been used for many years to treat nonhealing wounds.  Larvae are used to debride, disinfect and promote healing of chronic wounds and its use in the wound management market is on the rise.¹²

After a thorough debridement of nonviable tissue, a skilled clinician should choose the most appropriate dressing for the current wound status and tissue presentation. Wounds are complicated and are influenced by many variables. For this reason, a clinician should be prepared to change dressing choices when wounds show changes in presentation throughout the healing process. Appropriate treatment of wounds should be dependent on a thorough wound assessment as well as a complete and thorough assessment of the patient. The primary goal in choosing a wound dressing is to provide an environment that will enhance wound healing to the optimum level. It is a golden criterion that a wound heals better when a moist wound environment is maintained; thus, that should be the driving point in choosing the most appropriate dressing:

• Absorptive dressings are composed of highly absorptive layers of fibers. They are designed to minimize adherence to the wound and manage exudate.
• Alginate dressings, on the other hand, are nonwoven, nonadhesive pads derived from seaweed. These dressings form a moist gel when exudate saturates the fibers. Alginates are indicated for wounds with moderate to heavy exudate. They prevent wound maceration because of their high absorptive capacities. Alginates also come in rope format or ribbon form for packing.
• Antimicrobial dressings deliver antimicrobial agents such as silver, iodine, and Polyhexamethylene Biguinide against common infectious bacteria. They are indicated to reduce the risk of infection. Next in line are biological dressings, which are naturally derived from sources, such as pig’s intestinal mucosa. They come in gel, solution, or sheet form.
• Collagen dressings are the next batch of dressings. They can be gels, pads, particles, pastes, powders, sheets, or solutions. Collagen can be derived from bovine, porcine, or avian sources.
• Composite dressings are wound covers that combine varying components into a single product to combine functions, such as bacterial barrier, absorption, and adhesions. These dressings are multi-layered. Contact layers are thin, nonadherent sheets used to protect tissues from direct contact from other dressings, which tend to stick to the wound.
• Hydrogel dressings are basically made of water that aims to hydrate the wound. They often come in tubes and can be used in combination with nonadherent dressings, such as contact layers. They can also come in sheets that promote increased moisture in the wound bed.
• Impregnated dressings include gauzes and nonwoven sponges, ropes, and strips saturated with a solution, an emultion, oil, or some other agent or compound. Petroleum products are usually the most common types in this category. These dressings are nonadherent and are indicated in minimally draining wounds.
• Silicone dressings are soft wound covers composed of polymers reinforced with mesh or fabric.
• Transparent film dressings are adhesive dressings that are impermeable to liquid, water, and bacteria but permeable to moisture vapor and atmospheric gases at varying degrees.
• Wound fillers are dressings that come in various forms such as beads, creams, foams, gels, ointments, pads, pastes, powders and strands. They are used to maintain a moist wound environment and manage exudate.
• Foam dressings are thick dressings that are used to promote a high level of absorption. Foam dressings can also come impregnated with antimicrobial agents like silver.
• Gauze and nonwoven dressings are constructed of gauze and dry woven sponges and wraps that are used to cleanse, pack, and cover a wide variety of wounds.
• Hydrocolloid dressings are available in wafers, powders, or pastes. Wafers adhere to the wound and surrounding skin and are used to promote autolytic debridement.

There are also specialized ointments and creams used in the realm of wound care:

• Collagenase santyl is the only approved enzymatic debrider agent that is used to soften non-viable tissue adhered to the wound bed. It can also be used to soften thick eschar that needs to be prescoured or crosshatched for most optimal effect.
• Silver Sulfadiazine is a common antimicrobial agent that is used for deeper burns that require antimicrobial protection and to soften adherent slough in burns.
• Regranex (becaplermin) gel is indicated for diabetic foot ulcers. It contains beclapermin, a human platelet-derived factor for topical administration. It helps by promoting growth of cells that promote healing.
• Xenaderm (balsam peru/ castor oil/ trypsin) ointment is used for wound healing in the treatment of partial-thickness wounds particularly for incontinence-associated injury to the skin. This ointment physiologically stimulates blood flow to the wounded area in the capillary bed and acts as a protective covering between the skin and external moisture, irritants and infective agents.
• Sulfamylon (mafenide acetate) cream is an antimicrobial agent similar to Silver Sulfadiazine. It is often used for burns especially in cartilaginous body parts.
• Bactroban (mupurocin) is another antimicrobial agent that is also widely used for burns. It is primarily used when a patient has a Methycillin-Resistant Staphylococcus Aureus infection.

Honey-based dressings, which have been used in wound management for more than 4,500 years,¹³ are reintroduced in the market and are said to promote antimicrobial properties.  They are benefititng from new dressing technology as they now come in hydrocolloid sheets, combined with an alginate or a gel. They all promote autolytic debridement. Honey’s high osmolarity aids in cleansing and debridement and reduces edema and pain.¹⁴