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Burns, wounds, and physical therapy!
1. BURNS, WOUNDS,
AND PHYSICAL THERAPY!
BY: MICHELLE STAUFFER, SPT CLASS OF 2017
FACULTY MENTOR: DANIEL MALONE, PT, PHD, CCS
CLINICAL MENTOR: JODIE ROYER, RN, CNC (AT PRESBYTERIAN ST. LUKE’S)
CLINICAL MENTOR: DARCIE LUBY, PT, DPT, WCS (AT UNIVERSITY HOSPITAL INPATIENT)
2. OVERVIEW
Discuss various certifications available involving burn/wound care
Share interesting cases I experienced during my observations
Discuss key topics I researched
Explore physical therapy’s role in wound care
4. CERTIFICATIONS
CWCN: Certified Wound Care Nurse
Wound, Osteotomy, and Continence Nursing Certification Board
WCC: Wound Care Certification
National Alliance of Wound Care and Ostomy Certification Board
WCS: Wound Care Specialist
American Association of Wound Management Certification Board
5. CWCN
Directed for nurses
Must be a registered nurse (RN)
Must have a minimum of bachelors degree
Meet one of the 3 criteria:
50 ConED hours AND 1,500 clinical experience hours all in wound care within the last 5
years
Complete a wound, ostomy, and continence education program provided by the WOCN
board
Complete a graduate level nursing program with proof of course work
Renew every 5 years
6. WCC
Meet one of the 4 criteria:
Education through:
Wound Management Training Course
Active involvement of wound care full-time for 2 years or
part-time for 4 years all within last 5 years
Certification through:
Active certification of CWCN, CWON, CWOCN, WCS, or
WCSP
Experiential through:
Active involvement of wound care full-time for 4 years
within last 5 years
60 contact hours of wound care
Preceptor through:
Wound Management Training Course
120 contact hours with NAWCO clinical preceptor
Multiple health providers eligible:
RN, LPN, NP
PT, PTA
OT, OTA
MD, DO, PA
Renew every 5 years
https://www.nawccb.org/library/documents/Handbo
oks/WCC_Candidate_Handbook.pdf
7. WCS (WCSA OR WCSP)
WCS Eligibility criteria:
Minimum of bachelors degree
Wound experience for at least 3 years
Or completed fellowship of at least 1 year in wound
care
Practice as one of the professions seen on right
Interesting requirements:
Personal statement
Professional resume
Letters of recommendation
Recommended professions:
MD, DO, PA
PT, OT
DPM
RN
DMD or VMD
Renew every 10 years
http://documents.goamp.com/Publications/candidateHan
dbooks/ABWM-CWS-Handbook.pdf
8. PATIENT CASES
CASE 1: PILONIDAL CYST
CASE 2: BIPOLAR + OCD + WOUND
CASE 3: PIN FIXATION
9. CASE 1: PILONIDAL CYST
• Background: inflammatory process forms pit at
hair follicle base, hair folds below skin surface
further creating inflammatory process and
eventually cyst formation and potentially
infectious abscess
• Prevalence/Risk Factors:
• 2x Males > Females
• Ages 15 – 30
• Hairy body
• Overweight (BMI >25)
• Lack of hygiene
• Prolonged sitting
10. CASE 1: PILONIDAL CYST
Patient match:
Female
15 years old
Hairy body
Overweight
Sedentary lifestyle
Patient procedure:
3 cysts surgically removed
Large wound down to coccyx ~4in width,
6in length
Wound care:
Wound-Vac changed 3x/wk
11. CASE 1: PILONIDAL CYST
What treatment can physical therapists
perform to help healing?
Nutrition education
Importance of exercise
Hygiene education
12. CASE 2: OCD + BIPOLAR + WOUNDS
Male roughly 50 years old
Diagnosed with bipolar & OCD
Diabetes type 2, HBA1C level 10
Superficial stage 2 wound on posterior
neck
Stage 1 wound on forehead
13. CASE 2: OCD + BIPOLAR + WOUNDS
Healthcare: “I get aggressive with nurses touching me wrong”
Nutrition: “Sometimes I sleep for 3 days at a time and I’m not hungry”
Compulsions: “I feel there is something digging into my spinal cord and I need to
get out”
Delusions: “I can pull a string-like thing in my wound and I feel it here [front left
skull]”
14. CASE 2: OCD + BIPOLAR + WOUNDS
How do we as healthcare providers best treat this individual?
Support, caregiver
Frequent check ups on mood, exercise,
nutrition
CBT + physical activity + pharmacotherapy
Wound education, reassurance
15. CASE 3: PIN INSERTION
Severe burns to all extremities (60-70%
TBSA)
2-5 phalanges with pin fixation
Escharotomy to dorsal hand
16. Pin fixation and Kirschner wires
Both do the same thing
Pins have larger diameter to wires
Early intervention tool for traction of bone
fragment
See in orthopedics
CASE 3: PIN INSERTION
Patient developed osteomyelitis
Surgical removal of digits 3-5
Pinning prevents movement of
joint
Stiffness
Loss of ROM
Contracture?
22. PHYSICAL THERAPISTS IN WOUND CARE
Practice Act:
12-41-103. Definitions: (F) General wound care, including the assessment and management of skin
lesions, surgical incisions, open wounds, and areas of potential skin breakdown in order to maintain or
restore the integumentary system.
12-41-113. Special practice authorities and requirements – rules: (3) Wound debridement. A physical
therapist is authorized to perform wound debridement under a physician's order or the order of a
physician assistant authorized under section 12-36-106 (5) when debridement is consistent with the
scope of physical therapy
Rules/Regulations:
The term “wound debridement” as used in section 12-41-113(3), C.R.S., refers to sharp, enzymatic,
selective, and pharmacological wound debridement and can only be performed by a licensed Physical
Therapist unless otherwise authorized by Colorado law. Physical Therapists may not delegate such
wound debridement to unlicensed personnel, but may delegate soft or non-selective wound
debridement to Physical Therapist Assistants.
23. Strong associations between ankle ROM and calf strength with ulcer reoccurrence, healing, and size
Simple walking programs show improvements (gait speed correlates with life)
Electrical modalities have been proven to improve healing of wounds, particularly VLU
High-voltage pulsed current
Pulsed ultrasound
PT has low reimbursement rates, making it cost-effective
PT is another discipline involved = company makes more money
DRG’s
PHYSICAL THERAPISTS IN WOUND CARE
24. PT’S INDIRECT INVOLVEMENT IN WOUND CARE
Direct access
Primary care provider
PREVENTION!!!
Never too early to start
General health questions
Exercise
Diet
Hygiene
26. REFERENCES
1. PENG D, JIANG K. Comorbid bipolar disorder and obsessive-compulsive disorder. Shanghai Arch Psychiatry. 2015;27(4):246-248. doi:10.11919/j.issn.1002-
0829.215009.
2. Amerio A, Odone A, Marchesi C, Ghaemi SN. Treatment of comorbid bipolar disorder and obsessive–compulsive disorder: A systematic review. Journal of
Affective Disorders. 2014;166:258-263. doi:10.1016/j.jad.2014.05.026.
3. Pauls DL, Abramovitch A, Rauch SL, Geller DA. Obsessive–compulsive disorder: an integrative genetic and neurobiological perspective. Nature Reviews
Neuroscience. 2014;15(6):410-424. doi:10.1038/nrn3746.
4. Yim E, Kirsner RS, Gailey RS, Mandel DW, Chen SC, Tomic-Canic M. Effect of Physical Therapy on Wound Healing and Quality of Life in Patients With Venous
Leg Ulcers: A Systematic Review. JAMA Dermatol. 2015;151(3):320-327. doi:10.1001/jamadermatol.2014.3459.
5. Physical Therapists Practice Act.pdf. Google Docs. https://drive.google.com/file/d/0B-
K5DhxXxJZbZWgxLW9sYWRwbEE/view?usp=sharing&usp=embed_facebook. Accessed July 17, 2017.
6. Zhou K, Krug K, Brogan MS. Physical Therapy in Wound Care. Medicine (Baltimore). 2015;94(49). doi:10.1097/MD.0000000000002202.
7. Role of rehab in wound care. Wound Care Advisor. April 2015. https://woundcareadvisor.com/role-of-rehab-in-wound-care/. Accessed July 5, 2017.
8. Kloth LC. The Role of Physical Therapy in Wound Management - Part One. J Am Col Certif Wound Spec. 2009;1(1):4-5. doi:10.1016/j.jcws.2008.08.001.
9. Figee M, de Koning P, Klaassen S, et al. Deep Brain Stimulation Induces Striatal Dopamine Release in Obsessive-Compulsive Disorder. Biological Psychiatry.
2014;75(8):647-652. doi:10.1016/j.biopsych.2013.06.021.
10. Zschucke E, Gaudlitz K, Ströhle A. Exercise and Physical Activity in Mental Disorders: Clinical and Experimental Evidence. J Prev Med Public Health.
2013;46(Suppl 1):S12-S21. doi:10.3961/jpmph.2013.46.S.S12.
11. Sheridan RL, Baryza MJ, Pessina MA, et al. Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698
injured hands. Ann Surg. 1999;229(4):558-564.
12. Lindenhovius AL, Doornberg JN, Brouwer KM, Jupiter JB, Mudgal CS, Ring D. A Prospective Randomized Controlled Trial of Dynamic Versus Static Progressive
Elbow Splinting for Posttraumatic Elbow Stiffness: The Journal of Bone and Joint Surgery-American Volume. 2012;94(8):694-700. doi:10.2106/JBJS.J.01761.
13. Kowalske KJ. Burn Wound Care. Physical Medicine and Rehabilitation Clinics of North America. 2011;22(2):213-227. doi:10.1016/j.pmr.2011.03.004.
14. Clark DE, Lowman JD, Griffin RL, Matthews HM, Reiff DA. Effectiveness of an Early Mobilization Protocol in a Trauma and Burns Intensive Care Unit: A
Retrospective Cohort Study. Phys Ther. 2013;93(2):186-196. doi:10.2522/ptj.20110417.
15. Achauer BM, Bartlett RH, Furnas DW, Allyn PA, Wingerson E. Internal Fixation in the Management of the Burned Hand. Arch Surg. 1974;108(6):814-820.
doi:10.1001/archsurg.1974.01350300056015.
16. Studenski S, Perera S, Patel K, et al. Gait Speed and Survival in Older Adults. JAMA. 2011;305(1):50-58. doi:10.1001/jama.2010.1923.
Editor's Notes
Technically anyone can apply for this certification, but as the name implies it is best suited for nursing
A lot more encompassing than the CWCN.
The link is the handbook that includes all details needed to know about the test including topics covered
DMD: Dentist
VMD: Veterinarian
WCSA: associate good for nursing professions RN/LPN/PTAs/dietitians/medical sales professionals
WCSA Handbook: http://documents.goamp.com/Publications/candidateHandbooks/ABWM-CWCA-Handbook.pdf
WCSP: physician good for medical doctors MD/DO/DPM
WCSP Handbook: http://documents.goamp.com/Publications/candidateHandbooks/ABWM-CWSP-Handbook.pdf
Not much research on wound vac and pilonidal cysts
Few studies have proven beneficial…randomized prospective study saw vacs improved wound healing time, treatments needed, pain levels, and time to return to PLOF
PTs and nurses (without certifications) can change Vacs
Nutrition-every plate of food should be colorful like the rainbow, tans/beige/brown not typically good
Exercise of all types-standing to cook dinner, dancing with friends, taking stairs vs escalator in public places
Hygiene- regular showers, brushing teeth, washing clothes regularly
HBA1C want <7
OCD is tied with dopamine
OCD with bipolar 21% of bipolar cases
Treatments contradictory…SSRIs good for OCD but increase risk of mania in bipolar
Addiction/substance abuse common- caffeine, pain meds?
OCD creates enhanced and prolonged bipolar episodes
Compulsions arise during interims of depression/mania
Pilot studies…not strong evidence, small sample size but good initial research
OCD & bipolar can both benefit from exercise and physical activity (simple as walking)
Pin fingers (and toes) when tendon, bone, ligament is showing
Try to preserve the joint integrity to prevent loss
Get healthy tissue over injury site then operate to correct
Surgery only option to help with reoccurrence
Jas splint was no better than dynasplint
Good for burns as natural body process wants to move into plantarflexion
then the skin tightens
then contracture
http://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=2024
Extent of wound treatment varies state by state
Applied exercise science: 0.8m/s and increasing by only 0.1m/s increased life expectancy
Good article: “Effect of Physical Therapy on Wound Healing and Quality of Life in Patients With Venous Leg Ulcers: A Systematic Review”
Direct acesss means we need to educate our patients
we may be the first line of defense against something worse