With more than 3 decades of experience, Carrie Sussman first became interested in treating those with wounds when she was working as a geriatric PT. Though not currently in a clinical practice, she still works to provide the best possible care for patients as a guest lecturer, writer, and policy advocate for those with wound pain. She also hopes to educate clinicians who treat chronic wounds, empowering them with information and support.

One result of her efforts, along with the work of others in the specialty, is that awareness of wound pain management has increased in the clinical world, particularly among PTs.

Sussman recently spoke with Physical Therapy Products about the current challenges associated with chronic wounds, trends in treatment protocol, and why PTs are best suited to this type of work.

HOW DID YOUR WORK AS A GERIATRIC PT LEAD YOU TO WOUND CARE?

In my practice, I was providing rehab services for patients in long-term care facilities. I often worked with patients who had hip fractures, and one of the most common wounds I would see was pressure ulcers. In particular, pressure ulcers on the heel, which frequently occur after a hip fracture. Similarly, we dealt with patients in that same environment who had had strokes, and they would develop pressure ulcers on the seating surface.

The wounds made rehabilitation very difficult. It is very hard to teach patients sitting balance, and sit-to-stand activities, with a sore on the butt.

IS THAT WHY MANAGING WOUND PAIN IS SO IMPORTANT, BECAUSE THE DISCOMFORT IMPEDES PATIENT PROGRESS DURING REHABILITATION?

That is one component of it, certainly. If you hurt, progression through a functional program doesn't work.

HOW IMPORTANT IS IT FOR PTS TO BECOME INVOLVED IN WOUND PAIN MANAGEMENT?

Very much so. It is a natural fit, because PTs are chronic pain managers.

The source of the pain is usually trauma; a chronic wound frequently occurs because of an insult or trauma to the tissues. A wound may be due to pressure or it may be due to an internal condition such as venous disease; it may be due to a surgical wound that didn't heal correctly. There are a variety of ways in which wounds occur—but they are basically the result of some type of insult to the tissue.

And what does a physical therapist do? We treat tissue dysfunction. In fact, one of the four principal areas detailed in the APTA's Guide to Physical Therapist Practice is management of the integument.

So, is looking for wounds part of the initial assessment therapists are already performing?

That is exactly right. As part of the medical screening of the patient, the PT has access to a lot of skin visibility and they need to think in terms of overall integumentary integrity. They may be the first to discover a venous ulcer, for example—or the potential for a venous ulcer when they are examining a patient for gait. This is often the case because when treating a patient with a gait disability, physical therapists are looking at feet and they may be seeing a lot of edema, they may see discoloration, varicosities—they are looking at the skin, and it is telling them the story of the patient's problem.

AFTER THAT INITIAL ASSESSMENT, HOW SHOULD PTS APPROACH WOUND TREATMENT?

Let's talk about something like a venous ulcer. In that case, the standard of care is using a compression system. It depends on the specifics of the situation as to what type of compression, but physical therapists will definitely be in the role of recommending, as well as applying, the system and teaching the patient about how to use the appropriate compression for their problem.

PTs may also notice that the patient is already being treated, perhaps by another health care professional, for a venous ulcer. And that provides an excellent opportunity in which the disciplines can collaborate on the problem.

HOW DO YOU ADDRESS BOTH THE WOUND TREATMENT AND THE PATIENT'S PAIN?

Currently, one of the A-rated, evidence-based treatment interventions for wounds is electrical stimulation. At this time, the FDA has not given clearance to any company or any product for the use of electrical stimulation in wound healing. However, they have approved the devices for treatment of pain.

There are several references in the literature where researchers have performed RCTs (randomized controlled trials) for pain relief —neuropathic pain and postsurgical pain, among others—and in multiple guidelines, the use of electrical stimulation is recommended for wound healing. And this is "Level One" or "A-Level" evidence.

In this instance, using the electrical stimulation systems for an off-label use is a utility—and one that is being recognized more widely. As more evidence becomes available to support it, it will start to become part of more and more guidelines, because if you can treat the wound and the pain concurrently, you have a win-win situation.

ARE THERE ANY PARTICULAR SYSTEMS YOU ARE AWARE OF FOR THIS TREATMENT?

The most commonly used devices are the high-voltage stimulators, and there are a number of companies that make them, including Empi and the Chattanooga Group. There are multiple manufacturers on the market, but those two come to mind immediately.

In addition to the traditional method that most people think of about electrical stimulation—which is using a contact electrode on the skin and transferring the current through the skin or through the wound bed—the alternative method of applying electrical stimulation is performed using a coil, which has an electromagnetic field that induces the electrical current within the tissues. This is a form of diathermy; it is classified as a radio frequency, but it is a form of induced electrical stimulation.

There are several brands that are available for diathermy systems. Invivo Technologies is one, Regenesis® Biomedical Inc is another, and International Medical Electronics Ltd, which manufactures the Magnatherm, a device capable of being used as a thermal or nonthermal device, is another.

One advantage of using diathermy is that these are radio frequencies. Just like with a stereo, you can hear the music through walls. Consequently, you can use that capability in the way you treat patients. If your patient's injured tissues are underneath a cast—such as a total-contact cast on a diabetic patient or a patient who has had a traumatic wound that has resulted in a fracture that requires immobilization—a current can pass through a cast or through a dressing.

This means you can induce without having to remove the dressing. This is particularly helpful with negative-pressure therapy, for example. That is a big padded dressing, and this type of therapy can be performed right over the top of it—you don't have to remove the dressing.

As a result, your therapy doesn't have to coincide with the dressing change, as it does if you are using direct-contact, capacitive electrical stimulation. So there are some definite advantages to one method over the other.

DO YOU SEE ANY OTHER TRENDS DEVELOPING IN WOUND CARE AND THE MANAGEMENT OF WOUND PAIN?

Yes, there is another trend getting a lot of attention, and that is ultrasound. Now, I would like to clarify one thing: we are moving away from calling these devices modalities. We are now calling them biophysical agents or biophysical technologies.

WHY IS THAT DISTINCTION IMPORTANT?

Because "modalities" is very generalized, and it is really an old term. It can also be used to describe other types of treatments—for example, dressings have been qualified as modalities.

So there is a distinction, and it is important to make it. We think in terms of technology, and we also think in terms of more biologic treatments, so using more modern language, we will get the attention of health care professionals and patients. If we can connect the dots for people, they get it; they more fully understand the work we are doing and what we are trying to achieve. If we just say these are PT modalities, it really doesn't mean anything.

LOOKING AT ULTRASOUND, HOW IS THAT USED FOR THIS TYPE OF TREATMENT?

Ultrasound is an up-and-coming trend, but in a new way.

One such product is called MIST™ Therapy, and it is manufactured by Celleration Inc. It's the only one of these biophysical agents that actually has a merchandising allowance for wound healing. The MIST therapy system is a low-frequency ultrasound, and it is used to clean and stimulate granulation tissue for wound healing.

There are a couple of other forms of ultrasound that are now being used, and one is the type of ultrasound being used for wound debridement. The Qoustic Wound Therapy System™ from Arabella Medical is one of these types of systems.

These ultrasound devices are believed to have a beneficial effect in clearing the wound of biofilms. Biofilms are a type of infection where you have colonies of bacteria that live together so that wound healing is arrested. They don't necessarily show up as a blatant infection, so they don't necessarily overwhelm the host, but they really can diminish the healing response significantly.

Electrical stimulation also can control wound infection; there are a number of studies that show that as well. But right now there is a lot of attention on ultrasound and using it in these new ways.

Ultrasound can also be used as a diagnostic tool, because it can be used to look at soft-tissue injury, such as pressure ulcers that have not expressed themselves.

WHY IS IT IMPORTANT FOR PTS TO BE INVOLVED IN THIS TYPE OF TREATMENT?

This is part of our education and background, it is part of our licensure. And these are treatments backed by significant evidence—this is evidence-based practice.

ARE THERE ANY CASE STUDIES THAT COME TO MIND?

I have a patient I've worked with as a consultant for a number of years. He's a quadriplegic, and he has had a history of pressure ulcers on his ischial tuberosity. He uses electrical stimulation on a prophylactic basis as well as a treating basis.

Prophylactically, he uses it for muscle stimulation—to improve the development of his gluteal muscles—and also for improving the circulation in the region. He sleeps with the electrical stimulation on at night, using it to increase the blood flow to the tissues. This is another treatment practice for which electrical stimulation is approved by the FDA.

Our results have been intermittent, small tissue breaks which heal up with continued care. And when every so often he does see a breakdown—which is usually small—he uses the electrical stimulation for wound healing.

He has been doing this for about 7 or 8 years now, and during that time he has not had one major pressure ulcer. He is able to be up in his wheelchair and to be interactive with his family because of it.

Dana Hinesly is a contributing writer for Physical Therapy Products. For more information, contact .