PHYSIOTHERAPY IN WOUND
CONTENTS
Definition of wound
Classification
Phases of wound healing
Evaluation and stages of wound healing
Management
Types of wound dressing
Physiotherapy management
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INTRODUCTION
A wound is a disruption of normal anatomic structure
and function. Wounds result from pathologic processes
beginning internally or externally to the involved
organ(s).
An ulcer is a break in the continuity of an epithelial
surface either skin or mucous membrane due to
molecular death.
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CLASSIFICATION
A. Rank and Wakefield classification
1. Tidy wounds
surgical incisions and wounds caused by sharp objects
2. Untidy wounds:
Caused due to crushing, tearing, avulsion, devitalized injury,
vascular injury, burns.
May be associated with fracture of underlying bone as well
Wound heals by secondary intention
B. Other classification
6. Puncture wounds and bites
1. Clean incised wound
7. Abrasion
2. Lacerated wounds 8. Traction and avulsion injury
3. Bruising and contusion 9. Crush injuries
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4. Hematoma 10. Penetrating wounds
5. Closed blunt injury
CLASSIFICATION OF SURGICAL WOUNDS
1. Clean wound
Herniorrhaphy
Excisions
Surgeries of brain, joints, heart
Infective rate less than 2%
2. Clean contaminated wound
Appendectomy
Bowel surgeries
Gallbladder, biliary and pancreatic surgeries
Infective rate is 10%
3. Contaminated wound
Acute abdominal conditions
Open fresh accidental wounds
Infective rate is 15-30%
4. Dirty infected wound
Abscess drainage 5
Empyema
Infective rate is 40-70%
WOUND HEALING
Types:
1. Primary healing(first intention)
Occurs in a clean incised wound
Wound edges are clear and there is more epithelial
regeneration than fibrosis
2. Secondary healing
Occurs in extensive soft tissue loss.
Heals slowly with fibrosis
Leads to wide scar usually leading hypertrophy and
contarction.
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PHASES OF WOUND HEALING
1. Inflammatory phase (lag/substrate/ exudative phase)
Begins immediately after wound formation and lasts for4-6
days.
Shows features of inflammation: rubor, calor, tumor, dolor and
loss of function
Angiogenesis is enhanced through fibroblastic growth factor
Polymorphonuclear cells appears after 48 hours and secrets
inflammatory mediators and bacterial oxygen derived free
radicals
These cells also removes clots, foreign bodies and bacteria
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2. Proliferative phase (Collagen/fibroblastic phase)
Collagen and glycosamines are produced by fibroblasts.
It begins in 7 days and lasts for 6 weeks.
Hydroxyproline and hydroxylysine are synthesised by
specific enzymes using iron, alpha ketoglutarate and vitamin
C.
Tropocollagen is produced which aggregates to form
collagen fibrils.
80-90% of their final strength (in postoperative wounds) is
achieved in 30 days.
3. Remodeling Phase (Maturation phase)
It begins at 6 weeks and lasts for 2 years.
There is maturation of collagen by cross-linking which is
responsible for tensile strength of the scar.
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Collagen production is not present after 42 days of wound
healing.
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EVALUATION OF WOUND HEALING
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MANAGEMENT OF WOUND
Wound debridement (wound toilet, or wound excision) is
liberal excision of all devitalized tissue at regular
intervals (of 48-72 hours) until healthy, bleeding,
vascular tidy wound is created.
Primary suturing means suturing the wound immediately
within 6 hours. It is done in clean incised wounds.
Delayed primary suturing means suturing the wound in
48 hours to 10 days. It is done in lacerated wounds. This
time is allowed for the edema to subside.
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WOUND DRESSING
Types Characteristics Indications
Foams •Multilayer structure •Partial or full-thickness injury.
•Good absorption property, with a •Medium to massive exudation of
moist and warm environment for wounds. Absorbing effluent.
wounds.
Gauze •Woven/non-woven materials, •Suitable for one-time use in
mostly cotton. cleaning, hemostasis bandaging or
•Used to treat wound exudate, hygienic care of surgical or local
wound wrapping and protection. wounds in medical units.
•One-time use for operation
and wound care in medical
units.
Transparent •Polymeric materials •Suitable for treating superficial
membrane •Translucent allowing oxygen and wounds.
water vapor passing through •Protection of skin prone to abrasion
preventing water and germ from or external contamination.
passing through. •Maintenance of the first
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layer dressing.
Types Characteristics Indications
Alginates •Alginate is extracted •Wounds with partial to fullthickness
from algae. injuries.
•Woven or nonwoven •Medium to large exudates.
materials •Pithole or sinus tract.
strip and sheet dressings.
Composites •A combination of any •Grade II burn and small area Grade III
kind of dressings. burn wounds, surgical wounds,
infectious wounds, refractory chronic
wounds for debridement of rotten
granulation wounds and old granulation
wounds.
Hydrocolloids •Colloidal particles. •Superficial, moderately deep wounds
•Certain exudative absorption with small to moderate exudation and
capacity strong stickiness. desquamated or necrotic tissue.
Hydrogel Hydrogel sheet or amorphous Partial or full-thickness injury.
with rich water used for Necrotic or desquamate wounds small
auxiliary and autolysis to medium exudation.
debridement and softening Hydration promotes selfdissolving
eschar. debridement 13
Various wound dressings. A: Gauze dressing, B: Antimicrobial
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film dressing, C: Alginate dressing, D: Hydrocolloid dressing.
PHYSIOTHERAPY MANAGEMENT
Phototherapy
Therapeutic ultrasound
Electrical stimulation & electromagnetic therapy
Negative pressure wound therapy
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PHOTOTHERAPY
Low level laser therapy- deeper tissues
ultraviolet light – bactericidal effect
polarised light – polarises lipid bilayer, enhances enzymatic
activity
Modulate inflammatory responses, cellular respiration, promote
angiogenesis, fibroblast proliferation, collagen synthesis and
re- epithelialisation.
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THERAPEUTIC ULTRASOUND
Thermal effects- increased blood flow, collage extensibility
Non thermal effects- occur due to streaming and cavitation
Stimulation of protein synthesis, proliferation of fibroblasts and
inflammatory cells, increased angiogenesis, collagen deposition
and fibrinolysis, and release of cytokines and growth factors.
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ELECTRICAL STIMULATION AND
ELECTRO MAGNETIC THERAPY
Modalities- continuous or pulsed currents, high or low voltage currents, direct
or alternating currents.
facilitate the migration of epithelial cells and promote wound healing
Low-frequency electromagnetic field is known to influence the biologic tissue
in a variety of ways:
change in the permeability of cell membrane ion channels and signal
transduction, altered expression of genes controlling cellular proliferation,
increased cellular proliferation and epithelialisation, and enhanced
angiogenesis
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NEGATIVE PRESSURE WOUND THERAPY
Topical negative pressure (TNP) treatment involves negative
pressure on the wound surface to promote wound healing.
A pressure of −125 mm Hg is commonly used because this level
of pressure has been demonstrated to promote maximum increase
in tissue blood flow and maximum granulation tissue formation
increase in local blood flow, reduction of edema and wound
exudates, decrease in bacterial colonization, stimulation of cell
proliferation, induction of granulation tissue, and provision of
moist wound environment.
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