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DEPARTMENTS: PRACTICE REFLECTIONS

History, Current Practice, and the Future of Wound Care for Occupational and Physical Therapists

Garber, Susan L. MA, OTR, FAOTA, FACRM; O’Sullivan-Drombolis, Deirdre BScPT, MClSc (Wound Healing)

Author Information
Advances in Skin & Wound Care: August 2022 - Volume 35 - Issue 8 - p 416-419
doi: 10.1097/01.ASW.0000822704.43332.7d
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Introduction

For the 35th anniversary of Advances in Skin & Wound Care, a variety of thought leaders have been invited to share their insight into a range of topics of current interest to the field. In this special installment of Practice Reflections, Susan L. Garber and Deirdre O’Sullivan-Drombolis discuss the past, present, and future of wound care for occupational and physical therapists.

Wound healing is a complex and intricate process that relies on all systems of the mind and body working together in an optimal way. As such, effective clinical wound management must tap into the knowledge and experience of multiple health disciplines, and this interprofessional approach is reinforced by best practice guidelines worldwide. Physical and occupational therapists are integral components of this wound care team. Stemming from a common past, these allied health professionals each bring unique knowledge and experience that offer great benefits to patients.

PHYSICAL THERAPY

The Past: A Historic Review of the Physical Therapists’ Role in the Prevention and Treatment of Wounds

During World War I, occupational and physical therapy aides comprised the Reconstruction Aides community. Reconstruction Aides worked with wounded soldiers to restore them to a physical condition that would enable them to participate in military duty or civilian life to the highest degree and as soon as possible. The occupational therapy Reconstruction Aides focused on education, recreation, and vocational training, and the physical therapy Aides centered their therapies on corporeal concerns.

Physical therapy treatments included hydrotherapy, massage, active exercise, and, later, electrotherapy and mechanotherapy. Perhaps the most well-known practice associated with physical therapists’ wound treatment was hydrotherapy, or whirlpools for cleansing wounds of debris and bacteria, easing the removal of adherent dressings, and softening necrotic tissue before debridement.1 The use of Reconstruction Aides continued during and after World War II, these aides (now called physical therapists) provided care in acute care hospitals to treat the injuries of war including burns, wounds, amputations, spinal cord injuries, frostbite, and fractures.2

In 1997, the Guide to Physical Therapy Practice was published and within it “integumentary” was recognized as one of the four primary physical therapist practice patterns. One year later, as physical therapists’ interest in wound care increased, a Wound Management Special Interest Group was established within the American Physical Therapist Association.

The Present

As the burden of wounds that fail to heal in a timely manner increased and with the extreme shortage of nurses, the inclusion of physical therapists on the wound care team became common place by 2012.3 Not only do physical therapists possess extensive education in pathophysiology, kinesiology, anatomy, physiology, and functional movement, which enables them to address the underlying causes of skin breakdown, their curricula also includes courses on modalities and procedures specific to wound care.4

Most entry-level physical therapists have the basic integumentary skills, available tools, and hands-on skills to provide care for patients with wounds. There are many postgraduate courses available should a therapist wish to expand on these skills. Wound care, including debridement and treatment below the dermis, are within a physical therapist’s scope of practice, provided they have the appropriate training. Currently, many of the treatments that physical therapist undertake, such as biophysical agents, edema management, offloading, and exercise have high levels of evidence to support their use in treatment plans for patients with wounds, which is reflected in numerous best practice guidelines.5

Despite this, physical therapists are often underutilized members of the wound care team.2 This may be related in part to how physical therapist services are reimbursed or may result from individual therapists not realizing how their knowledge and skill set can help patients with wounds.

The Future

Physical therapists are movement experts. Their extensive knowledge of the biomechanical and mobility deficits that may contribute to a patient’s risk of altered skin integrity enable them not only to reduce risk of skin breakdown but also aid healing. Addressing the cause of a wound is the foundation of any treatment plan, and impairments in body function and structures such as aerobic capacity, mobility, circulation, strength, joint mobility, and postural alignment are often the culprit.

As we strive to provide ever-improving holistic care, physical therapists must be part of every wound management team. They will help address both the underlying causes of the wound as well as the physical consequences that having a long-standing wound can have on function. Moving forward, this type of interprofessional care will include telehealth.6

The incorporation of contemporary skin and wound standards into physical therapy programs must continue. The American Physical Therapy Association initiated the next update to the curriculum recommendations for entry level practice standards in 2021. Interested physical therapists should seek specialty certification in wound management. Beginning this year, the American Board of Physical Therapy Specialties will offer an approved wound management specialty certification.

OCCUPATIONAL THERAPY

Historically, physical therapy Reconstruction Aides participated in direct wound care, whereas occupational therapy Reconstruction Aides used various handcraft and functional activities for patients in the orthopedic and surgical wards of military hospitals and for those with psychiatric disorders.7 Occupational therapists did not provide wound care interventions usually ascribed to nurses and later to physical therapists. Their route into the world of wound care came about in a different way.

The Past: A Historic Review of Occupational Therapists’ Role in Preventing and Treating Pressure Injuries

Occupational therapists have participated in pressure injury (PI) evaluation, treatment, prevention, and education since the early 1970s, when the federal government established Rehabilitation Engineering Centers (REC), the purpose of which was to place engineers and clinicians together to solve problems affecting large numbers of Americans with disabilities.8 The Institute for Rehabilitation and Research, Baylor College of Medicine Department of Rehabilitation, and Texas A & M University Department of Biomedical Engineering comprised the consortium of the Texas REC. Its core area was “the effects of pressure on tissue;” its mission was to develop clinical strategies and technology to prevent PIs in persons with spinal cord injury (SCI). The Texas REC hired an occupational therapist to lead the clinical studies and evaluate procedures and tools to prevent and treat PIs (then called pressure ulcers) in individuals with SCI.

The first project of the Texas REC was to evaluate a device designed to assess the interface pressure between the person and the seating surface. The commercial markets were exploding with new materials and designs for wheelchairs and their associated equipment, but these new devices were not scientifically evaluated for effectiveness and safety. Manufacturers of wheelchairs and seating systems (cushions and positioning devices) would “donate” their products to rehabilitation centers and request subjective information. The development of the Pressure Evaluation Pad, an interface pressure monitoring device, provided objective data to determine the effectiveness of the seating systems in reducing the pressure in vulnerable anatomic areas.9 Numerous cushions and bed surfaces of various materials and designs came onto the market; therapists now had a new tool and technology to identify the most effective and safe seating surfaces for their patients.

The Texas REC also established a Tissue Pressure Management Clinic in which a team of clinicians provided wound care, equipment evaluation, and individualized prevention education.10 Although occupational therapists did not perform wound care directly, they were the leaders in evaluating and providing effective wheelchair seating and positioning devices, prevention education for patients and families, and follow-up consultations. In addition, occupational therapists collaborated with nurses to assess specialty beds, bed surfaces, and positions that would reduce pressure on high-risk areas of the body while patients were confined to bed.11

The Present

In 1990, the US government, through the Agency for Health Care Policy and Research (AHCPR, now the Agency for Health Research and Quality) created clinical practice guideline panels to address some of the most frequent medical problems faced by Americans. The AHCPR identified PIs as a significant problem, especially among older adults and individuals with physical impairments. The AHCPR and panel Chair, Dr Nancy Bergstrom, sought an occupational therapist to serve on the panel. Since the mid-1970s, only one occupational therapist had been associated with PIs.13 She was assigned to the two clinical practice guideline panels: “Pressure Ulcers in Adults: Prediction and Prevention” and “Treatment of Pressure Ulcers.”12,13 In the late 1990s, the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine created panels to develop clinical practice guidelines specifically for persons with SCI. The PVA’s PI guideline panel was chaired by the aforementioned occupational therapist and those guidelines were published in 2002 and updated in 2014.14,15 All of these guidelines (AHCPR and PVA) were based on an extensive review of the published evidence. Hundreds of articles and reports were reviewed and graded for accuracy, scientific relevance, and level of evidence. In some cases, professional opinion was the only evidence available and was so noted.

Table - COMPARING PHYSICAL AND OCCUPATIONAL THERAPY ROLES IN WOUND CARE
Comparator Physical Therapy Occupational Therapy
Traditional roles Reconstruction Aides focusing on soldiers’ physical abilities including direct wound care, most notably active exercise and whirlpool baths Wheelchair, seating, and positioning evaluation; prescribe appropriate devices; patient/family education to prevent occurrence and recurrence.
Education Doctorate level in US, Masters level in Canada
Most programs provide basic information pertaining to wound care
Postgraduate courses available with direct wound care and debridement
No formal education courses in wound care; however, wheelchair mobility and its associated equipment are addressed in rehabilitation courses.
Skillset Movement experts with extensive training in anatomy, biomechanics, physiology, pathophysiology, and functional movement that enable thorough assessment and treatment of many of the underlying impairments that lead to altered skin integrity. Experts in evaluating for mobility equipment and associated devices; patient and family education are part of the treatment plan; occupational therapists acquire specific wound care skills from conferences, symposia, or professional organizations outside of occupational therapy.
Practice settings In most areas of care, including hospitals and rehabilitations facilities, private office practice, clinics (both private and publicly funded), home/community care, long-term care Rehabilitation centers; in-patient hospitals; nursing homes and assisted living facilities; home/community care.

In many facilities, multidisciplinary teams addressed PI prevention and treatment, with individual professionals responsible for very specific purposes.16 Usual practices, as reported by occupational and physical therapists, included patient education, remobilization, functional activities, and assessment of and prescription for equipment needs. In many facilities, occupational and physical therapists perform similar services.

In 2010, Australian occupational therapists explored the role of occupational therapists in wound care in the Hunter Region of Australia. They used semi-structured interviews with nine occupational therapists who were involved in “pressure care.” The results indicated that intrinsic and extrinsic factors influenced occupational therapy clinical decisions, including occupational therapy knowledge and experience, client-centered approaches, and availability of resources.17

In 2013, and updated in 2018, the American Occupational Therapy Association published a position paper “The Role of Occupational Therapy in Wound Management.”18,19 These documents are expansive in describing what an occupational therapist can do in the clinic, limited by each state’s practice act and licensure requirements. Unlike in the profession of physical therapy, there are no specific courses within occupational therapy curricula that address the specifics of wound care interventions. Occupational therapists interested acquiring knowledge and skills in this area of practice participate in continuing professional development activities through professional organizations or companies associated with wound care, PIs and their treatments, and associated technologies. Some of these programs certify the therapists as wound care specialists. Pressure injury prevention is addressed within many rehabilitation courses.

The Rehabilitation Engineering and Assistive Technology Society of North America was founded in 1979.20 Since that time, this organization has become the leader in setting standards and training in the areas of assistive technology and mobility. It offers certification in the areas of assistive technology, seating and mobility, and rehabilitation engineering technology.

The National Pressure Injury Advisory Panel (formerly the National Pressure Ulcer Advisory Panel) provides interprofessional leadership to improve patient outcomes in pressure injury prevention and management through education, public policy, and research. Their website (NPIAP.org) includes links to many free educational and clinical materials, white papers, position statements, monographs, and slide decks. Topics include wheelchair seating, positioning, cleansing wounds, pressure injury staging, nutrition and prevention, among many other related topics.

The Future

Beginning in 2021, the American Occupational Therapy Association offered examination-based advanced certifications to replace the previous peer-reviewed reflective portfolio application process. A new certification commission is determining the steps to transition to an examination-based program. Wound care and PI prevention, treatment, and education may be part of the program in the future although there are numerous clinical training and educational programs available from other sources. Most likely, it will be up to the individual states’ licensing boards to determine degree of training, education, and clinical practice within their states. However, occupational therapists continue to be leaders of PI prevention and education in many facilities across the US by objectively assessing each patient’s needs.

CONCLUSIONS

Occupational and physical therapists strive to optimize a person’s ability to participate in everyday life. Physical therapists focus on movement and how impairments in strength, range of motion, endurance, and balance negatively affect active participation and overall health, including the integumentary system. Occupational therapists focus on strategies, education, and equipment to facilitate engagement in activities of daily living, work, and leisure that reduce PI risk. Both have the foundation and skills to address not only the underlying causes of altered skin integrity, as per best practice guidelines, but also to promote independence and cooperation. Although occupational therapists and physical therapists are frequently part of an interprofessional wound care/PI prevention and treatment team, their skills are often underutilized.

Vigorous ongoing education is essential at every level of entry and postgraduate education if physical and occupational therapists are to be active and effective members of wound care and PI prevention and treatment teams. The governing bodies of both professions must support and advocate for physical and occupational therapists’ ability to engage in wound care and PI prevention. As innovative solutions in treatment and delivery systems evolve, they will bring interdisciplinary, client-centered teams together using telehealth, electronic documentation, apps, and social media—the way of the future.

REFERENCES

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