Physical Therapy for Chronic Ulcers in Long-Term Care

TO THE EDITOR:

I read with interest the article on chronic ulcers in long-term care by Dr. Paul Takahashi.¹ I am a Physical Therapist involved in skilled nursing facilities. I noticed the only mention of therapist involvement concerned the use of stationary arterial boots to augment blood flow for wounds of ischemic nature. Rehab has many more effective tools for addressing the complex needs of patients suffering from chronic wounds. Physical agent modalities such as electrical stimulation, subthermal diathermy, subthermal ultrasound, and infrared light therapy are supported in numerous randomized clinical trials as effective treatments for the closure of such wounds described in Dr. Takahashi’s review. The literature provides evidence of an average of 30-50% acceleration in the healing process for all four of these modalities. Medicare provides reimbursement for both estim and diathermy for wound healing. Unfortunately, ultrasound, while effective, is no longer covered by Medicare, nor is infrared light therapy based on its FDA approval; however, it too is an effective treatment option for wound healing. These modalities increase microcirculation in the treatment area, facilitate collagen production, stimulate healing, reduce edema, promote epithelial contraction, and reduce pain. Infrared light therapy is also an effective treatment for diabetic neuropathy by facilitating a cascade of events resulting in the neuronal axon repair. It’s unfortunate that this application is considered an off-label use, because it increases the patient’s sensation, and thereby reduces the risk of diabetic ulcers. Thermal diathermy can promote transitory increases in circulation by applying it over an artery proximal to the wound, which is effective for wounds that are ischemic in nature.

Medicare guidelines for physical agent modality treatment of wounds necessitates a 30-day period of documented skilled nursing treatment, requires the wound to be classified a Stage III or IV, and mandates that modality use is adjunctive to skilled nursing. It is imperative that both disciplines work together in managing these patients through coordinated treatments to accommodate dressing changes, measure the wound, assess pain, and assess efficacy. Both disciplines need to be involved in reviewing mitigating factors such as comorbidities, nutritional status, and labs to assess prognosis and alter plan of care, as necessary. The closure of any wounds is critical, as mentioned in Dr. Takahashi’s article, to reduce deleterious consequences such as life-threatening infections or life-altering amputations.

Many rehab departments in long-term care settings have some form of modality available to them to address wound healing in their population. Due to its success, it would be beneficial for more health care providers in this setting to realize the physiological benefits of physical agent modalities for healing wounds and improving the quality of life for their residents/ patients. In the same edition [July issue], there is an abstract touting the rising cost of liability for wounds of any nature, despite the care taken by the facility in minimizing the risk. Involving rehab in implementing a sound wound healing program can provide a reduction in wounds, improvement in quality of life, reduction in survey tags, and reduction in the liability exposure of the facility. Stephen Walker, DPT Rock Hill, SC

Reference

1. Takahashi P. Chronic ischemic, venous, and neuropathic ulcers in long-term care. Annals of Long-Term Care: Clinical Care and Aging 2006:14(7):26-31.

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RESPONSE FROM DR. TAKAHASHI:

Regarding Mr. Walker’s recent letter about the role of physical therapy in wound healing, I agree with his points and appreciate his perspective. Physical therapy has an extremely important role in the multidisciplinary care team in a skilled nursing facility. Each member of the team—nursing staff, physical therapy department, dietician, certified nursing assistant, and attending medical staff—provides a unique and specialized view of a new or chronic wound. Residents often utilize physical therapy for chronic wounds in long-term care for numerous reasons. Many wounds require the use of physical therapy modalities such as whirlpool for debridement or to enhance optimal blood flow; methods for enhancing blood flow are often dependent upon individual facilities. Only one or two modalities may be available at a single facility. Specialized wound care centers may have multiple modalities available to assist with nonhealing ulcers. The care team should utilize physical therapy modalities when appropriate to assist in wound healing in residents.

Paul Takahashi, MD
Mayo Clinic
Rochester, MN