Healing wounds with physical therapy: working with a physical therapist to help wounds heal--from severe burns to diabetic ulcers--ensures that your body's overall function is considered.

While most people think of exercising, muscle stretching, and strengthening when they think of physical therapy, specialists in the field also work with patients to heal acute and chronic wounds. "Having functional skin is vital to a patient having functional mobility," says wound specialist Pamela G Unger, PT, CWS, partner and director of administrative and clinical services at the Center for Advanced Wound Care in Pennsylvania. "Skin protects the joints and muscles. If you have an open wound on your leg, for example, and your leg is swollen, you won't walk as much or as well."

An increasing number of wound care clinics are physical therapy directed, says Unger. That's because physical therapists assess the entire body--how a patient's function is affected by a wound that won't heal--and then work with the patient to heal the wound while they perform more "traditional" physical therapy such as exercise, positioning, or use of modalities to maintain or improve function.

Leg and foot ulcers, most frequently caused by conditions such as diabetes and circulation problems, are among the most-often treated wounds. According to wound specialist Luther C Kloth, PT, MS, CWS, FAPTA, professor in the Department of Physical Therapy at Marquette University in Milwaukee, leg and foot ulcers fall into three main categories: venous insufficiency ulcers, arterial insufficiency ulcers, and diabetic/neuropathic ulcers.

Venous insufficiency ulcers. When the veins in the legs can no longer efficiently move blood out of the lower extremities toward the heart, a backup of venous blood occurs in the extremity. The result is increased pressure in the veins of the foot, ankle, and leg causing swelling that leads to ulceration.

Physical therapists are extensively trained in muscle anatomy and physiology, Kloth explains, making them experts at encouraging blood flow toward the heart through exercises that activate the calf and foot muscles. The physical therapist may recommend specific exercises or activities for patients who can walk, or, for people who are non-ambulatory, the physical therapist may apply pulsating electrical stimulation to make the calf and foot muscles contract. The physical therapist also may apply pneumatic compression and/or compression bandaging to the swollen foot, ankle, and leg to help reduce venous hypertension and swelling.

Physical therapists can teach patients how to use an electrical stimulation device at home, how to apply compression bandages themselves, and how to rest at different times during the day, raising the extremity to help reduce swelling.

Arterial insufficiency ulcers. When a person has plaque in his or her arteries, which deliver blood from the heart to the lower extremities, arteriosclerosis (calcified or blocked arteries) and/or atherosclerosis (narrowing of the arteries) can occur.

"If the blood does not supply adequate oxygen and nutrients to tissues," Kloth explains, "the cells begin to die. The dying and dead tissues can lead to dry gangrene," which most often initially affects the toes and foot.

Physical therapists may assess a patient's walking ability to determine if he or she experiences "intermittent claudication," or calf pain when walking, due to insufficient delivery of arterial blood flow to the calf muscles. In patients who are just beginning to show signs of arterial insufficiency and mild claudication, the physical therapist may develop a "progressive ambulation program," according to Kloth, working closely with the patient's vascular surgeon. There is current evidence, he reports, that some of these patients can actually develop new blood vessels by walking progressively longer distances.

Diabetic/neuropathic ulcers. A person with type 1 or type 2 diabetes can develop "peripheral polyneuropathy," Kloth explains, a condition in which certain nerves of the lower extremities no longer conduct impulses adequately. If you touch the foot of a patient with diabetes with a pinprick, for example, he or she may not feel it. Also, the patient's feet may not sweat adequately, making them dry and subject to cracking. Such patients are vulnerable to undetected foot injuries, which can lead to a plantar foot ulcer.

"The strategy here is pressure relief," Kloth stresses. "First, we evaluate the foot to see where the weight-bearing pressures are." If there is an open wound, "the patient may well be a candidate for a total contact cast," he says. This is a snugly fitting cast applied to the entire foot and ankle, up to the knee. It is designed to more evenly distribute pressure over the plantar surface of the foot when the patient is walking.

In all types of leg and foot ulcers, the correct dressing is vital. Selection of an appropriate dressing, and instructions for applying and changing the dressing, are all part of the physical therapist's plan of care, Kloth says.