1-25 Wound Healing (OT643) – Flashcards

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Learning Objectives ***USE TO TEST KNOWLEDGE FOR EXAM!!!***
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At the end of the session, students will be able to: 1. Define mechanisms and types of wound healing:, including tissue repair, tissue regeneration, primary closure, and secondary closure. 2. Describe what is happening physiologically to the body during the inflammatory, proliferative (reconstruction and epithelialization) and maturation (remodeling) stages of wound healing. 3. Describe implications for OT treatment at each of these stages.
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Learning Objectives 2
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4. Explain why treatment post tendon injury requires a balance of immobilization and mobilization for an optimal functional outcome. 5. Describe treatment for fractures, including open vs closed reduction and types of fixation (cast/splint, internal fixation, external fixation). 6. Describe the difference between flaps and grafts for reconstruction of tissue deficits (skin, skin and underlying soft tissue, tendons, bones)
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Learning Objectives 3
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5. Describe pain assessments used in occupational therapy. 6. Explain options for pain management that are within the scope of occupational therapy practice.* *Note: Creating specific evaluation and treatment plans for pain management will be covered in more detail in subsequent classes. The objectives are intended to provide an overview.
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Tissue Damage Relevance to OT
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- Many diagnoses include injury and/or pathology that impacts the skin and musculoskeletal system. - Occupational therapists must consider this in d`eveloping evaluation and treatment plans in order to: + Avoid further injury + Facilitate healing +Preventing impairments that may result from scarring or immobilization + Anticipate, identify, and address occupations impacted by tissue damage, wound healing, and scarring.
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Mechanisms of Wound Healing
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- TISSUE REGENERATION +Regeneration of identical cells without loss of function - TISSUE REPAIR +Damaged tissue is replaced, but new tissue lacks the structure and function of the original tissue. - PRIMARY CLOSURE (skin): Wound edges are in close proximity with little or no tissue loss - SECONDARY CLOSURE: Wounds heal through contraction & re-epithelialization
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Wound Chronicity
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- ACUTE WOUNDS or healing wounds are those that progress in an "orderly and timely" reparative process - CHRONIC WOUNDS or non-healing wounds may: + Heal more slowly than normal + Recur + Not heal at all
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Wound Healing
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All tissues follow the same wound healing process. • The variation in cellular make-up of different types of tissue warrant consideration. - Three (or 4) overlapping phases of wound healing *+ INFLAMMATORY* ==>1 to 6 days for skin wounds *+ PROLIFERATIVE (reconstruction & epithelialization)* ==>3 to 20 days for skin wounds *+ MATURATION (Wound closure)* ==>14 days to 1 year for skin wounds* *Time frames are approximate and are impacted by the preceding stage and additional factors
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1. Inflammatory Phase
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- Begins at time of injury & lasts up to 6 days - Cardinal signs: + Warmth +Redness + Swelling + Pain + Decreased function
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1. Inflammatory Phase: Physiological Response
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- Biochemical, cellular, and vascular - First requirement is to stop bleeding (Haemostasis) +Vessels vasoconstrict (briefly) and clotting occurs +Fibrin strands create a network to stabilize the platelet plug -Vasodilation of surrounding vessels to: + Increase blood supply for healing + Neutrophils proliferate and migrate into the wound + Macrophages come into the wound, clean up the dead Neutrophils...this needs to happen otherwise stage will not progress... - Prepares the wound for closure
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1. Inflammatory Phase: O.T. Treatment
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- Immobilize, if needed, in position of function - Keep wound moist and reduce bacteria - R.I.C.E. may be indicated, depending on tissue + Rest + Ice + Compress + Elevate - Goal is to control edema, prevent dysfunction - Wound care: Keep area moist - Modify activities, as needed, to protect wound
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2. Proliferative Phase
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- Begins after inflammatory phase resolves - May last anywhere from 14 to 20+ days - Two components/phases: + Reconstruction + Epithelialization
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2. Proliferation Phase: Reconstruction
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- Fibroblasts migrate to the area, secreting a matrix of collagen and elastin + This cross-linking within this new connective tissue increases the strength of the wound + Fibroblasts appear in large numbers around day 3 and peak in numbers around day 7 - New blood vessels grow into the matrix - Vascularized matrix called granulation tissue - Wound also contracts from the edges (i.e. pulling wound together)
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2. Proliferation Phase: Epithelialization
2. Proliferation Phase: Epithelialization
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- Migration of epithelial cells (keratinocytes) across the surface of the wound + From wound margins, remnants of hair follicles, sebaceous, and sweat glands - Vascular tissue recedes - The proliferative phase is complete when a collagen layer has formed and epithelium has covered the wound
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2. Proliferation Phase: O.T. Treatment
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- Movement helpful, if not contraindicated + Depends on tissue type and severity of injury - Continue to keep moist and prevent infection - Heat and/or cold may be used but must be monitored + Depending on wound, heat and cold may be contraindicated - Monitor pt. for increased pain or swelling - Grade activity depending on wound strength
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2. Proliferation Phase: Goal Of Treatment
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- Increase passive range of motion - Gentle tension to increase tensile strength - Begin scar remodeling with movement - Help pt. feel comfortable with gentle use - Prevent position of dysfunction
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3. Maturation Phase
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Begins as early as 2 weeks and can last up to one year (see pics)
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3. Maturation Phase: Physiological Response
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- Fibroblasts begin to disappear - Capillary density decreases (less red) - Collagen: key factor in remodeling + Predominant constituent of the wound matrix + Reorganizes to increase wound strength + Scar tissue typically remains weaker than normal tissue + Initially, type III collagen predominates, then balance between type III and type I is restored
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3. Maturation Phase: Physiological Response (cont'd)
3. Maturation Phase: Physiological Response (cont'd)
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- As remodeling occurs, collagen fibers increasingly assume characteristics of tissue - Longer remodeling time, increases likelihood of hypertrophic scarring (skin healing) (pic 2) + Excessive, raised scarring - Keyloids are a scars that extend beyond the wound margin (pic 1)
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3. Maturation Phase: Complications of Scarring
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- Poor cosmesis - Change in skin function + sweat glands + sebaceous glands + resistance to mechanical forces + hair follicles (depending on depth of injury) - Loss of PROM (and AROM)
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3. Maturation Phase: O.T. Treatment
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- Scar management + Pressure ==; Garments ==; Silicone/scar pads + Stretch ==; Reorganizes for increasing tensile strength + Friction massage ==; Mobilizes fluids ==; Breaks up adhesions
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3. Maturation Phase: OT Treatment Cont'd
3. Maturation Phase: OT Treatment Cont'd
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- Tissue stretching for increasing ROM + May use dynamic splinting - Strength building
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Tendon Healing
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- Lacerations or complete tears require surgical repair...WILL NOT HEAL ON ITS OWN!!! - Treatment requires a balance of: + Immobilization to let the tendon heal...BUT SOME NEEDED...SO... + "CONTROLLED" Mobilization to prevent adhesion/scarring of the tendon to adjacent structures ==> Gliding is crucial to tendon function - Knowledge of tendon healing is crucial + Used to determine safe advancement of exercise and activity SCARRING IS PERSON DEPENDENT!!! FLEX PROTOCOL
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Tendon Healing 2
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- Inflammatory phase: + Tendon is at its weakest + Usually from injury to about 4 weeks - Proliferation phase: Tendon gaining tensile strength + Still at risk for overstretch or rupture + Usually from week 4 to 7-8 weeks post repair - Remodeling phase: Tensile strength continues to increase and remodeling occurs + Collagen remodels in response to stresses + Usually from 7-8 weeks until 12 weeks post injury
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Complications from Tendon Repair
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- Tendon rupture (NO PAIN HAPPENS, no nerves...JUST POPS!) + Requires additional surgery - Lost PROM + Tendon shortening + Secondary shortening of joint structures - Lost AROM + Adhesions limit tendon glide + "Lag" from overstretch (primarily finger extensors) (PROM SHOWS TISSUE IS SOFT, BUT ACTIVE SHOWS PATHOLOGY)
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Fracture healing
Fracture healing
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- Stages are the same - With good alignment, bone will have the same tensile strength and function of original bone https://www.youtube.com/watch?v=VZF3xicLtT
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Facilitating Fracture Healing
Facilitating Fracture Healing
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- Reduction: Approximating the fracture ends + Closed reduction + Open reduction - Fixation + Cast or splint + Internal fixation (XRAY PIC) + External fixation (TWO EXTERNAL PICS)
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Facilitating Fracture Healing 2
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- Movement limitations + Immobilization + Restrictions - Resistance restrictions + Lifting + Weight-bearing
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When Wounds Won't/Don't Heal
When Wounds Won't/Don't Heal
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- Grafts: Transfer of tissue from one area of the body to the injury site...THIS OCCURS IN HOPES OF VASCULARIZATIONS WILL ATTACH AND KEEP TISSUE ALIVE...IF DOESN'T, TISSUE WILL DIE W/IN 1-2 WEEKS + Skin grafts + Tendon grafts + Bone grafts
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When Wounds Won't/Don't Heal 2
When Wounds Won't/Don't Heal 2
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- Flaps (MORE THAN A GRAFT CAN PROVIDE) + Requires a blood supply + Examples: ==; Cross-finger flap (TOP PIC...SEWN MID TO INDEX FINGER FOR BLOOD SUPPLY) ==; Free flap ==; Groin flap (SEW HAND/FINGER INTO GROIN...must keep other fingers mobile)
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Pain Evaluation
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- Informal Assessment + Patient reports ==; What makes worse, better. ==; Where, when, how does it feel + Pain diary + Non-verbal behavior - Pain Scales + Visual analogue scale (VAS) (10 cm line w/NO hashmarks...much more objective) - Functional Outcome Scales + DASH (Disabilities Arm Shoulder Hand) + PRWE (Patient Rated Wrist Evaluation)
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Pain Treatment
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- Medical Treatment + Systemic ==; Narcotics ==; Anti-inflammatories + Local/regional blocks (catheter w/anesthetic release)
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Pain Treatment 2
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- OT Treatment Positioning Relaxation Disattention Guided Imagery Movement Non-painful manner ROM Dance (Harlowe ; Yu) Positioning Relaxation Disattention Hypnosis Distraction Guided Imagery Positions without movement Positions with movement (Mirror Box)...unilateral can help contralateral healing Body Mechanics Manual Therapy Massage Myofascial Release to break adhesions Physical Agent Modalities
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