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Stages of Wound Healing

Patti Sharp, OTD, MS, OTR/L, BCP

June 16, 2021

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Question

What are the stages of healing and what is anti-deformity positioning? 

Answer

Wound Healing

  • Response to injury is proportional to the trauma
  • Many internal and external factors impact healing 
  • Prolonged or delayed healing leads to scar formation, which can result in deformity and functional deficits
  • The physical therapist’s (or occupational therapist’s) job is to promote optimal healing while preserving factors which contribute to function (ROM, joint integrity, muscle strength, neuromuscular control, etc.)
  • Can be broken into 3 main phases

The three main phases of wound healing are the inflammatory phase, fibroplasia and proliferation, and finally maturation and remodeling phase.   

Inflammatory phase 

  • Begins immediately after injury
  • Marked by influx of white blood cells, vascularity, and swelling to promote healing 
  • This phase facilitates rapid healing but can persist and tend to “over-heal,” which results in scarring

Therapy's main role in this stage is to immobilize and protect affected joints and to keep joints in antideformity positions.  

The body wants to move into a position of comfort with everything flexed which is a position of comfort.  However, that's a position of deformity.  All of our functional movements are with extension at most every joint.  That is the position we function in the world.  For larger injuries, traumas, and burns, bed positioning occurs early on should occur.  For smaller injuries, splinting and wrap the body areas is done to prevent those contracted deformity positions.  We want to preserve extension and regain flexion. You can always regain flexion, but it's really hard to regain extension if you've let something heal in flexion.  That is the concept of anti-deformity positioning.  

Fibroplasia and Proliferation

  • Begins 4-5 days after injury and lasts two-six weeks
  • The stage is marked by collagen synthesis and hypersynthesis (Tomasek, et al, 2002)
  • Wound healing begins with the appearance of granulation tissue

Therapy's main role in this phase is at weeks one to three immobilizing and protecting affected joints to allow for increased vascularization and protect new collagen deposits (Bouffard, et al., 2008).  Weeks three to six include progressive mobilization of joints to facilitate tissue growth and elongation as well as joint function. 

Maturation and Remodeling

  • Collagen fibers need assistance to reorganize otherwise tend to bunch up and will line up along the lines of stress (Ghosh, et al., 2020)
  • Tensile strength of collagen steadily increases and can pull joints out of place – estimated 12 times that of normal skin
  • Normal skin can stretch up to 50% of original length; active scars can extend 15% and mature scars only 4% (Parry, et al., 2019)

Therapy's main role in this phase is to mobilize joints, using pressure and stretch to match the increasing tensile strength and use of orthoses as needed to counteract tensile strength.  

For more information on scar management and the therapist's role, check out the course, Scar Management for Therapists


patti sharp

Patti Sharp, OTD, MS, OTR/L, BCP

Patti Sharp is an occupational therapist at Cincinnati Children’s Hospital. She worked primarily in pediatric burns for several years, and now works with a wide variety of patients in pediatric rehabilitation. Her recent work has focused on bridging her burn experience with general pediatrics, bringing scar management care to post-trauma and post-surgical children. Patti has a passion for evidence based practice and aims to share that passion with students and peers. 


Related Courses

Scar Management for Therapists
Presented by Patti Sharp, OTD, MS, OTR/L, BCP
Recorded Webinar

Presenter

Patti Sharp, OTD, MS, OTR/L, BCP
Course: #4058Level: Introductory1.5 Hours
  'wish that she had spent more time on treatment'   Read Reviews
A review of scar biology and abnormal scar development, with a focus on those scars that may pose barriers to function, is included in this course. Information on conservative care provided by PTs, including scar assessment, intervention, and outcomes measurements will also be provided. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Wounds in Patients With Neurological Impairments
Presented by Quyen Catania, PT, DPT, CWS, CLT, NCS
Recorded Webinar

Presenter

Quyen Catania, PT, DPT, CWS, CLT, NCS
Course: #4357Level: Intermediate2 Hours
  'teaching style'   Read Reviews
This webinar introduces participants to the different types of wounds commonly found in patients with neurological impairments. It provides clinicians with basic treatment and risk reduction techniques to utilize in their practice settings. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Swell to Well: Wound Management for Clients Living with Lymphedema
Presented by Neely Sullivan, MPT, CLT-LANA, CDP
Recorded Webinar

Presenter

Neely Sullivan, MPT, CLT-LANA, CDP
Course: #3666Level: Introductory2 Hours
  'CDT learning'   Read Reviews
This seminar will describe the anatomy and physiology of the lymphatic system in relation to risks for developing wounds. This session will also focus on different types and stages of wounds commonly occurring and outline wound management interventions for individuals living with lymphedema. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Therapist's Management of Upper Extremity Burns
Presented by Nora Barrett, MS, OTR/L, CHT
Recorded Webinar

Presenter

Nora Barrett, MS, OTR/L, CHT
Course: #3411Level: Advanced1 Hour
  'Very informative'   Read Reviews
This course will cover the therapist’s management of upper extremity and hand burns from acute injury through scar formation with rehabilitation implications including edema management, orthotics, precautions and appropriate exercise throughout each phase. Wound coverings, dressings, and scar management techniques will be addressed. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA

Physical Therapist Screening of the Integumentary System, the Window Into One’s Health
Presented by Lydia Thurston, PT, DSc, ATC
Recorded Webinar

Presenter

Lydia Thurston, PT, DSc, ATC
Course: #3944Level: Intermediate2 Hours
  'The topic was well thought out and instructor was very thorough and detail oriented in the topic that was presented'   Read Reviews
A 2-hour intermediate continuing education course for clinicians interested in strengthening their knowledge and skills in the screening examination of the integumentary system. Clinical decision-making concepts and integumentary conditions will be reinforced and applied in a primary care approach to physical therapist examination that can be seamlessly integrated into inpatient, outpatient, and wellness-based physical therapist practices. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

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