Examining the Significance of Today’s PT Education on Wound Management

WATCH: Author Harriett B. Loehne, PT, DPT, CWS, FACCWS, discusses the article. 
LISTEN: Author Karen A. Gibbs, PT, PhD, DPT, CWS, discusses PT education standards in this exclusive podcast.   

Integumentary/wound management has long been a small but significant component of physical therapist (PT) practice. Historically speaking, PTs became involved in caring for wounds of burn patients due to their background and education in subjects such as anatomy, physiology, tissue healing, and, yes, even the now-dreaded use of whirlpool. As the profession of physical therapy has advanced and expanded, so has the knowledge and skill in the examination, evaluation, treatment, and prevention of open wounds. Changes in practice are reflected by changes in education and research. With the widespread initiation of evidence-based practice,¹ direct access,² and the shift to doctoral-level education,³ it never has been more important for PT graduates to be prepared to meet expectations of contemporary wound management.  While wound management is a very specific body of knowledge,⁴ concepts are incorporated across all practice areas^5-8 as all patients have skin (or a lack of it in the case of open wounds). The very foundation of physical therapy education and training gives today’s PTs a unique (albeit simple and elegant) perspective in treating patients who are living with open, chronic wounds – true functional wound healing and not just wound closure. A strong background in systems review and screening, tissue healing, infection, infection prevention, pathophysiology, and anatomy provide PTs with an excellent foundation for screening and differential diagnosis in the area of wound management. Principles such as range of motion, strengthening, mobility, gait, offloading, and return to function are tenants of PT practice and are a perfect complement to more traditional techniques focused on obtaining wound closure. Armed with this extensive background, PT graduates (unlike nursing graduates) also may perform sharp debridement in all 50 states as a component of entry-level education and licensing.

In order to meet high clinical expectations, entry-level education programs include semester-long courses dedicated to wound management, deliver content over multiple courses, present content in dedicated blocks of time, and/or provide content through some combination of these methods. To help guide educators in both initial development and periodic updates of wound management content, the American Physical Therapy Association (APTA) has published three consensus documents: Minimum Required Skills of Physical Therapist Graduates at Entry Level⁹ (Minimum Skills), Normative Model of Physical Therapist Professional Education¹⁰ (Normative Model), and the APTA’s Academy on Clinical Electrophysiology and Wound Management Guide for Integumentary/Wound Management Content in Professional Physical Therapist Education¹¹ (Wound Management Guide). These documents give an effective description of PT education and training in the area of integumentary/wound management. A brief description of each along with example content is provided within this article. 

APTA Curriculum Planning Documents

Minimum Skills. The Minimum Skills⁹ document provides educators with a general listing of overall skills that all entry-level graduates are required to demonstrate. Topics specific to wound management shown in Table 1 on page 13 include tests and measures for basic examination of the skin and peripheral circulation, identification of signs and symptoms of inflammation and infection, enzymatic and mechanical debridement, basic wound dressings and topicals, and the application of vasopneumatic and prefabricated compression garments and wraps.¹ In curriculum planning, this document is used as the most basic checklist to ensure education programs are including at least the minimum wound management content. Minimum Skills is available for free download from the APTA website (www.apta.org). 

Normative Model. The Normative Model¹⁰ expands Minimum Skills content by providing details for curriculum development and includes terminal behavioral and instructional objectives. Organized by practice expectations as well as foundational and clinical sciences, this document was designed with a dual purpose: assist academic faculty in curriculum planning and serve as a resource for the Commission on Accreditation in Physical Therapist Education in the accreditation of educational programs. Examples of wound management-specific learning objectives from the Normative Model are shown in Table 2 below. Where the Minimum Skills document indicates graduates are required to perform tests and measures of “peripheral circulation (deep vein thrombosis [DVT], pulse, venous stasis),”⁹ learning objectives in the Normative Model reflect the detailed knowledge and skill associated with evidenced-based critical thinking, integration, problem solving, and differential diagnosis expected of entry-level PTs:

• “Describe the pathology of vascular conditions.”
• “Evaluate PT interventions for commonly seen vascular conditions in terms of their evidence base in the scientific literature.”
• “Differentiate between vascular disease and neurological disease with similar signs and symptoms.”
• “Compare and contrast the signs and symptoms of occlusive arterial disease of the lower extremities with those of radiculopathy.”
• “Explain the medical and surgical management of patients/clients with vascular conditions commonly seen by PTs.”
• “… provide treatment for a 60-year-old Hispanic woman with diabetes mellitus type 2 and a foot burn.”¹⁰ 
  

Learning objectives in the Normative Model demonstrate the breadth and depth of entry-level PT education in the utilization of biophysical agents, medications, and imaging related to integumentary/wound management:

• “Describe the indications and contraindications of various therapeutic modalities used by PTs in the management of wounds and ulcers.”
• “Identify the pharmacological agents routinely prescribed for bacterial skin infections.”
• “Compare and contrast the effects of comorbidities and drug interactions on tissue healing.”
• “Identify the imaging techniques routinely prescribed for DVT.”
• “Use results of various imaging procedures for the integumentary system in patient/client management.”¹⁰

Detailed learning objectives, including those mentioned above and in Table 2, show the scope of foundational wound management/integumentary knowledge and skill in entry-level education. The Normative Model is published in book form and can be purchased from the APTA website (www.apta.org).

The Wound Management Guide¹¹ was developed to expand upon and integrate easily with Normative Model foundational principles and provides the most detailed information of all three documents. Unlike the other curriculum documents, the Wound Management Guide is presented as a source of recommended content that can be added so that a more complete program of study in integumentary/wound management can be offered to students. Of the three, it also is the only document that is entirely dedicated to integumentary/wound management content. The Wound Management Guide is designed to assist both the novice and the experienced wound management educator in designing specific learning activities during the didactic and clinical portions of entry-level PT education. Items listed as “primary content”¹¹ are paired with terminal behavioral and classroom instructional objectives. Unique to this document are instructional objectives specifically designed for use in the clinical environment. Clinical instructional objectives are written such that students with limited wound management opportunities during clinical assignments still can practice and utilize integumentary knowledge and skill. Examples of content from the Wound Management Guide are shown in Table 3. 

Concepts introduced in the Minimum Skills and Normative Model are expanded in the Wound Management Guide and convey the most accurate description of the well-prepared PT’s potential for participation in wound management. As an example, progression regarding the concept of inflammation and infection across all three documents is shown in Table 4 . 

Information in Table 4 demonstrates the higher level of integration and application of concepts presented in the Wound Management Guide. This document is available for free download from the APTA website as well as from the Academy of Clinical Electrophysiology and Wound Management website (https://acewm.org). Examples from the Minimum Skills, Normative Model, and Wound Management Guide clearly demonstrate the importance of PT inclusion and active participation on interdisciplinary¹² wound management teams, and show how the PT truly can bring a unique, function-based approach to wound management. While all entry-level programs must meet minimum required curriculum expectations, the challenge for all entry-level education programs is to develop curricula that provide sufficient recommended integumentary content that prepares graduates to fully serve patients with integumentary compromise.

Conclusions

From the most basic listing of general content topics to extensive and detailed classroom and clinical learning objectives, the three APTA documents presented here not only assist faculty in curriculum development, but also they stand to demonstrate the breadth and depth of the knowledge and skill in the area of integumentary/wound management of today’s PTs. However, considering a relatively small scope of practice and limited curricular contact hours, it can be challenging for entry-level programs to incorporate recommended integumentary content that extends beyond required material. Unfortunately, the gap between required and recommended content allows many graduates to move through entry-level programs with varying degrees of wound management exposure. Academic faculty members who are responsible for the delivery of integumentary content must continue to advocate for sufficient contact hours within entry-level programs. Likewise, clinical faculty must continue to offer experiential learning opportunities that include wound management exposure. Integumentary practice has advanced well beyond the days of whirlpool for open wounds and, with a strong focus on wound healing and return to function, today’s PTs are a primary component of the interdisciplinary¹² wound management team.

Karen A. Gibbs is associate professor in the department of physical therapy at Texas State University-San Marcos. Harriett B. Loehne is president of the Academy of Clinical Electrophysiology & Wound Management, American Physical Therapy Association, and Harriett B. Loehne & Associates, Fort Myers, FL.

References

1. American Physical Therapy Association. Evidence-Based Practice. 2008. Accessed online: www.apta.org/uploadedfiles/aptaorg/about_us/policies/hod/practice/evidencebased.pdf.

2. American Physical Therapy Association. Direct Access: How it Can Change Your Practice. 2015. Accessed online: www.apta.org/directaccess/howitcanchangeyourpractice.

3. American Physical Therapy Association. Vision 2020. 2015. Accessed online: www.apta.org/vision2020.

4. Horn, J. One program’s journey to joint commission certification for wound services. J Acute Care Phys Ther. 2012;3(3):242-245.

5. Hinkle C, Buchanan A, Pas J. Physical therapy management of patients’ status post-bariatric surgery in acute care: A systematic review. J Acute Care Phys Ther. 2013;4(2):45-64.

6. Horn J, Irion G. The integument: Current concepts in care at end of life. J Acute Care Phys Ther. 2014;5(1):11-17.

7. Samuriwo, R. Pressure ulcer prevention: The role of the multidisciplinary team. Br J Nurs. 2012;(Suppl):S4-S13.

8. Toma R, Brown S. Rehabilitation considerations and medical management in an adult patient with toxic epidermal necrolysis. J Acute Care Phys Ther. 2012;3(3):232-241.

9. American Physical Therapy Association. Minimum Required Skills of Physical Therapist Graduates at Entry Level. 2005. Accessed online: www.apta.org/uploadedfiles/aptaorg/about_us/policies/bod/education/minreqskillsptgrad.pdf.

10. American Physical Therapy Association. A Normative Model of Physical Therapist Professional Education: Version 2004. 2004. Alexandria, VA: APTA.

11. American Physical Therapy Association. APTA’s Academy of Clinical Electrophysiology and Wound Management Guide for Integumentary/Wound Management Content in Professional Physical Therapist Education. 2014. Accessed online:  https://acewm.org/integumentarywound-management-curriculum-recommendations-updated.

12. Moore Z, Butcher G, Corbett LQ et al. Exploring the concept of a team approach to wound care: Managing wounds as a team. J Wound Care. 2014;23(5 Suppl.):S1-S38.