The Best Shoes to use when Engaging in Lymphedema Therapy


When your patient has chronic edema or lymphedema, your therapy may need to include Complete Decongestive Treatment (CDT). CDT includes manual lymphatic drainage, compression, skin care, exercises, and patient education- and is the gold standard of treatment for those with swelling issues. It, however, can come with some complications- namely, what are the best shoes I can wear when I am getting treated for lymphedema?

Complete Decongestive Therapy is an essential treatment tool that all physical and occupational therapists should have in their arsenal- to read more about the benefits of CDT, check out some of our other edema-related articles!

When it comes to the practicalities of these techniques, however, one issue that patients and therapists can both bump on a lot is – “what are the best shoes can I wear when I am going through though the ‘compression stage’ of lymphedema treatment?”. Using short stretch bandages and foam as a part of your multilayered compression wrap is widely accepted to be the best way to treat fibrosis, edema, and get great results- but it can make the foot bulkier and thus impossible to get into previously used shoes. So, what to do?

Grab some edema management resources for your clinic right here!

Well, firstly- assure your patient that using short stretch bandages and foam is likely to be a relatively short-term part of their treatment. The overarching goal usually is to get the person into a compression garment that they can use long-term, which are far less bulky. Using adjustable bandages is essential for the initial phase of treatment, as the persons limb may be decongesting rapidly, as well as requiring an increased level of compression. Once the limbs have decongested to the stage where a garment can be used, they are often able to return to the footwear they were using previously. In the meantime, I suggest to my patient to get some larger, adjustable shoes that they can use during this phase pf treatment. Depending on the physical status and lifestyle demands, the person may even want more than one pair of shoes they can use- which can increase costs. Therefore, I’m including here some of the favorite shoes that I have personal experience with, don’t break the bank, and that I recommend to my patients, as well as the pros and cons of each!  

1.Darco Body Armor Cast shoe

You may already be familiar with the phrase Darco shoe, which has been synonymous with a ‘cast shoe’ in medical circles. The old style of cast shoe was a flat base with straps- and essentially merely acted to save the base of the foot or cast from contact with the floor. These certainly didn’t do much for walking or support!

This new style of Darco shoe is far better, as it offers a lot of structure and support, as well as being adjustable to the size of the foot within the bandages. These have been among the best shoes our patients with lymphedema have used. I also like that this shoe has a rubberized sole for walking outdoors, and that you can order them in singular, which can work well for your patient who has unilateral edema. Right now, this shoe can be ordered for $25.99 on Amazon, or $20 on the Walmart website.  

2.Top adjustable slipper

best shoes lymphedemaThese slippers are clearly very appropriate for a bandaged foot, as they have a deep, top-sided Velcro opening that accommodates the bandages and adjusts as the bandages flattens and the foot decongests. This shoe has been reported to be very comfortable by all he patients I have had that have used it- where it comes short is on the weather- accessibility, as well as the aesthetic (depending on the age range and preferences of your client).

If your client wants to have an indoor and an outdoor shoe, this is definitely a good choice for indoor shoe, to keep the bandages clean and keep your client from slipping. I would advise a client to order these in a half size up. Right now, these slippers run $22 on Amazon.  

3.Extra wide Velcro sneaker

best shoes lymphedemaFor indoor/outdoor use, these wide sneakers are a good option, especially for your more active patients who will be covering a lot of ground, and need something supportive. These shoes have been a popular choice amongst my active clients, as they can be ordered in one size up and will accommodate the bandages well. There are several color options also, which is important- your client should feel engaged in this process as much as possible to have a sense of ownership over their wellness journey.

The main drawback to this shoe is that, although they accommodate a good amount, they are somewhat less spacious than an option like the DARCO shoe. If this is the shoe that your client selects, you may want to adjust the thickness of your bandage and use the inherent compression of the shoe to help maintain the ideal pressure level on the foot. This shoe is also far better if you are ordering shoes in winter or your live in a wetter part of the world! Currently, $39.98 on Amazon.  

4.Diabetic shoes

best shoes lymphedemaDiabetic shoes can be a helpful corner of the market to explore, as they typically prioritize the shoe’s ability to expand. They should also have soft material and no rough inner edges that can injure the foot (or, for our purposes, snag on the bandages). There are often a range of options to choose from, including open toe, sandal, closed, etc. When looking at diabetic shoe options for your client, however, make sure that they are adjustable enough to be able to accommodate a bulky bandage on one or both sides. If your person has unilateral edema, they should still be able to wear both shoes.

The main drawback with these shoes is that they are a bit pricier than the other options explored here. However, these may be the best shoes that your patient with lymphedema will wear even beyond the stage of treatment- which may not be able to be said for an item such as the Darco shoe! Have a look at these diabetic shoes- currently $58 on Amazon.  

Working with a client with chronic edema can be a challenge, and any support and advice we can offer to make their lives easier and eliminate decision fatigue can often be very well received. I would recommend noting the best shoes that work well for your current clients with lymphedema, and keeping a list of options that they may want to consider, if the current situation is not working!

If you are interested in learning more practical tips and techniques to help manage and treat chronic swelling, be sure to check out our course,  Edema Management in In-Patient Rehab for applicable advice from a seasoned clinical problem-solver!

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6 Common Skin Infections you might see with Chronic Edema


Chronic edema and skin infections go hand-in-hand. Chronic, un-resolving edema may have many causes- including, but not limited to dependency/immobility, Chronic vascular insufficiency, diabetes, CVA, lymphedema, renal or cardiac disease, and so on. Given the prevalence of these conditions amongst our patients, it goes without saying that we encounter clients with chronic edema… a lot!

Treating swelling is an important part of the plan of care, and cannot be overlooked for a patient under our care. However, and area that, as clinicians, we should also be keenly aware of- are the skin infections that this client is much more likely to encounter as a result of their chronic edema.

Want to upskill your practice in treating and managing chronic edema? Check this out!

When working with a patient with chronic swelling, we should be sure to educate them about various infections that they may have a high risk of developing. This way, the client will be alert to potential signs of skin issues and seek medical treatment/pause their edema management program.

So, first- why is a person with chronic edema more likely to develop various skin infections? To answer this, we have to look at the processes involved in chronic swelling. Swelling often initially develops as an inflammatory response to an insult or trauma- and in a functional system, the lymphatics will kick into gear to move this fluid, returning it back into the lymphatic system for cleansing and eventually the circulatory system where it is eliminated naturally. 

The lymphatic system also has a vital role in fighting disease and infection, through the movement and monitoring of lymph fluid. When this system is overwhelmed (by chronic edema) or impaired, it is not effective in countering disease. This again leads to a predisposition to developing skin infections.  

If, however, the fluid remains in the tissues (lymphostasis), it can cause complicated skin issues. This is in large part owing to the content of that lymphatic fluid. The purpose of the lymphatic fluid is to transport various molecules from the tissues, including protein, fatty acids, cells and particles, bacteria, fungal/dirt and dust spores, cancer cells and other inflammatory substances, and any other cells that may require cleansing or transport out of tissues for a healthy system.  

Confusingly, the presence of edema in the tissues (lymphatic congestion) can often present as reddened/darker skin, with pain, heat, and swelling. This can make it trickier to parse apart actual infection from congestion. Congestion requires edema management, whereas infection requires medical attention as well as ongoing skin and swelling treatments.

Have a look at these 4 characteristic skin changes that can occur with chronic swelling!

As a result of this lymph fluid stagnating in the interstitial spaces and tissues of peripheries, skin infections may develop in response to the inflammatory properties of the lymph and the molecules with it.

So what skin infections are you likely to encounter when working with a person with chronic edema? Let’s take a look at the 7 most common skin infections you should know about, and be educating your patients/caregivers about as well!

Cellulitis

The most common of the skin infections that affect those with chronic edema and lymphedema is cellulitis. Cellulitis is a bacterial infection, which can either enter through a break in the dermis or through an area of inflamed tissue. Many people with chronic edema or lymphedema may experience this skin infection as a recurring condition, that can arise when their limb is particularly congested or swollen.cellulitis skin infections edema

Signs of cellulitis includes: a feeling of general malaise, fever, pain, nausea/vomiting; a red or purplish, painful, and swollen rash in the affected region, which may spread if left untreated. It is important to reassure your patient that this infection in non-contagious, which may be a distressing thought to them.

Treatment of cellulitis is urgent- left unattended, it has the capability to spread further into the skin and tissues, cause serious illness, and further impair the lymphatic system in the region, which will lead to long term swelling (and in turn, a higher risk for future cellulitis). We can see now why cellulitis can recur so frequently in those with chronic edema.

The borders of cellulitis are diffuse and can reach into lower layers of skin and tissue than other infections. It may also spread along tendons and muscles.

Cellulitis requires immediate antibiotic administration to heal. As a clinician you should advise your patient to demarcate the edges of the rash, and be able to report as to whether it has spread (and how quickly). Compression can also help to prevent further swelling, help the infection clear more quickly, and reduce pain- Although, if the person is participating in an edema management program involving the use of manual lymphatic drainage.

For more information about the diagnosis and treatment of cellulitis in those with chronic edema, read the British Lymphology Society Consensus Document on Cellulitis.  

Erysipelas

Also a common skin infection affecting those with chronic swelling, erysipelas affects the superficial layer of skin. It is a bacterial infection, similar to cellulitis- however erysipelas affects the skin nearer to the surface, whereas cellulitis often involved deeper tissues and structures. Erysipelas will present as a fiery, red rash, with clearly delineated (sometimes referred to as “map-like” borders).

Erysipelas bacteria may also enter through a break in the skin, such as an abrasion, insect bit, ulcer, or burn. Signs of erysipelas are a raised, bright red (not dark) rash, with clear and sharp borders. It can spread if left untreated, and as before, can become a recurring condition for a client already predisposed to infection.

Erysipelas is treated with antibiotics, either oral or IV (depending on the severity of the condition). Treating the edema through elevation, cold packs, and compression will also help with clearing the infection.  

Lymphangitis

Lymphangitis, an inflammation of the lymphatic system and channels. Infected lymph fluid travelling through the lymph vessels is the cause of lymphangitis, and also its defining characteristic.

An infection enters the lymphatic channel through a wound or skin break- commonly an insect bite, or a large abscess that is facilitating an inflow of bacteria into the lymphatic system. Chronic lymphangitis may also occur as a result of recurrent acute bacterial lymphangitis infections.

Lymphangitis presents as a red streak or several red streaks spanning from the site of open skin, which ay be warm, are soft and not raised, tender, and swelling.  The person with lymphangitis may feel feverish/flu-y, malaise, elevated pulse, and sometimes enlarged lymph nodes.

Antibiotics are used to treat lymphangitis, and the person should be educated to monitor for worsening swelling after the course of the antibiotics, as the lymphatic system may be impacted and at risk for future lymphedema.  

Grab these Free Edema Resources for your clinic!

Folliculitis

folliculitis skin infection edemaFolliculitis is an infection and or irritation of the hair follicle. Damaged follicles may the site of a bacterial infection, complicating the folliculitis further. It has been linked in those with chronic edema to Intermittent Pneumatic Compression, lack of skin care, use of hot tubs, or shaving of curly hairs and subsequent ingrown hairs.

Though not excessively major as an infection, folliculitis has the possibility to develop into a more serious condition, especially if affecting a person with lymphedema/chronic swelling. Folliculitis usually will present as tiny red or white bumps around the hair follicle, which can become pustulus, itchy, and painful.

This condition can be prevented in those with chronic edema by avoiding tight clothes; not shaving arms/legs, or shaving with care; meticulous skin care and use of barrier cream; avoiding hot tubs and heated pools.  

Fungal infections

fungal skin infectionFungal infections can occur commonly in Stage 2 and Stage 3 lymphedema. In chronic edema, skin may lose its architecture and skin folds can develop- which are dark, moist breeding grounds for fungal growth. Infections may also pop up on the skin as a result of skin conditions such as hyperkeratosis or papillomatosis, which can hold moisture and can lead to fungal infection.

As people with chronic edema and lymphedema may have difficulty with adequate washing and drying of their feet and toes, fungal infections may set in here also. These infections are highly contagious and can be transferred by infected footwear, socks, and liners.

Signs and symptoms of fungal infections include irritation, scaly rash, greenish discoloration, redness and itchiness, a distinctive odor, and blistering.

Prevention of fungal infections are the best treatment, as with most infections. Meticulous skin hygiene, towel drying, use of anti-fungal sprays and powders can help to prevent fungal infections from setting in and occurring. If an infection has set in, a physician must be consulted, and medicated creams may be prescribed to treat the infection.  

Contact dermatitis

dermatitis skin infection edemaContact dermatitis is an infection that can occur as an allergic reaction to a foreign or irritating substance. In people with chronic edema, it can occur as a reaction to bandaging, use of pumps, or other irritants.

It presents as itchy, red, swollen, inflamed skin, which may feel as though its burning or tender.  The skin can become very dry, which may lead to cracking or tightness and even blistering.

Treatment for contact dermatitis, especially for those getting treatment for lymphedema, it is beneficial to use barrier lotions and creams between dressings and bandages; anti itch creams; identification of the irritant and avoiding of it when possible; steroid creams and possibly oral medications.  

 

Skin infections and issues are to be expected when working with clients who have chronic edema, and as clinicians it is imperative to include education about this when we work with out clients with chronic edema.

This is a topic that I routinely address several times to make sure that the person is aware of varying signs and symptoms to look for, when to seek medical advice and how to increase comfort at home, and- importantly- how to avoid the development of these common skin infections in the first place, if possible.

Want to learn more about types of swelling, assessment, creating a plan of care, and providing effective management? Check out our ever popular course, Edema Management in Inpatient Rehab for a comprehensive, practical information. You are going to love the hands-on, evidence based techniques that you can use to greatly improve your patient outcomes!

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Occupational Therapy and Diabetes- check out these 5 uncommon goals!


Occupational therapy and diabetes… are there some overlooked opportunities?

As an OT who spends much of her clinical career in an inpatient rehab setting, or treating lymphedema outpatient- I see a LOT of people with diabetes! Diabetes Mellitus is a pervasive issue, affecting 1 in 10 people in America, and leading to a host of unpleasant health complications. Have you ever wondered if your occupational therapy role could be less compensatory and more focused when it comes to setting goals and working with your patient with Diabetes? Here, I’m going to focus on some of the essential ways an OT can be instrumental in treating a person who has DM in a holistic and practical way.

Re-thinking Diabetes

occupational therapy diabetes

Firstly- you may think you don’t need to know any more about diabetes- what it is and who it affects. Older people who have sugar issues, right? Well, perhaps surprisingly, DM can come in more than two forms.

A proposed reclassification system from a researchers in Finland and Sweden, in 2018, broke up Diabetes into 5 sub groups, instead of the usual Type 1 and Type 2. Why do this? It became clear that by dividing Diabetes into these subgroups, correlations between each group and increased risk of developing certain complications became clear. Of course- it clearly follows that by knowing why the Diabetes developed that future health impairments would be easier to predict.

Yes- by defining the type, we can now identify who is at what risk of developing differing complications- such as amputation, kidney damage, retinopathy, and cardiovascular diseases.

These ‘types’ of diabetes were:

Group 1: Severe autoimmune diabetes (SAID) –   Corresponds to Type 1 diabetes and latent autoimmune diabetes in adults (LADA) and is characterized by onset at a young age, poor metabolic control, impaired insulin production and the presence of GADA antibodies
Group 2: Severe insulin-deficient diabetes (SIDD) –   Includes individuals with high HbA1C, impaired insulin secretion and moderate insulin resistance. This group had the highest incidence of retinopathy
Group 3: Severe insulin-resistant diabetes (SIRD) –   Characterized by obesity and severe insulin resistance. This group had the highest incidence of kidney damage
Group 4: Mild obesity-related diabetes (MOD) –   Includes obese patients who fall ill at a relatively young age
Group 5: Mild age-related diabetes (MARD) –   This is the largest group and consists of the most elderly patients

As healthcare practitioners, this brings us closer to providing a patient-specific plan of care, as opposed to the same treatment to every person with diabetes. In occupational therapy, this drives us even further to educate patients about their increased risk for certain outcomes, teach them how to monitor their health and what ‘red flags’ to be alerted to, given their specific sub-classification of Diabetes.

How can occupational therapy be most effective when working with people with diabetes?

Occupational therapists can be key practitioners with people with diabetes over several domains of function. When a client with diabetes presents into a setting like hospital and inpatient rehab, OTs are *sometimes* reduced to mostly teaching compensatory methods- such as strength and endurance building, and education about doing what the dietician tells them to. But what if there were more specific, and less common goals that we could be focusing on?

Let’s go through and examine some Occupational Therapy-specific goals that can be set when working with diabetes- and how to meet them!

  1. Health awareness and Education

OT uncommon goal? “independently use a tracking and planning device to manage a healthy diet and exercise program.”

diabetes

Occupational therapists are uniquely positioned to help people examine their lifestyles and the intersection between the person, environment, and their occupation. Often, lifestyle adaptation and modification must occur to ensure that healthy choices are being made to ensure ongoing wellness- and who better to evaluate the ability to modify the environment than OTs!

Helping your patient examine their current roles, routines and habits is the first step in the self-monitoring and awareness your client will need to cultivate. If your client needs to change their diets and exercise habits, you can help them track their food intake- where, what and when they are eating, how their mood and environmental triggers may be hindering their efforts, and how to modify these external cues to create a more sustainably health-focused lifestyle.

As an OT, you can also help you patient with the technological skills they may need to use a smartphone app (if they use a device). A great list of some apps that are free and easy to use can be found- right here.

Self-tracking is all well and good, but for lasting success, planning ahead is also crucial! Empower your client to plan out meals and snacks, monitor their own insulin levels, and engage in an easy to achieve and sustainable exercise program- however that looks for your client.

2. Community integration/Socialization

OT uncommon goal? “Engage in a social activity based around food or exercise once per week in a healthful manner”

Socialization and being part of a community is an important aspect of holistic treatment. If you teach your client to manage their insulin, prepare safe meals and complete a HEP at home, they will be safe for a while- but it isn’t sustainable! Social isolation is a major problem that can have its own health risks.

Therefore, incorporating a community integration goal from the get go, that addresses making healthful choices in a restaurant (such as looking the menu up ahead of time, or having a few key items to order), as well as linking exercise to a social activity (such as a walking program) may be a powerful means of creating an atmosphere of motivation and independence for your client. After all, doing things together is way more fun that going it alone!

3. Leisure

OT uncommon goal? “Make a diabetic friendly dessert once a week” or “join a diabetic-friendly exercise group”

occupational therapy diabetes

Leisure goals can often be more satisfying to work on than, say, a BADL goal! Drilling down on your patients interests can be a way of accessing a more playful way of looking at, and meeting, their overarching health goals. Does your client love to cook/bake? Help them look up diabetic friendly recipes that can help scratch that itch (think- low sugar ice cream, almond butter cookies, or anything from this list). If your person has shown that they can track their carbs and understand balance, then they can still have fun with food!

Diabetic-friendly exercise groups can be a great resource for fun, making connections and learning more about the condition (and how to handle it in an ongoing way). Help your client look into local groups, or even online support groups that they can lean into to make their exercise program more enjoyable and east to integrate into their lives. 

If an exercise group specific to diabetes is not available, then help the person find an exercise/movement output that is meaningful to them! This may be empowering them to find a walking partner, a swimming class, or another activity such as gardening that will help them to move their body in an enjoyable way.

4. Basic ADL goals

OT Uncommon goal: “Independently manage self-care of lower legs”

This goal, as the preceding ones, can have many subcomponents. As clients with Diabetes are at high risk for Peripheral Artery Disease and Neuropathy, the Occupational therapist can teach the client to monitor for, or treat, the symptoms that they may be at risk for. This goal may seem self explanatory, but all too often the foot care component of diabetic management can be vague, non sepcifc, or left up to the nurse/podaotrust to complete. OTs have a great oportyunitie at this pont to teach a client how to complete their own self management, what red flags to be midful of, and how to modify their current routine to include this step.

To download a self check sheet, and other helpful resources- get our FREE ‘Ultimate Guide to the management of the Diabetic Foot

Neuropathy is mot commonly associated with the feet, but can also affect the distal upper extremities.

5. Foster a sense of empowerment and control

OT uncommon goal: “Use active and passive reinforcements to facilitate an environment of success and control in order to boost self-efficacy and esteem.”

The person who has contracted Diabetes may be feeling overwhelmed, disappointed, out of control, or even grieving for a former “way of life” wherein they felt well, had more self-regard and less restrictions. A disease of diabetes, I think we could all agree- is very much a condition of “cannot’s”- “you can’t eat that” “you must do this” “you can’t skip this medication, or this exercise, or essential step”. I am in no way advocating a romantic, rose-tinted view of this condition- it is serious, and can lead to even more serious complications if treated incorrectly. However, I strongly believe that as OTs, we take a holistic and person-centered approach to everything we do. Part of this may be heading off issues such as a flagging self-image, a sense of powerlessness or even depression, before they occur (or preventing them from getting worse!).

Use of techniques such as temptation bundling (doing one favorite activity with a less preferred one), such as listening to music when planning out your weekly meals; or positive, specific affirmations left as reminders in places people can see (examples from this list include “I create good health by talking about and thinking about my wellness.” and “I most love the parts of me that need love the most right now.”

As with many different aspects in occupational therapy, thinking outside the box can make a huge difference in the lives of our patients with diabetes. By focusing on ‘uncommon’ goals such as these, we may transition away from more compensatory strategies and into a more empowering and holistic space.

If you want to learn more about wounds and wound management, have a look at our LIVE or SELF-PACED course, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This course offers 7 Cont-ed units, practical downloadable tools and resources, and is taught by an expert wound care specialist who makes the education accessible to everyone. Check it out!

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Edema Management- Set up your own program and maximize your results!


Edema management. It is not something that you can expect at every hospital… inpatient rehab… or even outpatient facility. Yet, I doubt there are many clinicians who wouldn’t agree- this is a big issue for our patients!

Edema is one of the most chronically underdressed issues, particularly in rehab. The reasons for this are many! It can be masked by other issues, such as medical fragility; it can hide in plain sight, for those who have had slowly worsening chronic swelling; or it can simply be written off as ‘not my area’, by therapists, nurses, and physicians. And a dedicated edema management program? Usually nowhere to be found!

This combination adds to the problem of edema. Under-recognized as an issue, it often is left to slowly progress over time, adding in a host of complicating factors along the way. Untreated edema will contribute to a lack of mobility; a higher risk for skin infections and breakdown; decreased independence and ability to engage in the community, and more. In fact, addressing edema can be incredibly helpful! Here, we can prevent our clients from entering this ‘vicious cycle’ of progressive disability and impairment.

And yet- it isn’t! But maybe, that should change.

edema management program set up

Many in-patient rehabilitation facilities have dedicated programs for the wellness of their clients; such as brain injury/stroke/disease-specific care/palliative. These specialized services empower the clinicians and provide resources to the clients to have a more successful outcome. A specialized edema management program, however, are less commonplace – even though edema is a debilitating issue for many patients.

Edema can occur from an orthopedic injury, be neurological in nature, or even congenital. Patients who present to inpatient rehab post-surgery, CVA, or trauma, are likely to have issues with swelling. A process wherein that edema is identified, addressed as part of the plan of care, and continued follow up support given, results in far better outcomes for the patient and carer.

Setting up any type of program is intimidating- and an edema management program is no different. Let’s have a look at the reasons we should be advocating for this service, and how you can be instrumental in setting up this service in-house!

So why should we include edema management in the plan of care?

Firstly, the clinical reasons:

Mobility. The person is clearly more likely to be able to move around, walk for longer, and transfer in and out of bed if they are not struggling with heavy and edematous limbs. Stiffness and discomfort experienced with edematous limbs, also makes it more difficult for our patients to move around. They may be discouraged from ambulation by how strenuous they may find walking on heavy and stiff limbs.

This, naturally, does not help with their goals in rehab. It also impairs their chronic edema issues, and will compound upon the lack of circulation and muscle strength. In a nutshell: Swelling -> less walking -> more swelling!!

Related to this point- treating the person’s swelling is going to improve their skin integrity, aid with wound healing, and decrease the number of infections that they contract. Chronic edema is known to be a cause of cellulitis and erysipelas, both of which can continue to recur if the swelling is untreated. Wounds do not heal as quickly and as well as they might when the circulation around the wound is impaired. Additionally, stagnating lymphatic fluid leads to a cascade of unusual skin conditions, predisposing your client to skin breakdown and infections.

Download our limb girth measurement and tracking forms right here!

Footwear considerations are also key. A person with chronic and worsening edema is likely to have difficulties finding and maintaining proper footwear. This has a functional impact on their community involvement, and leave them at risk for skin breakdown and injury. Our patients should be able to don their shoes to be an active part of their community and to protect their feet- but many people with undertreated edema resort to wearing cast shoes or some other suboptimal option for community engagement. A common goal in inpatient rehab (for both OT and PT) is applying footwear/walking in shoes.

Now: the non-clinical reasons!

Aside from the clinical reasons to treat edema (of which we have so many!), there are also a host of administrative reasons to begin to address this issue. We all are working in a system, which we should strive to make as efficient and fair as possible, with best outcomes. Providing sub-standard care is unethical, AND inefficient!

From an administrative point of view- first in line is the reduction of re-admissions. We are sure to have fewer re-admissions and a higher quality of health if the patient is at a lesser risk of infections with improved skin integrity.  It is also important to note that chronic edema has a progressive nature and will not just “go away by itself” if ignored. Thus, it is important to address it early on in their rehab stay, and make sure our patients are aware of the warning signs.

Additionally- it will set you and your facility apart from other places. The lack of knowledge of edema and the means to treat it in the healthcare is astounding! As clinicians, we are in a fantastic position to advocate for and educate our patients (and ourselves!), to prevent the continual worsening of edema. As we know it can lead to permanent disability, we should be educating healthcare workers all around us to recognize that this is not a transient symptom.

Patient satisfaction is, of course, hand-in-glove in addressing the areas mentioned here! Your patients are going to be so appreciative of the attention given to an issue that may have previously been completely unaddressed, and the more positive outcomes that will arrive with the treatment. Anecdotally, I have found that my patients are so grateful to be heard and treated for this condition, saying things like “I didn’t know I could do anything for this” “No one was ever listening to me about this” and “I can’t believe how much better I feel”.

Lastly, and importantly when it comes to getting the resources and support of your administration, is the marketability of a program like this. Referring doctors, referring facilities, and liaisons will be able to advertise and refer appropriate patients when there are the systems to address the areas they need.

Right! I’m convinced. But where do I start?

First- you should begin by up-skilling in the area of edema management.

Getting some practical skills that you will need in the area of edema management will be crucial in setting up a successful program- this is, after all, a clinical intervention- and you should have the clinical knowhow to support the program. There are several options to upskill- once of which is to become a certified lymphedema therapist (CLT). Becoming a CLT will provide you with a lot of clinical skills and background, intensive practice in manual drainage techniques and compression bandaging. If your facility is investing in its staff, in terms of continuous professional development and program set-up, they may pay for, or reimburse, your registration fees.

Of course, getting the certification is not mandatory for treating these issues. Edema treatment is well within the scope of Physical and Occupational Therapists and nurses! Check out Edema Management in In-Patient Rehabilitation for a comprehensive seminar that focuses specifically on how to incorporate these skills into your practice.

Second- do your assessment of need.

Do an audit, a chart review, or even a straw poll of the patients that you and your colleagues are currently seeing. Would any of them benefit from an program such as this one being in house? Do they have swelling, pain, skin issues, wounds that could be treated if an edema management program was set up? I have found, when working in in-patient rehab, that 70-80% of my patients would benefit to some degree. Swelling, skin issues, and high risk conditions such as diabetes will all be appropriate for preventative care, if not treatment.

Gaining this information will strengthen the need for your program, and get extra support from your colleagues and administrators. It will also provide a baseline that you can point to, of people who need services that are not provided.

Thirdly- Educate your staff and colleagues.

Educating your team as to what you wish to add is crucial. Change can be challenging, as especially with a condition as poorly understood as edema. By including your therapy, nursing, and admin team from the start- it can be tackled together! Educate your team about: the misconceptions of edema; the people who will be appropriate for this program; and what interventions your program will include. Explain the different bandage materials that you will be using, so that floor staff will have a heads up! You will want to clearly delineate what is expected and what will be changing, and how you can be contacted for further insights or if there are any issues.

If possible, try to assemble a sub team that can help set up your program, handle issues, and help you educate. Include wound care, nursing, RNT, PT, OT and anyone else you think would be a great advocate!

Fourthly- set up your program and examine what you need.

edema management program development with ARC seminars

In order to begin your program, you will require supplies, resources, assessment tools, and informational packets. I always recommend that people run a smaller, easy-to-manage pilot group to begin with- 10 patients, who all have LE needs, for example. Prepare the order for supplies, the HEPs and plans, and any other tools you need for this group. Note your documentation and admin requirements. Make sure you are using subjective and objective outcome measures to track their progress, and take photographs as much as is possible!

It may be worth exporting their results onto a chart, or writing up a comprehensive report. This way, you can track their results and figure out what worked best. Pointing to their outcomes will also provide support for your program! If you need further supplies or more expensive equipment in the future; having this data will be invaluable.

Read this article to learn how to boost patient compliance with edema management!

Setting up an Edema Management Program will not be easy- but I guarantee, it will change your practice forever! This under-recognized and mismanaged condition only complicates the lives of our patients. Having a dedicated service will maximize your outcomes! No matter where you work- you’ll see the need.

If you found this program development article helpful, you’ll love our popular and engaging seminar on the topic of Edema Management. Check it out and read more right here: Edema Management in In-patient Rehabilitation!

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How to Improve Diabetic Neuropathy and Foot Ulcers


The prevalence of diabetes continues to increase in the US (and worldwide) each year.  Of all the complications that can arise, diabetic neuropathy is the most common – present in approximately 50% of people diagnosed.  Diabetic Neuropathy can lead to other disabilities such as Diabetic foot ulcers, amputation, gait and balance impairment, and so on.  It’s imperative that we, as clinicians, are equipped to properly identify the risks; and educate our patients and their caregivers to prevent such disability from occurring.

Risk Factors:

how to improve diabetic neuropathy and foot ulcers self check

There are certain risk factors that may be present prior to a diabetic foot ulcer forming.  These include poor control of blood sugar, cigarette smoking, previous foot ulcers and amputations, and most commonly, diabetic neuropathy and peripheral vascular disease.

Diabetic Neuropathy – As mentioned, this is very common among the diabetic population and can be very costly to their health.  Diabetic Neuropathy happens when nerves become damaged from chronic uncontrolled high blood sugar.  This damage can affect various parts of the nervous system that control motor, sensory, or autonomic functions – all of which can contribute to the patient developing a diabetic foot ulcer.  If the nerves that control muscular control of the feet have been damaged, the patient may start posturing their feet in a way that is biomechanically destructive.  This can cause increased pressure on bony prominences and other abnormalities and put their feet at higher risk for forming ulcers. 

Diabetic neuropathy can also be characterized by pain and/or numbness in the legs and feet if the sensory nerves have been damaged.  The pain is often directly associated with the nerve damage itself and is not in relation to an environmental or outward source of pain. 

Numbness, on the contrary, presents other concerns. If a diabetic foot ulcer has started to develop, the person may not feel pain or other sensations usually associated with wounds. This may allow the wound to progress unnoticed, as the patient continues to bear weight over the ulcer.  When autonomic dysfunction occurs, this can lead to changes in perspiration leaving the skin overly dry and prone to cracking.

Peripheral Vascular Disease – Smoking and Diabetes are among the most powerful risk factors in developing PVD.  PVD is characterized by atherosclerotic changes of the blood vessels where the arterial walls gradually harden and narrow as plaque builds up inside.  This restricts blood flow and limits the amount of oxygen and nutrients the blood can carry to that area.  Some studies show an important distinction that PVD in a person with Diabetes mostly occurs in the femoral and tibial arteries. Other risk factors (such as smoking) will affect more proximal vessels.  The nature of PVD makes it easy to imagine why this would put a person with Diabetes at risk for developing a foot ulcer – the feet are not getting the oxygen and nutrients they need to sustain healthy tissue! 

The prevalence of PVD among people with Diabetes is difficult to pin down due to the variability of symptoms. Some people may present as asymptomatic.  A great way for clinicians to help identify the presence of PVD is the Ankle-Brachial Index.  Research has shown this to be highly sensitive and specific when compared to angiographically confirmed disease… and the great news for us is that it doesn’t require any fancy equipment!

For great resources to use in the clinic, check out our ‘Ultimate Guide to Managing the Diabetic Foot’!

Time for healing:      

Wounds often take a longer time to heal for a person with diabetes, and here’s why:

Diabetic Neuropathy – As mentioned above, this could be a risk factor for developing diabetic foot ulcers to begin with, but it is also a major player in the wound healing process.  If the nerve damage is contributing to a sensory loss… the person is going to be at a very high risk to reinjure/reopen the wound site again and again.  They can’t feel it, so it won’t be “a problem” for them until it’s too late.  A vicious cycle! 

how to improve diabetic neuropathy and foot ulcers self check

Peripheral Vascular Disease – Blood flow with good oxygenation and nutrition supply is essential to proper wound healing.  When this is compromised, as it is in people with PVD, the body simply does not have the fundamentals that it needs to move through the wound healing process and repair tissues.  If a more severe lack of oxygenated blood exists, this could lead to ischemia and necrosis of the tissues, which would then need to be debrided… making the wound larger.  In other cases it could lead to gangrene and eventual amputation.

Infection – Diabetic foot ulcers are often at higher risk for infection, which would then prolong the healing process.  When a person has diabetes, they produce certain enzymes and proteins that make the immune response less effective.  So, when a diabetic foot ulcer is present and bacteria enters in, your body is already at a disadvantage in fighting off infection and moving on to healing the wound. 

Prevention is Key!

If you or someone you know is at risk for developing diabetes, it is imperative to take steps toward prevention!  This is sometimes easier said than done. But, making small changes at a time will give you the best results… by far! Don’t take everything on all at once. If you’re a clinician healing your patients and their families, don’t overwhelm them with information – start slow.

Check out this page to get great tips and resources from the American Diabetes Association on how to prevent Diabetes!

But if Diabetes is already present, there are plenty of ways we can still help our patients prevent complications, such as Diabetic neuropathy and foot ulcers. 

  • Get blood sugar under control – This seems obvious, right?  But it’s often very difficult for people to do in real life.  There are so many factors that play into this, from food preferences, habits, culture, family support, etc.  It’s important to get as many team member as possible involved to help reinforce the small changes that the patient will need to make along the way.
  • Follow up with appropriate practitioners – Depending on the risk factors identified, ensure your patient is seeing the experts they need.  Some examples are: Endocrinologist for management of diabetes; Vascular Surgeon or Interventional Radiologist for management of PVD; Dietician for nutritional recommendations; Community based support groups for Psychosocial support; and of course Physical and Occupational therapy!
  • Footwear recommendations – Especially if the person is presenting with Diabetic Neuropathy, you want to ensure that they have proper footwear to support their feet and prevent any unnecessary pressure of shearing of their skin.  They may need to wear certain types of socks; and need education on how to properly don them in order to prevent bunching of the material within the shoe.  They may do well with a wider size to allow more room, or they may need specially ordered Diabetic shoes.  The Healthy Feet Store may be a great resource for some patients!
  • Daily self-check/foot inspection – Once this becomes a habit, it will be an invaluable part of your Diabetic patient’s routine.  This can be an effective way for prevention of diabetic foot ulcers through getting the patient to be more engaged in their care.  They will need a long-handled mirror or a mirror they can place on the floor under their feet.  Here are the steps involved:
    • Skin inspection – Look at the skin on the top of your feet, the soles of your feet and in between your toes.  (Use the long-handled mirror for places you are unable to see.)  Observe for: cuts, scrapes, bruises, dirt/grime, blisters, discoloration, or developing calluses.  Anything that is new or abnormal should be noted.
    • Nail inspection – Look at your toenails for uneven edges, broken nails, ingrown toenails, or signs of infection.
    • Sensation – Feel all over your feet for changes such as numbness, increased sensitivity, lumps/bumps, cold areas, tingling or painful areas.
    • Smell – Try to smell the skin for fungal or bad odors. A change in smell or a bad odor can indicate a problem or a possible infection.
    • Hygiene – Clean your feet of any dirt or grime and dry the skin very well. This will help to prevent any possible infections. Wash using warm, not hot water, and do not soak your feet. Apply lotion and rub it in until feet are dry.

As with many different aspects in healthcare, prevention certainly is key!  But more often then not we are seeing patients after their conditions have become chronic and they are already experiencing a host of complications.  It is no different with our patients with Diabetes.  Identifying what is already present and what they are at continued risk for is where we can still play a role in prevention.  We can prevent the progression of their disease or prevent the development of complications by providing education and strategies to make the changes they need to make more attainable.

If you want to learn more about wounds and wound management, have a look at our LIVE or SELF-PACED course, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This course offers 7 Cont-ed units, practical downloadable tools and resources, and is taught by an expert wound care specialist who makes the education accessible to everyone. Check it out!

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3 Wound Care Treatments… that will Blow Your Mind!


Wound care treatment can be weird…and wonderful! You’re probably familiar with some of the more commonly seen wound care treatments- such as absorbent dressings, chemical debriders, barrier creams and even impregnated gauze. However, in parts of the world that these conventional treatments might not be available, other wound care treatment options are employed… and can be far more effective than you would think!

Wound treatment dressings serve multiple purposes- a moist environment at the interface of the wound; a barrier between the wound and microorganisms; and non-toxic, non-allergenic, non-sensitizing agents. Wound dressings can also contain anti-inflammatory substances, proteins, vitamins, and other wound healing properties.

Here we take a closer look at three weird and wonderful wound care treatments that you may never have heard of. Do you think any of these could be useful where you work?

Fish Skins

Fish skin has been increasingly used, and recently FDA approved, to act as a ‘scaffold’, or support network, to skin. Products made from dried and processed fish skin (in which allergens are no longer present) act as an extracellular matrix- which is a group of proteins and starches which play a vital role in skin and wound recovery- when placed on wounds. In healthy skin, a matrix surrounds cells and binds them to tissue. This boosts the growth of new skin. However, in chronic wounds, this structure does not form, and so the extracellular matrix made from the fish skin product provides the cells of the body a structure that they can grow around, so that healthy tissue may form. As the product is biodegradable and natural, it eventually becomes absorbed into the wound as the healthy skin grows over.

Fish skin is rich in nutritious materials, including Omega 3 fatty acids, that are naturally anti-inflammatory. This also helps speed up healing in chronic wounds and skin breakdown.

Sterilized fish skin can be used to aid with collagenase transfer and ease pain; and can be easier that gauze when it comes to dressing changes for burns. You can see fish skin used in countries such as Brazil and Denmark, to successfully help with diabetic wounds, burns, or non-healing injuries.

To download a FREE E-Book: ‘The Ultimate Guide to Managing the Diabetic Foot” click here!

Bananas

Here’s another food-based super product: bananas! Banana leaves and peels have been used for many years in certain countries. The leaves have been proven, in more recent times, to have medicinal properties. This can make them an acceptable alternative to more costly, synthetic wound care materials- especially in developing countries. Banana leaves cool the skin and do not stick to open wounds. Several studies have examined the use of banana leaf dressings, which were shown to result in rapid epithelization and less pain during wound changes than typical gauze-and-Vaseline dressings. Clinical research has shown that banana leaf dressings also can reduce pain and help protect wounds from infection, as well as aiding healing.

Banana peels have been aid with skin regeneration and re-mineralization and have anti-inflammatory and pain relieving properties. Healing occurs at a DNA level, with some of the compounds found in banana peels increasing cell proliferation, inducing and enhancing the healing process. They also contain vitamins, minerals and antioxidants.

Another reason to use banana leaves and peels? They are antimicrobial! Lab testing has demonstrated that banana peel extract significantly inhibits growth of bacteria. They are free, widely available in tropical countries, and easy to apply and use.

Learn more: Ostomy Management for clinicians- 6 goals and how to meet them!

Honey

And lastly in our foodstuff-based interventions for wound care- honey! You may or may not have heard of the antibacterial, powerful effects of honey for wound healing. People have used honey for centuries, for all manner of wounds and skin conditions, and it now has commercialized products inspired by its medicinal properties (honey-impregnated dressings and ointments such as MediHoney or TheraHoney).

Honey is central in wound healing for many reasons- including its broad-spectrum antibacterial effect. Honey can kill and block possibly harmful infections, through a combination od hydrogen peroxide and methylglyoxal, which, in Manuka honey, can withstand significant dilution by wound exudate and still maintain enough activity to inhibit bacteria growth.

It also has anti-inflammatory and osmotic effects owing to its high sugar content- drawing water from issues and allowing for an outflow of lymphatic fluid (as can also be seen with negative pressure wound therapy/Wound VACs).

Honey has an acidic pH which stimulates oxygenation of the tissues- integral to wound healing; and has bioactivities that stimulate an immune response, suppress inflammation, and bring on autolytic debridement.

Research comparing the effects of honey with alternative wound dressings and topical treatments on the healing of acute and/or chronic wounds concluded that honey can heal partial thickness burns and infected post-operative wounds more quickly that conventional treatment (which included polyurethane film, paraffin gauze, soframycin-impregnated gauze, etc.).

As you can see, the science behind the healing of wounds encompasses many weird and wonderful treatments! Have you experienced any of these methods to assist in wound healing where you work? What do you think?

Interested in learning more about wound care, and practical approaches to assessment, treatment, and documentation? Check out A Comprehensive Guide to Wound Care, our immensely popular, continuing education course for nurses and therapists, and see for yourself how you can target the #1 issue that keeps patients from returning home. Available live- In person and Virtual!

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Ostomy management for clinicians- 6 goals and how to achieve them!


What might your ostomy-related goals be in in-patient rehab?

Empower resources ostomy

In in-patient rehab, stays may be short. When, as a nurse or therapist, you have a client with a new ostomy, it is easy for goal-setting in this area to be overlooked. Trained wound and ostomy staff (WOCN: Wound, Ostomy and Continence Nurse) are not always available in every setting. Nevertheless, each interaction with members of staff (nursing, therapy, medicine), are both opportunities for teaching, and opportunities to normalize and accept the situation for the person with ostomy.

This article is filled with resources, video links, reference guides that you can use and provide to your patient! Here, we also go through five goals that you, as a clinician, should be setting or considering, when your client has an ostomy. We also take you, step-wise, through how you can break down and meet this goal- which is extremely handy if ostomy care is not something you are doing on a daily basis!       

Through reading and understanding these goals, you can get a basic understanding of how to manage an ostomy- and how to help your patient manage it, too!

Want more wound care resources? Get ‘The Ultimate Guide to Managing the Diabetic Foot’, a 14 page manual packed with client handouts and clinician resources, right here!

Setting goals for ostomy care

Ostomy pouch

Depending on the patient’s situation, you will be setting varying goals. If their caregiver is likely to manage their ostomy, you can change the verbiage to reflect this. If the patient is capable of managing their ostomy themselves, then it is incredibly important that they are independent with this before returning to home.

Knowing where to access supplies and ongoing education is also going to be important. Support, community resources, advocacy will be part of your patient’s ongoing life with an ostomy, and increase their self-efficacy and esteem. Provide them with support from the outset and they will be set up for success!

How to write ostomy goals in rehab

Protocol for each goal:

Patient should able to:

  1. Teach back the terms related to the ostomy and the correct names of the supplies used
    • Explain what an ostomy is, and point to the various body parts in consideration. Use simple terms: an ostomy is a surgical procedure, creating an opening for stool or urine to be excreted; a stoma can refer to the opening on your abdomen, or the flat or protruding part of the visible intestine; ostomies are defined by their location- such as a colostomy, which opens the colon, ileostomy at the ileum, and urostomy at the bladder.
    • Encourage person to touch and explore the area surrounding and the stoma. This can help them learn about what the various areas are called, and the tactile cues can aid in understanding. The stoma should not feel sore or tender- it does not have any sensitive nerve tissue. Becoming comfortable with this newly visible part of their body can go a long way toward confidence when it comes to changing their pouch.
    • Show and demonstrate the various ostomy supplies, verbalize and have person repeat
      • Have a reference guide nearby that you can use, with the specific type of supplies you are using
  2. Perform adequate skin care and teach back infection reduction techniques
    • Discuss risks for skin breakdown
      • Improper application of the pouching system will be the main issue contributing to skin breakdown. Teach your patient to properly clean and protect the skin around their stoma; change immediately with a  leak; monitor for adhesive sensitivities; be gentle and methodical with ouch removal to avoid skin tears; and perhaps even working with a nutritionist to identify foods that are irritable to the digestive system. Be sure your patient knows these risks and is carefully monitoring for them
    • Work with the team. Ensure that a nurse, even if not a WOCN, is advising on skin issues and protection.
    • Discuss risks for infection. Excessive moisture, poor hygiene, irregular changing of the pouch, or a poor technique can all contribute to infections or increase the risks
      • Fungal infections can be a risk factor, especially for those with diabetes, anemia, lowered immune systems, or those taking antibiotics
      • Folliculitis can be an issue if a hair follicle becomes inflamed (a client may not have shaved the area around the seal), and may also lead to a fungal infection
  3. Verbalize how often the ostomy should be emptied and changed; be independent with emptying ostomy
    • Explain why and how often emptying and changing should occur; this will vary depending on the location of the ostomy. A colostomy may require pouch emptying only 2-3 times a day, whereas an ileostomy or urostomy may require emptying 6-8 times a day.
    • An ostomy should be changed when it is less than half full. Generally about two hours after eating/drinking, before activity, showering, bedtime, etc. should be when the ostomy bag is emptied. Depending on the location of the ostomy, your client may expect more or less output (with higher in the digestive tract creating more output).
      • Write on whiteboard or visual planner that person uses, or help them set timed reminders
      • Refer them to a reference guide/video to help them understand the process.
    • Ensure your person can handle the ostomy
      • Think about the skills required to manage an ostomy. Fine motor control and coordination, hand strength, balance (sitting or standing) and cognition. Modifications can be made to ensure your person is as independent as they can be with this new skill.
      • Consider practicing opening, closing, emptying, and changing with and empty pouch and clean supplies, in order to build confidence and really understand the process
    • Ensure they can get up close to the toilet
      • Empty directly into toilet. In many in-patient facilities, ostomies may be emptied into a receptacle, but this does not prepare the person for return to function in the community; and is not a sanitary option outside of the person’s own environment.
        • It is also key to consider strategies for emptying that work in public settings, as well as the home. You may only work with your client for a short time- but if they do not have a toileting routine that will work outside of the home, it can impede their return to the community. This is a key role in early rehab.
        • Drop some toilet paper into toilet to prevent splashback. Sitting on the toilet (facing either direction), kneeling, squatting, or standing over the toilet may be a skill you will need to think about with your person
      • Clean the ends of the outlet and close
    • Discuss and demonstrate ‘burping’ ostomy
      • Ideally, the filter manages excess gas build-up- but may be clogged or just may not work
      • Burping will release excess gas built up through the outlet at the bottom or through the opening at the top
  4. Be independent with changing pouch
    • Practice with empty or clean supplies if able, to build confidence
    • Discuss different places it can be changed: in shower, by sink, in front of mirror; changes every 3-7 days depending on type of stoma, personal preference, type of pouch.
    • Practice collecting and making sure all supplies are to hand
      • Measuring guide, wet paper towels, wash cloths, dry towel, scissors, pouch system being used (1 or 2 piece), stoma powder, paste.
    • Remove the pouch by gently pressing down on the skin with moist/wet towels, lifting the corner. Collect any stool/urine in old pouch.
    • Skin checks when pouch is removed- skin cleanse with water only and dried completely. Crusting or other skin care techniques can be completed at this point
    • Stoma measurement to ensure no change in size and to cut a hole matching the size of the stoma (1 piece system) or the flange attaching to the bag (2-piece system) Watch these videos for more information of how to change the ostomy bag!
  5. Recognize resources available to them
    • Professional support: Even if there is not access to a WOCN in your facility, some ostomy appliance manufacturers have consulting WOCNs available by phone. This can be a useful resource to those who may need some discussion, tips, or input
    • Ostomy systems: There are hundreds of variations of pouches and systems, and many products for skin protection and care. Different systems also make a difference in terms of fine motor demands, visual demands, ad even abdominal muscle tone. People who may be experiencing difficulty should know that if one system is not working as well as they would hope, or if they are having ongoing issues, that another system may work for them. Consulting WOCNs at ostomy appliance manufacturers may provide sample systems for trial use
    • Online support: Exchanging experiences, reading and watching videos from some great online experts may help your client to realize what is ‘normal’ for them in this situation- and what is not working. They may incorrectly believe that a wear time is shorter than it should be, or that the amount of burping/changing is to be expected, when they may instead require input into the supplies they are using.
  6. Be engaged in psychological acceptance and counseling
    • Talk to them about living with ostomy: does not limit engagement in activity
      • Odor management – this is a huge worry for people, however there should be no odor when the pouch is attached correctly
      • Natural process- you can assure your person that there will be an odor experienced when burping, emptying or changing the pouch, but that there is a smell attached to anyone’s bowel movements. Encourage them to see this as a natural process of elimination, albeit mechanically aided on their part
      • They will be able to function in anything they would want to with an ostomy- an ostomy shouldn’t limit any activity they wish to pursue
    • Dealing with other emotional complications that may have brought them to the point of ostomy (CA, illness, grief/anger, body acceptance/self-esteem)
    • Encourage touch and exploration- this will be very importance for self-esteem and bodily acceptance. Some people will not want to engage with their ostomy or stoma whatsoever, but this will prolong the pain and grief they are experiencing
    • Remind them of their strength. Whatever got them to this point could not have been easy… yet here they are! Remind them of the strength they have already shown and continue to show as they live with this ‘new normal’
    • Do not be afraid to bring up return to activity- especially hobbies, things they love to do, and sexuality. Waiting for your person to bring it up may be too embarrassing for them! You can also wear a badge or a pin that says- ‘ask me anything about your ostomy’, or similar
    • Support groups online and in-person. Set them up with online groups and connect them with others- as above, don’t wait to give them the supports they need and may be craving

Including appropriate goals for ostomy care and management is crucial in an in-patient (or, really any, setting). Unfortunately, many in-patient clinicians do not see this as part of their more conventional rehab goals- and so, it can be passed over or ignored. Breaking down the needs that your client has: increased understanding, independence with self-care, skin protection, etc… and setting the appropriate, step-by-step goals can help to bridge some of the intimidation around this sensitive area.

I hope that seeing some of these ‘ready-made’ goals can help you to become more confident around ostomy care, and in including it as part of your therapy or nursing plan!

Are you are interested in upskilling your practice? Check out A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This engaging and super-practical seminar will give you the hands-on skills and the confidence you need to be able to assess and manage all types of wounds. Now available live or virtually!

Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂

Under pressure: How to overcome the pressure ulcer problem in rehab


Rehab professionals encounter pressure ulcers more frequently than we would like to admit.  But you must wonder, with something that theoretically should be very preventable… are we truly understanding pressure ulcer staging and prevention, so we are best equipped to move our patients through a path to recovery?  A rehab team has so many layers of unique areas of expertise and there are many ways that the team can come together and tackle the problem of pressure ulcers!

Learn more about the role of Occupational Therapists as valuable members of the wound care team!

Team Approach is Best!

We do not work as silos, right?  We function best in every aspect of care when we work as one cohesive unit, all bringing our individual perspective to the situation.  We all have something valuable to contribute when it comes to pressure ulcer prevention and treatment of pressure ulcers when they do happen, and it’s important that we all recognize and respect each team members involvement! 

Ideally, having a dedicated wound team is best.  These would be your go-to wound gurus that would not only assess and treat pressure ulcers (and other wounds), but they would be able to answer questions that are posed by other team members, the patient, or the family due to having an increased level of training and experience around wounds.  Better treatment and better customer service – who could ask for more?

Pressure Ulcer Staging

If a dedicated wound team is not possible in your place of work, it is of utmost importance to have a clear understanding of how quickly pressure ulcers can develop (in order to prevent them) and then also to understand how pressure ulcer staging works (in order to make more informed decisions regarding your role in their treatment). 

Like many physical afflictions, pressure ulcers do not affect all people in the same way.  It depends on many physiological factors as well as environment.  Some studies have shown that in higher risk individuals, pressure ulcers (of all stages) can develop in as quickly as one to two hours!  In other individuals, the damage that may occur beneath the surface of the skin, as with deep tissue injury, may not be evident until several days later. 

Because it can happen so quickly in some and be unnoticeable in others, we must all be diligent to frequently inspect skin and be able to recognize what we may encounter in our patients that are unable to reposition themselves or are unable to feel the building pressure under their body parts. 

Here is a quick guide to pressure ulcer staging to get you on your way to a more upskilled approach to assessment!

Stage I: Skin is intact.  Skin is reddened and is not able to be blanched (does not momentarily whiten when quick pressure is applied).  In skin with darker pigmentation, the skin may not look red, but will be a different color than the surrounding area.  The affected area is often warmer than the surrounding tissue.  The affected area may have a different texture (may be either softer of firmer) than the surrounding tissue.
Stage II: The skin is no longer intact, leaving an open wound.  Does not extend past layers of skin.  Can also appear as a fluid filled blister.
Stage III: The wound extends past the layers of the skin into the adipose tissue, but not as deep as the muscle, tendon, or bone.
Stage IV: The wound extends past the skin and adipose tissue, now exposing the muscle, tendon, and/or bone.
Deep tissue injury: Open wound is not present, but tissue beneath the surface has been damaged.  Skin may appear purple or dark red or there may be a blood-filled blister.
Unstageable: The stage is not clear due to the presence of slough.  If you cannot see the base of the ulcer, you cannot assign a stage to it as you may not know how deep the wound goes and what tissues are exposed/involved.

Want more wound care resources? Get ‘The Ultimate Guide to Managing the Diabetic Foot’, a 14 page manual packed with client handouts and clinician resources, right here!

How much of a problem are pressure ulcers… really?

It is estimated that over 2.5 million people develop pressure ulcers each year in the United States.  And as you may imagine… when they are present it can have a significant effect on a patient’s overall health, their ability to participate in daily life, and their ability to participate in therapy.  Depending on the location of the pressure ulcer and the pressure ulcer staging, they may only be able to tolerate being in any given position for a short amount of time, which limits their ability to participate in functional activities that are meant to strengthen them during their therapy sessions.  They may have an increased amount of pain associated with the pressure ulcer and can only manage short bouts of activity at a time.  If the pressure ulcer is on their foot, the physician may not want them to bear weight to allow better healing.  All of these factors can prolong a person’s stay in rehab and effect their overall outcomes at home. 

Being treated for a pressure ulcer can be an extremely isolating experience as well.  If the wound treatment takes extensive amounts of time, or if the pressure ulcer has large amounts of drainage coming from it, or if there is a foul odor… you may not want your friends or family around too often and you certainly don’t want to deal with those things out in public!  This may be a great opportunity for all clinicians involved to educate patients are caregivers about their situation and remove any sort of stigma associated with pressure ulcers or their treatments!

How can we help?

As mentioned before, working together as a team is one of the best ways we can address the problems our patients are facing, and that includes pressure ulcers!  Here are a few great ways we can collaborate and better serve our patients:

Co-treat:

Literally… work together. In the rehab world, PTs and OTs do this all the time (and if they don’t, they should!)  This is a great way to address many different impairments at the same time and to learn from each other.  Some things that one discipline is focusing in on can more easily be carried over to future individual sessions after the patient has been observed performing them! 

We can use this same concept in wound care!  PTs or OTs (and even SLPs) can participate in a wound dressing change with the nurse.  The nurse can lead the way if the therapist is not well versed in the wound world, but the therapist can assess and identify other avenues of treatment that may assist in wound healing.  As they see the wound uncovered, they can determine if any type of modality can be used as an adjunct to wound healing. 

This could even be simply related to the pain that is incurred during the wound dressing change itself.  With a bit of scheduling gymnastics, therapy can coordinate with nursing as to when a dressing change will occur and time the application of stim, ultrasound, etc. in order to alleviate pain and assist with the process of the wound treatment.  These modalities can also act to increase circulation to the area and indirectly help with wound healing. 

If SLP is co-treating with nursing, this may be a great opportunity to see how well the patient or their caregiver will be able to carryover the steps involved in a dressing change or even if they can carryover the importance of repositioning and strategies to offload high pressure areas.

Prevention

As we learned, pressure ulcers can develop quickly in higher risk individuals.  If we can prevent them from happening in the first place… that’s where we want to be.  We can certainly work together to be most effective in prevention.  Nursing will be inspecting skin at regular intervals, but OTs usually see a whole lot of skin in the rehab setting too!  Being mindful of any changes or anything that looks out of the ordinary during bathing and dressing tasks will be a great help in continuously assessing for signs of pressure which may lead to ulcerations down the road. 

Therapists are also constantly assessing levels of pain.  Pain could be an indicator of pressure, so it’s imperative that we really get down to the bottom of the source of pain rather than simply asking if the patient is due for their next pill.  This way, we can adjust equipment or positioning and possibly prevent a pressure ulcer from forming.

Positioning 

This is definitely an area that therapy and nursing overlaps.  This should be quite intuitive in how the different disciplines would work together to come up with the best positioning devices, strategies, schedules, and overall plan to address the individual needs of the patient.  Therapy can recommend and provide the appropriate wheelchair, cushion, or any other specialty items needed.  Nursing can evaluate the bed and mattress and initiate a turning and/or out of bed schedule.  Then as we go through our days, we can be in constant communication with the other about what’s next.  If the cushion turns out to be uncomfortable, the therapist can proactively provide and “option B” for the evening shift nurse to trial with the patient until they can get back in the next day to evaluate the situation.  If therapy is assisting the patient back to bed at the end of a session, the nurse should be notified as to how they are positioned, so they can keep track of when they need to be repositioned and how.  Positioning isn’t new for any of us, but we have to communicate well and always be on the same page.

Refine your skills

Not all teams start out with wound care experts.  But it doesn’t mean it should stay that way!  There are many avenues you can go down to find out more about how to address pressure ulcers and how to assess and treat wounds in general.  You may start of with reading some articles.  Finding out the latest and greatest research is a good place to start.  Taking continuing education classes will give you more hands-on, practical knowledge.  (Scroll to the bottom to find a link to ARC’s, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician.)  You can take it a step further and become Wound Care Certified!  Visit this website to see the benefits of becoming certified and what steps you need to take.

Wound care is not everyone’s cup of tea.  But, pressure ulcers are real… and they can show up real quick if we aren’t careful!  Working as a team and finding ways to build in a comprehensive program for pressure ulcer treatment and pressure ulcer prevention is where you will give your patients, yourself, and your co-workers the best rehab experience possible.

Want to see some videos about pressure ulcer and other wound management techniques? CheckCheck out these videos from our resident guru, Michelle, that you can apply immediately…no matter what setting you work in.

If you are interested in upskilling your practice, check out A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This engaging and super-practical seminar will give you the hands-on skills and the confidence you need to be able to assess and manage all types of wounds.

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Edema Management: How to improve patient compliance


Compliance with the care plan can be a thorny issue in the realm of the treatment of swelling and edema.

Patient compliance (or lack of compliance) is a major issue for many clinicians. At times, it can be one of the biggest barriers to implementing a care plan. This lack of patient compliance can be particularly noticeable when the suggested intervention is painful, unpleasant, or challenging- which edema management certainly can be!

Of course we know, people who are dealing with an issue that brings them to our services have already been through a lot! By the time we see someone in physical/occupational/speech therapy, or are providing nursing care, they are already overwhelmed. They might feel beat, exhausted, or just want to give up already! Does this sound familiar?

Here, we outline how to ensure your patient is as compliant as possible with your treatment plan for their swelling and edema.

Explain their condition… in a way that they understand!

Chronic edema is a condition that can be surrounded by misunderstanding and incomplete information. There can be a conception that swelling, especially when is is initially caused by trauma or an acute event (injury, surgery, etc), will just “go away by itself”. This misconception is not only untrue, it can be actively damaging! This lack of understanding of how the lymphatic system works can lead to ‘acute’ swelling developing into a chronic, unmoving lymphedema.

However, a patient whose edema is brought to your attention as a problem- it may be impacting their mobility, placing them at higher risk of falls, leading to infections or chronic skin breakdown- might have an incorrect perception that their swelling will disappear once the offending cause (Diabetes, Trauma, CHF… the list goes on) is under control. Unfortunately, this isn’t the case!

If left to persist in the extremity, edema can overwhelm and ‘wear down’ the lymphatic system, leading to a high-protein lymphedema. This can be recognized through some of the characteristic skin conditions that are associated with chronic edema.

We, as clinicians, may understand the importance of addressing edema as early as possible- but the first step in getting buy-in from your patient is getting them to realize this, too! Depending on their level of health literacy, you may want to use a metaphor or mnemonic to help them remember this complicated concept. You can explain: the lymphatic system is working away like a train- chugging away and removing the additional fluid as fast as it can- but over time and being worked at maximal capacity, the engine and wheels begin to wear and fail, and it can’t transport its load as efficiently as before. Over time, it becomes slow and worn and then cannot even transport a light load efficiently.

Show them the outcomes of their efforts

Gaining patient compliance and buy-in, especially when you need them to be active participants in decreasing their swelling and edema, is going to hinge on their understanding the value and results.

Edema management is multi-faceted. Complete Decongestive Therapy is an umbrella term, encompassing the main tenets of edema management- including Manual Lymphatic Drainage, Compression Bandaging, Decongestive Exercises, Skin Care, and Patient Education. For your patient to be compliant with this course of action, they will want to see the outcomes of their efforts.

Taking girth measurements, and explaining the difference between limbs (“your right leg is 25% bigger than your left!”); or- if both limbs are affected equally- “your limbs are 20 cm smaller in total this week than 2 weeks ago!”. It can be incredibly motivating to know that the work they are doing- and it is work, even if it is ‘just’ wearing their compression stockings!- is having a measurable effect on the size of their limbs.

Taking regular progress photos, and tracking the photographic changes over the days and weeks that you are working with your patient can be extremely effective. The condition of their skin, the girth of the limb and general improved appearance may be a more compelling reason to stay the course with regard to treatment plans than all the didactic education in the world.

improve compliance with edema
The ‘before’ picture was taken upon evaluation, and the second picture was taken after 9 days (before discharge).

I had a non-compliant patient in my care in in-patient rehab, who had presented with LE cellulitis, amongst other conditions (pics of hyperkeratosis leg, arrows to conditions). I was able to convince her to a trial of treatment, which included proximal MLD, impregnated gauze on the areas of hyperkeratosis, compression bandaging with chip pads to soften fibrosis, and exercise. Within a week I was able to show her this progress picture (see before/after pic). Despite being resistant to the idea of Complete Decongestive Therapy to decrease her infections, improve her skin and general outcomes, the photographic progress was more compelling to her as a reason to persist with the plan of care.

And lastly- use their own subjective reports to show them the difference in their function. With chronic edema, the person has likely had a slow and steady decline in function, that may have affected their mobility, pain and fatigue levels, perceived endurance, skin feel/breakdown, and so on. You may be able to show your patient- “When we first met, you needed assistance swinging your legs out of bed and reported it was a Rate of perceived exertion of 8; today you did it yourself and told me it was closer to a 2!”. Hearing their own subjective reports as to how difficult some tasks had been, before engaging in their plan of care, may be more personal and engaging to them. This may help with compliance with regard to edema management; the memory of how difficult some items have been will probably not be long-forgotten.

Listen; and meet them where they are at

‘Buying in’ to a plan of care may be the last thing your already overspent patient wants to do. And you may have an idea in your mind as to what they ‘need’- thorough manual lymphatic drainage, high levels of foam and compression bandaging with short stretch bandages, and daily decongestive exercises, for example. If this is too overwhelming for your patient- you may get a very resistive response. This is where your skilled, careful listening will come in.

Once explaining what you want to achieve and work on with your patient, you should listen closely. They may agree to you plan ostensibly, but not follow through- or instead, can resist you completely. Try to hear what their biggest concerns are, and if you can modify or water down your ‘perfect’ plan, do it! Any intervention will be better than no input whatsoever. Although the best intervention might include a short stretch bandaging complex- if this is too bulky and labor-intensive, you can explore other options. These other options may be less effective, or work less quickly, but are still preferable to no intervention. Off the shelf garments that can be less bulky and obvious, such as the Exo line from L&R, may be a more acceptable solution.

Make it easy!

Going through the rehabilitative process is hard enough! Try to make compliance with your proposed plan as easy as possible for your person. Teach them self management techniques- and make sure they are as simple as possible! (Check out some videos teaching simple proximal drainage techniques, right here)

compliance edema
ReadyWrap

This also follows into compression- make sure that you provide your patient with the tools they need to be able to don it as easily as possible. The Slippie Gator can be a helpful aid for donning compression stockings. ReadyWraps are an extremely intuitive compression garment, that your patient can adjust and continue to decongest in.

Decongestive exercises can be made easier by tying them to an existing home exercise program, that your patient may already be familiar with. Decongestive exercises are simple and straightforward, and anchoring them to a routine or existing program will help make them more intuitive to include into daily life.

Building healthy habits for edema management, including skin care and risk reduction, is vital. Examine, with your patient, how you can make this as intuitive as possible!

Patient compliance in the management of edema and swelling has long been a tricky issue. By following some of these techniques, you may be able to help reach your patient where they are at, and engage them fully in their plan.

If you found this compliance article helpful, you would love our popular and engaging seminar on the topic of Edema Management! Check it out and read more right here: Edema Management in In-patient Rehabilitation!

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Occupational Therapy and Wound Care: a match made in heaven?


I have a confession to make. My name is Emily…. and I’m obsessed with wound care.

I never imagined my occupational therapy career would lead me down the path it did- working heavily with people with chronic edema, skin conditions I had never heard of, and hand-in-hand with this- wound care.

Whether this is a role for an OT or not is a question that comes up again and again. One of the things I love about OT is the wide range of areas we practice and are effective in. I always felt- if I’m going to be working in a field for 40+ years, I want to have options of different fun things to grab my interest every few years!

This held really true when 5 years after graduation, I fell down the edema rabbit hole. This massively misunderstood and under-treated area captured my attention, and the payoff of seeing people becoming more mobile, engage with their communities again, and improve their QOL was (and is) fantastic!

However, as any clinician who encounters chronic swelling of any kind knows, skin breakdown and infection is never far behind. And that is where my newest pet obsession- wound care- comes into its own!

To read about some of the characteristic skin conditions associated with edema, check out this article.

Is wound care within the scope of practice of an OT?

Wound care is squarely within an OT’s scope of practice, and intersects with many of our other, occupation-based, interests. Check out the AOTA’s position paper on Occupational Therapy and wound care for details on what occupational therapists may complete as part of their wound care practice.

Skin integrity is central to a person’s ability to function at the best capacity. A wound- whether it is a pressure ulcer, a burn, an ostomy, an abrasion, or any other skin condition- will stymie or completely alter a person’s ability to pursue meaningful occupation. This runs contrary to what OT’s hold centrally- that engagement in activities and tasks is integral to a meaningful life. Engaging in these activities, and the associated mobility, helps some types of wounds, like pressure ulcers, from occurring (or worsening!).

Why would occupational therapy get involved with wound care? Isn’t it more of a nursing role?

Firstly- wound care is a concern for everybody on the team. If a client has a wound, this will be the #1 thing that will complicate their stay, impede upon their outcomes, and is the most likely factor to send them to a long-term facility instead of going home.

Wound care is a huge deal! But yet, many, many clinicians don’t feel comfortable or equipped to manage these issues.

Within the multidisciplinary team, OTs have a really distinctive role they can play. As I mentioned before, prevention of wounds is an area that we can be instrumental in. Positioning, use of equipment and cushions, pressure-relief: these are strategies that OTs are uniquely positioned to address, with our ability to analyze activity and engagement.

wound
  1. Before the wound: Wound prevention in our vulnerable population is also an extremely important role that OT’s can play. Through activity analysis, positioning, appropriate equipment usage, environmental modifications, and lifestyle/risk reduction- we can help keep skin intact. Returning to previously held activities and roles- but ensuring it in a safe and skin-protecting manner is an area that many OTs can identify with.
  2. As a wound occurs: Managing wounds as they occur is a vital skill for a clinician working with vulnerable clients- as many occupational therapists are. We work with people in very close and intimate way, and are able to monitor and observe their skin. Therefore, we’re in a unique position to notice if a wound/pressure area is developing, or worsening (such as dehiscence/surgical). If an OT notices a wound is happening, we should be able to know how to accurately assess this, know the correct terminology to use, and know how to go forward with intervention- both to the area itself with medications and dressings, and also in support (positioning, swelling management, etc.). When working with someone who is at risk to develop a wound (such as- someone with Spinal Cord Injury, or Diabetes, or chronic swelling, and so on), we can also be looking out for high risk areas and teach a person how to monitor and assess their own skin.
  3. During wound healing: Lifestyle modification to maximize safety while living with a wound may be a less considered area for OT’s- but equally valid! Many of our clients will have wounds when they come to us, which may take some time to heal. Think of someone with a new ostomy bag, for example. This issue is a perfect intersection between functional engagement and skin/wound care, where OT’s can be instrumental in success. Similarly, living with trachs/PEGs/pressure wounds/post-surgical wounds are all open areas that a person may be dealing with for some time. Teaching a client how to manage these wounds, yet engage safely with daily tasks is vital for an occupational therapist. OT’s can also teach clients best practice to ensure that the wound heals as best and as fast as possible. We may also use modalities to speed up wound healing by stimulating circulation, granulation, and so on.
  4. After wound healing: Occupational therapists are one of the clinicians best positioned to discuss risk factors, required environmental changes, and ongoing skin management (both self-administered or directing a caregiver). OTs can work with clients to make sure that their life supports them not getting a wound again. Whether it is compensatory techniques for checking shower temperature for someone with neuropathy, or how to make sure maceration is not occurring, by teaching how to keep skin fastidiously dry with a person who has lymphorreah- OTs have the necessary skills to analyze activities for risk and help ameliorate those issues. (We can’t help it that we rock!)

Is it worth it for my administration to get an OT involved with wound management?

Look, we all want what is best for our patients, every day! But as clinicians- we are able to be able to think like that. Our bosses and administrators have to deal with the bottom line- insurance companies, productivity, and more. So when you’re trying to advocate for upskilling in the area of wound-care- you must be able to justify it. Luckily…. its totally justifiable.

Including the whole rehab team in the approach and treatment of wounds has a big impact on the overall outcomes of the patient. Larger increases in independence scores, better patient satisfaction, more discharges to home as opposed to long term care (or re-hospitalization), and a shorter and more efficient use of interventions are some of the effects that you will notice if you work in a hospital or subacute setting. In addition, there are billing opportunities for therapists, both in terms of prevention and intervention. If you are an OT that works in an outpatient or home care setting, these factors still hold true, and also include a decrease in unnecessary emergency room and hospital visits.

These are all amongst the financial and QOL reasons that Occupational Therapy, and other therapy clinicians, are important members of the wound care team.

Want more wound care resources? Get ‘The Ultimate Guide to Managing the Diabetic Foot’, a 14 page manual packed with client handouts and clinician resources, right here!

What kind of wound care procedures are Occupational Therapy allowed to do?

According to the American Occupational Therapy Associations 2018 position paper, an OT can provide the following interventions. These interventions, of course, must be in accordance with a plan of care established by an OT, and varies depending on each practitioner’s level of competence and scope of practice. Interventions include:

  • Application of clean dressings with both exudating and non-exudating wounds
  • Application of wound closure strips
  • Removal of sutures
  • Application of appropriate topical agents to facilitate healing and debridement
  • Application of enzymatic agents for debridement
  • Mechanical debridement using forceps/cotton-tipped applicators/wet-to-dry dressings/pulsed lavage
  • Application of negative pressure wound therapy
  • Sharp debridements using scalpel or scissors
  • Application of silver nitrate for reduction of hypertrophic granulation tissue
  • Application of physical agent modalities such as whirlpool/electrical stim/ultrasound
  • Education of clients and caregivers in techniques for donning and doffing pressure garments
  • Use of specialized techniques for the management of lymphedema

This list does not include other, more typical OT interventions, such as: education to the client and caregiver about skin care, risk reduction, and self-management; modification and environmental accommodation; and use of adaptive equipment.

Does an OT have to be certified as a WCC to provide these services?

No! These services are within the scope of practice of an OT/OTA, in accordance with the AOTA’s position paper. It falls on the clinician to make sure they have the skills and competence to provide these services, however.

Becoming a WCC (Wound Care, Certified) is a great option if you know that you want to open your own clinic; or really dedicate yourself to wound care. To become certified, you must be a clinician (Nurse, PT/A, OT/A, Doctor); have about 120 hours of wound care experience (or 2 years working in a center treating wounds); and have completed a wound care certification prep course (which cost over $2500- ouch!). As an investment in your Wound Care Career, however, this is the gold standard of what you should aim for!

occupational therapy wound care

If you are interested in building your skill and becoming more confident in assessment and hands-on management of all kinds of wounds, you should have a look at our one-day course, A Comprehensive Guide to Wound Care: Tools for the everyday clinician. This course provides the participant a specific overview of different wounds; teaches both through hands-on application (yes, you get to use real debriding ointments to build your confidence!). Some examples of the ‘wounds’ that you get hands-on practice with during this course: Pressure ulcers, dehiscence wounds, tunneling/undermining wounds, ostomies, tracheostomy/PEG sites… and many others!

So as you can see- Occupational Therapy and wound care go hand-in-hand! I hope by now that you are as obsessed as I am 🙂 If you are interested in learning more wound care management techniques, check out these videos of Michelle teaching various wound care techniques that you can apply immediately, no matter what setting you work in.

If you are interested in upskilling your practice, check out A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This engaging and super-practical seminar will give you the hands-on skills and the confidence you need to be able to assess and manage all types of wounds.

Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂