Dehisced surgical wound
Venous Insufficiency wounds
Sherri Boos, PT, DPT
Yukon Wound Care and Rehabilitation
1808 Commons Circle, Suite B
Yukon, Oklahoma 73099
Sherri Boos, PT, DPT
Yukon Wound Care and Rehabilitation
1808 Commons Circle, Suite B
Yukon, Oklahoma 73099
Our balance system helps us walk, run, and move without falling. Balance is controlled through signals to the brain
from your eyes, the inner ear (vestibular system), and the sensory systems of the body (such as the skin, muscles,
It is important to see your doctor if you have unexplained dizziness or balance issues. If you have any of the following other symptoms, be sure to seek emergency medical care:
• Chest pains
• Numbness or tingling
• Falling or problems walking
• Weakness in the legs or arms
• Blurred vision
• Slurred speech
• Sudden hearing loss
• Severe neck stiffness
• Head trauma or injury
• High fever
Dizziness and balance difficulties are symptoms of another problem. The first thing you should do is try to find out
the underlying cause. You should have a medical examination with special attention given to checking for problems
that can be associated with balance difficulties. Unfortunately, in many cases, the dizziness and balance
difficulties cannot be treated medically or surgically. In these cases, the balance problem itself may need to be
treated through balance rehabilitation.
If you experience light-headedness, a sensation of losing your balance, or a sense of feeling unsteady, you may be one of the millions of Americans who experience dizziness. Dizziness is one of the most common complaints and affects 20% to 30% of the general population. In fact, dizziness is a common reason that adults seek medical attention. When your balance is weakened, you may feel unsteady, woozy, or disoriented. You may have blurred vision or experience a sensation of movement. It may seem that the room is spinning (vertigo). You may not be able to walk without staggering, or you may not even be able to get up. Sometimes nausea, vomiting, diarrhea, faintness, changes in heart rate and blood pressure, fear, and anxiety accompany the dizziness and balance problems.
Dizziness can be associated with a variety of conditions, including:
• Viral or bacterial infections, including ear infections
• Foreign objects in the ear canal
• Blood pressure changes
• Vascular problems
• A fistula (hole) in the inner ear
• Ménière’s disease
• Medicines or drugs poisonous to the ear or balance system (ototoxic medicines)
• Multiple sclerosis
• Visual disorders
• Tumors, especially of the vestibular portion of the eighth cranial nerve (known as acoustic neuroma)
• Head injury
Vertigo is a type of dizziness in which there is a sense of movement or spinning. Changing position, such as sitting up in bed, can make it seem worse. Nausea and vomiting may accompany the vertigo at times.
Balance system assessment is often recommended when a person has:
• Rapid, involuntary eye movement (also known as nystagmus)
• Complaints of vertigo or dizziness
• Balance dysfunction
• Difficulty walking
• Suspected disease of the vestibular system
• The cause of the symptoms
• Where in the balance system the problem is occurring
• What changes are happening in the balance function
• How vision, the inner ear, and other sensory systems affect functional balance
Some of the tests of balance can be done in the physician’s office or at the bedside in the hospital. Others require specialized equipment located in the audiology office or clinic.
Your audiologic (hearing), balance, and medical diagnostic tests help indicate whether you are a candidate
for vestibular (balance) rehabilitation. Vestibular rehabilitation is an individualized balance-retraining exercise program. The retraining teaches compensations that may decrease dizziness, improve balance, and improve general activity levels. Many audiologists provide limited vestibular rehabilitation. However, other clinicians, such as physical therapists are trained to provide more extensive vestibular rehabilitation. Rehabilitation with a clinician who specializes in vestibular rehabilitation may be effective in minimizing or relieving some of the symptoms. This is especially true if the dizziness is caused by head movement, motion sensitivity, or certain positions. Rehabilitation is also excellent for recovery of balance and improving daily functional activities.
Audiologists perform audiologic and balance assessment to gather information about your hearing and balance function. Test results help determine the possible causes of dizziness. Results of these assessments, in combination
with medical findings, will provide diagnostic information trained to provide more extensive vestibular rehabilitation. Rehabilitation with a clinician who specializes in vestibular rehabilitation may be effective in minimizing or relieving some of the symptoms. This is especially true if the dizziness is caused by head movement, motion sensitivity, or certain positions. Rehabilitation is also excellent for recovery of balance and improving daily
Neck pain that sometimes follows dizziness and may be hard to figure out for practitioners if the dizziness and neck pain are connected or separate (Wrisley, 2017). Cervicogenic dizziness is difficult to diagnose due to non specific test to confirm a diagnosis. A correct diagnosis is provided to a patient when a neck injury or pain is reported along with complaints of dizziness (Wrisley, 2017).
Patients with cervicogenitic dizziness typically describe symptoms of dizziness during head movement or after remaining in position for a long period of time (Wrisley, 2017). I addition, patients may complain of imbalance that worsens with head movement.
Cervicaogenic dizziness requires a physical examination with complete medical history as symptoms may mimic other causes of dizziness. In an effort to achieve an accurate diagnosis your practitioner will perform specific test to rule out vestibular or central vestibular systems (Wrisley, 2017). Your health care provider may perform a test that causes nystagmus (rapid eye movement) causing dizziness symptoms along with nausea and vomiting. A positive test with subjective findings are usually positive, but false positives do occur.
Cervicaogenic dizziness frequently follows whiplash or head injury and is usually related to brain injury or inner ear injury (Wrisley, 2017). Most patients diagnosed with cervicogentic dizziness recover quickly with routine treatment on the neck using medication, gentle passive mobilization, exercise and posture correction. Patients that do not respond to conservative treatment may require additional vestibular therapy that encompasses eye exercise, balance therapy, walking etc. (Wrisley, 2017).
Sherri Boos, Pt. DPT
Wrisley, D. M. (2017). Cervicogenic Dizziness | Vestibular Disorders Association. Retrieved from http://vestibular.org/cervicogenic-dizziness
Burns can be extremely painful for the patient and difficult to manage for the clinician. Over the years I treated many burns including babies, children and older adults. Understanding burns is the basic requirement that is absolutely necessary in the healing process. During the initial assessment staging the wound is vital and is done by sensation tests throughout the involved tissue because the entire burn will vary in depth causing sensation changes over the peri wound and wound itself. First degree wounds are the most painful because nerve endings are inflamed and fully exposed encompassing the epidermis layer causing redness and swelling (MedlinePlus, 2014). First degree burns usually heal in 7 to 10 days with topical medication and light debridement. Second degree burns involve the epidermis and dermal layers and remain painful because the nerves are exposed causing redness, swelling and blisters (MedlinePlus, 2014). Second degree burns heal in 10 to 21 days requiring topical medication and moderate firm debridement timely to avoid scaring. Third degree burns involve the epidermis, dermis and hypodermis layers with much less pain because the nerves are fully damaged causing numbness, redness, swelling, blisters and thick eschar (MedlinePlus, 2014). Third degree burns heal in 21 days to months and usually require surgical debridement, skin grafting resulting in severe scaring and soft tissue restrictions.
Burns are devided into 4 categories of depth: epidermial, superficial partial thickness, deep partial thickness and full-thickess (Devgan et al. 2006). Epidermal and superficial partial thickness are considered 1st and 2nd degree requiring non-operative wound treatment, but deep partial thickness and full-thickness are considered 3rd degree burns and often require operative more invasive care (Devgan et al. 2006). Clinical understanding of these categories is vital in the wound healing process because burn wounds undergo a conversion process that imped healing (Devgan et al. 2006). The conversion process is described as 3 complicated zones: viable zone of coagulation, continued viable stasis zone and edematous zone of hyperemia (obstruction of blood flow) (Devgan et al. 2006). Wound healing is interrupted in these 3 zones requiring timely assessment and intervention, which is why this research article looked at various modalities to improve depth assessment (Devgan et al. 2006). The most used and cost effective method is bedside clinical exam with an accuracy of two thirds of burns assessing appearance, staging of capillary refill, capillary staining and sensation testing with light touch and pin prick (Devgan et al. 2006). However, bedside assessment limitations are consistent clinical knowledge of burns leading to error of overestimation of burn depth and validity of diagnosis (Devgan et al. 2006). The available modalities that are listed in this article are: biopsy and histology, thermography, vial dyes, indocyanine green video angiography and laser doppler flowmetry (Devgan et al. 2006). Biopsy and histology is 100% accurate but has drawbacks of invasiveness and added tissue damage and scarring, increased cost of experienced pathologist and subjective interpretation (Devgan et al. 2006). Thermography is a modality that measures tissue temperature to diagnose burn depth with an accuracy of 90%, but has disadvantages of false positive depth secondary to loss of heat within the tissue after 3 days of the burn (Devgan et al. 2006). Vital dyes is a modality rarely used that employs intravenous injection of fluorescein dye surveyed by illumination of 360 to 400 ultraviolet light over damaged tissue looking for depth but cannot differentiate between superficial and deep partial-thickness wounds or recognize healthy tissue covered with eschar (Devgan et al. 2006). Indocyanine green video angiography (ICG) is a modality that uses videography that pictures changes in tissue perfusion with intravenous injection of IGC looking for dye uptake within the damaged tissue (Devgan et al. 2006). This modality has the potential to gain popularity but has disadvantages of cost and large infrastructure requirements as well as interference with topical medication used for burn intervention (Devgan et al. 2006). Laser doppler flowmetry monitors perfusion using mono frequency light waves with an accuracy of 90 to 97% (Devgan et al. 2006). However, this modality has limitations as well because it involves using a probe and pressure directly on the burned tissue subjecting the tissue to infection and additional wound trauma (Devgan et al. 2006). In addition to the above modalities there is considerable research that is underway using advance modalities of: Optic measurements, nuclear imaging, and non-contact high frequency US to improve burn depth assessment (Devgan et al. 2006).
All of the mentioned modalities sound very promising in assessing burn depth to aide in diagnosing and timely intervention in burn victims. However, in my opinion improvement in consistent clinician assessment is necessary followed by a referral as soon as possible to the next level of care for the best outcome.
Sherri Boos, PT, DPT
Figure 1 (MedlinePlus Medical Encyclopedia Image, 2014).
Burns: MedlinePlus Medical Encyclopedia Image. (n.d.). Retrieved August 3, 2014, from
Devgan, L., Bhat, S., Aylward, S., & Spence, R. J. (2006). Modalities for the assessment of burn
wound depth. Journal of Burns and Wounds, 5, 7-15. Retrieved from Utica College.
Falls, trauma and sport related injuries cause problems to bones and soft tissue structures. Because soft tissue structures can be strained or even ruptured a grading scale is used to determine damage and proper treatment (Boissonnault, 2011). Grade I soft tissue strain is an over stretch of tissue without rupture. Grade II soft tissue strain is a partial tear in the tissue without disruption to the fascia. Grade I and II injuries cause local tenderness, edema, muscle spasm, bruising and pain with movement (Boissonnault, 2011).
Early treatment for grades I and II consist of rest, ice, compression and elevation. Once the acute swelling and pain subsides approximately 7 to 10 days a referral to physical therapy to restore motion, weight bearing, reduce swelling and pain and restore soft tissue function is necessary.
However, grade III soft tissue injury is more involved resulting in compete tear of soft tissue (muscle) and fasciaresulting in total loss of movement and possible surgical repair. Grade III injuries cause edema, blisters, pain, superficial and deep bruising, and palpable soft tissue defect. Referral to a wound care specialist for debridement and wound healing may be required along with a referral to orthopedic specialist for joint repair. Once the grade III injury is repaired and healing has occurred a referral to physical therapy is protocol to restore motion, reduce swelling and pain, regain weight bearing and normal function.
Boissonnault, W. G. (2011). Primary care for the physical therapist (2nd ed.). St, Louis, Missouri: Saunders.
Cellulitis is a quick spreading infection caused by bacteria that enters the skin and subcutaneous structures resulting in severe inflammation that invades superficial tissue (Goodman & Fuller, 2009). In adults the bacteria that usually causes cellulitis is either streptococcus pyogenes or staphylococcus and in children the bacteria is commonly haemophilus
influenza type b, other types of bacteria can cause cellulitis but is not as common (Goodman & Fuller, 2009). Patients at high risk for cellulitis include older adults and individuals with diabetes, malnutrition, steroid medication, and existing wounds (Goodman & Fuller, 2009). Anyone can acquire cellulitis because all of us have bacteria on our skin and under our nails that could enter with a scratch or scrap of the skin. Frequent hand washing is the best way to avoid getting cellulitis, the Center for Disease Control and Prevention (CDC) strongly recommend washing your hands for 20 seconds while humming the happy birthday song twice (CDC Features – Wash Your Hands, 2014). Hand washing is recommended after food preparation, blowing your nose, coughing, toileting, touching trash or pets, changing diapers, touching dressing or sores, before eating and preparing food (CDC Features – Wash Your Hands, 2014). Many times patients with lower extremity edema resemble cellulitis as a result of medication induced sodium overload and can add to the clinician’s confusion (Simon, 2014).
Cellulitis typically affects the soft fatty tissue and skin, but can invade the deep tissue around the muscle causing skin erythema, edema, blisters, tenderness to touch and severe weight bearing pain, and occasionally nodular firmness (Goodman & Fuller, 2009). I frequently describe cellulitis to my patients as a soft tissue infection that resembles a severe sunburn occurring from the inside out. Cellulitis presents as blotches of red skin that is hot and painful with defined borders and frequently cause red lines stretching out from the blotches that signify infected lymph structures (Goodman & Fuller, 2009). In addition, odor within the wound of cellulitis is not apparent because the exudate is serous thin (clear or yellow) drainage not purulent thick (green or yellow) drainage. Epidemiology of cellulitis has a rate of 24.6 per 1000 persons affecting males more than females and patients between 45 and 65 years old with the most common infected site being the lower extremity (Ellis et al. 2006). My role in cellulitis is recognizing the clinical signs, to avoid misdiagnosis and to provide appropriate intervention using topical medication and debridement. Additional interventions include: extremity elevation, topical medication such as Silvadene, gel cool packs, dressing to absorb exudate and if necessary debridement (Nazarko, 2008). Patients will complain of sudden fever or flu symptoms, severe pain in the affected area, redness and swelling that spreads quickly (PubMed Health, 2013; Nazarko, 2008). Cellulitis is frequently misdiagnosed by as much as 1/3 of the time because the symptoms are confused with venous eczema, oedema with blisters, venous insufficiency ulcers, deep venous thrombosis (DVT), thrombophlebitis, liposclerosis, and vasculitis (Nazarko, 2008).
Cellulitis is diagnosed using clinical features of a sudden onset of a red distinct area that is hot, swollen with or without blisters and extremely painful to touch and walk on along with accurate patient history (Nazarko, 2012). Upon patient exam the reddened area is outlined with a permanent marker to observe progression of infection or improvement followed by consistent observation (Nazarko, 2012). In most cases of cellulitis there will be presence of a lesion, cut or fissure that indicates bacteria entry with systemic symptoms of inflammation (Simon, 2014). Many individuals will go to urgent care facilities for cellulitis that is why a classification system was developed for clinicians to use to categorize for timely intervention (Nazarko, 2008; Nazarko 2012). This system uses 4 classes to help providers identify interventional strategies including: class one is patients that have no poisonousness systemic symptoms who respond to oral antibiotics, class two are patients who feel either healthy or ill, but have predisposing factors such as peripheral vascular disease, chronic venous insufficiency, or extremely obese affecting healing require intravenous out-patient antibiotics, class three are individuals feeling ill and have acute sign of confusion, tachycardia, shortness of breath, hypotension, or other causes that may influence healing requiring in-patient antibiotics, class four are patients with septicemia or necrotizing fasciitis requiring in-patient intensive care and antibiotics. (Nazarko, 2008; Nazarko 2012). Evidence-based treatment for cellulitis is oral antibiotics such as cephalosporins for non-problematic cases and doxycycline or co-trimoxazole for stronger bacterial strains (Petrou, 2011). Basic CBC lab test can be used to help in differential diagnosis of cellulitis as well as biopsies to identify whether the invasion is bacterial, viral, fungal, parasitic, or a mycobacterial cause (Petrou, 2011). Complications of cellulitis include: sepsis, osteomyelitis, lymphangitis, endocarditis, meningitis, shock and gaseous gangrene (PubMed Health, 2013). To make cellulitis more complicated for the clinician there is secondary causes of cellulitis that include: surgical dehisced peri wound cellulitis, abscess cellulitis, burn cellulitis, trauma cellulitis and lymphedema cellulitis, but these are not the typical bacterial invading cellulitis but rather the result of a primary cause.
In conclusion, cellulitis is a condition that progresses quickly within approximately 24 hours resulting in defined redness, swelling, blisters, severe superficial inflammation, pain, and flu like symptoms usually with some type of skin lesion, cut or scratch that allows bacteria entry. Timely accurate diagnosis is imperative because delayed and / or inappropriate treatment can cause septicemia, death, unnecessary tissue grafting, increased hospitalization length of stay, re-admissions and outrageous health care cost. Cellulitis requires specific oral or intravenous antibiotics to combat the bacterial infection, pain medication to alleviate pain and interventional wound care is needed to facilitate quick healing and avoid scaring. Cellulitis classification system approach using 4 classes was introduced to health care providers to facilitate out-patient verse in-patient care and to assist in urgency decision and avoid unnecessary hospital admissions. Cellulitis can be confusing for providers because many providers confuse the condition with other similar conditions such as venous eczema, traumatic injury inflammation, oedema with blisters, venous insufficiency ulcers, DVT, thrombophlebitis, liposclerosis, and vasculitis. Unsophisticated lab test such as a CBC can help in diagnosing cellulitis as well as detailed biopsy. Modalities of choice are plain radiography for differential diagnosis initially followed by the inexpensive ultrasound that is extremely accurate and readily available. CT and MRI modality is noninvasive, but are more expensive imaging tests that can identify superficial cellulitis extending to deep tissue anatomy to rule out life threating conditions such as necrotizing fasciitis. Simple frequent hand washing using the 20 second rule is recommended by the CDC to minimize contracting bacterial cellulitis and many other invasive conditions. Cellulitis can be treated with many different topical agents including Silvadene, Bacitracin and Neosporin to sooth the burning inflamed tissue and help in healing progression. It has been my experience that Silvadene topical cream refrigerated is more soothing to cellulitis that Bacitracin or Neosporin.
Cellulitis – National Library of Medicine – PubMed Health. (2013, May 15). Retrieved August 6, 2014, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001858/.
CDC Features – Wash Your Hands. (n.d.). Retrieved August 8, 2014, from http://www.cdc.gov/Features/HandWashing/
Ellis, S., VanOrman, E. R., Hatch, B. E., Jones, S. S., Gren, L. H., Hegmann, K. T., & Lyon, J. L. (2006). Cellulitis incident in a defined population. Epidemiology Infect, 134(2), 239-299. doi:10.1017/S095026880500484X. Retrieved from Utica College.
Goodman, C. C., & Fuller, K. S. (2009). Pathology implications for the physical therapist (3rd ed.). Missouri: Saunders Elsevier.
Nazarko, L. (2008). Infection control: Cellulitis. Nursing & Residents Care, 10(4), 177-179. Retrieved from Utica College.
Nazarko, L. (2012). An evidence-based approach to diagnosis and management of cellulitis. British Journal of Community Nursing, 17(1), 6-8. Retrieved from Utica College.
Petrou, L. (2011). Cellulitis conundrum. Clinical Dermatology, 35-36. Retrieved from Utica College.
Simon, E. B. (2014). Leg edema assessment and management. Med Surg Nursing, 23(1), 44-53. Retrieved from Utica College.