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How Physical Therapists Can Be the Key to Jumpstarting Slow to Granulate Wounds

I know we have all had those patients with diagnoses that impair their wounds forming granulation tissue to fill wound depth. Perhaps there are comorbidities such as diabetes, peripheral artery disease or malnutrition. Skin flaps, cellular and/or tissue-based products for wounds, and hyperbaric oxygen therapy are alternatives, but not every patient can tolerate surgery or a hyperbaric chamber, has a shallow enough wound or enough arterial supply to make these other options successful. What to do? If a physical therapist rounds out your staff, then treatment with modalities may be an answer.

Therapeutic Modalities Used to Stimulate Wound Healing

Electrical stimulation (ES) has been shown in numerous studies to promote increased circulation, as well as granulation tissue formation and antimicrobial effects. While there are contraindications related to location of the wound, cancer and untreated infection, many patients with chronic wounds can benefit from electrical stimulation. ES increases cell motility, has antimicrobial effects, increases granulation, promotes re-epithelialization and increases arterial circulation.

The wound can be treated directly, or with electrodes adjacent to the wound. As an added benefit, studies show that the stimulation to the wound can also reduce wound-associated pain, thereby improving quality of life and adherence to the plan of care.1 Contact and non-contact ultrasound therapies have more recently been shown to effectively treat non-healing wounds. Fibroblast activity, calcium channel conduction, collagen production, histamine release and macrophage activity are all accelerated. Of course, this cellular activity leads to decreased wound healing time.2

Manual Lymphatic Drainage Therapy in Wound Care

Manual Lymphatic Drainage (MLD) is traditionally provided by manual lymphatic drainage therapists (PT, OT, PTA, COTA and Massage). Normally, lymphatic vessels are intertwined with arterioles at a distance of 1mm. With lymphedema, this can increase to 10mm. The increase in proteins due to the wound draws more fluid to the area. The lymphatic vessels are called to transport more fluid and large molecules. Even if the lymphatic capillary is functioning, it is 10 times harder to remove debris from a wound. MLD can reduce this diffusion distance and thereby decrease infection risks, increase blood flow to a wound and clear larger protein debris from the wound area. MLD consists of decongestive exercise, manual therapy to move lymphatic fluid, multilayered short stretch compression bandaging and garments, meticulous skin and nail care and education of patient/caregivers in the same. Multilayered short stretch wraps used in many wound clinics effectively move fluid.

Unfortunately, the proteins will remain and delay wound healing, continue infection risk and lead to fibrotic tissue. Patients that use a revolving door at your wound clinic with recurrent edema related ulcers may benefit from care from a skilled lymphedema therapist. Thankfully, with the internet, these specialized therapists can be found by searching for a certified wound specialist through a certifying professional wound care organization, or for a lymphedema therapist at the Lymphology Association of North American. Posting jobs on job sites such as or will find you a qualified therapist to add to your clinic.

Have an interested therapist you would like to train? Lymphedema training courses abound now in the USA: lists educational programs that can lead to qualifying to sit for national certification as a CLT-LANA (Certified Lymphedema Therapist-Lymphedema Association of North America). Wound certification can be done through the American Board of Wound Management or the National Alliance of Wound Care Certification Board. A dual certification is available through the International Lymphedema and Wound Training Institute leading to credentials as a Certified Lymphedema Wound Therapist. Adding a therapist to your clinic can offer another chance for wounds to heal and your patients to regain quality in their life. Sometimes it takes a village of health care team members to heal a wound.


1. Scarborough P. E-Stimulation: An Effective Modality to Facilitate Wound Healing. Today's Wound Clinic. 2012 May;6(4). Available at:…

2. Cameron MH. Ultrasound and Tissue Repair. Advance Healthcare Network for Physical Therapy and Rehab Medicine.…. Published June 1, 1999. Accessed August 17, 2016.

About the Author

Janet Wolfson is a wound care and lymphedema educator with ILWTI, and Lymphedema and Wound Care Coordinator at Health South of Ocala with over 30 years of field experience. 

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.