Chronic wounds are a significant healthcare challenge affecting millions of people worldwide. These wounds often fail to heal within the expected time frame, leading to prolonged pain, reduced quality of life, and increased healthcare costs. In order to effectively manage chronic wounds, it is crucial to identify and address their underlying causes. This blog post will explore the concept of root cause treatments in chronic wound care and discuss evidence-based approaches for promoting, healing and preventing wound recurrence.
Understanding Chronic Wounds and Root Causes:
Chronic wounds are generally defined as wounds that fail to progress through the normal healing processes of hemostasis, inflammation, proliferation and then maturation. We no longer associate a specific timeframe with “chronicity” but can refer to a wound as being recalcitrant or difficult to heal if we are not seeing a healing response after several weeks of treatment. We are moving away from the term “chronic” in wound care as this implies something that cannot be healed and that the patient will be living with forever. At Athena Specialty Group, we prefer to look at these challenging situations as wounds that are “hard to heal”. These types of wounds that may be “hard to heal” commonly include pressure injuries, diabetic foot ulcers, venous leg ulcers, and arterial ulcers. While various factors contribute to delayed wound healing, it is essential to identify the root causes specific to each patient in order to implement targeted treatment strategies.
Sometimes this root cause is an external factor that we can influence and sometimes it is an internal, physiological factor we need to help manage or overcome if possible. These might be things like adjusting the pressure being placed on the wound during sitting or ambulation, better managing the patient’s blood glucose levels, using therapeutic compression to reduce edema or making recommendations to help improve a patient’s nutrition. Herein lies the challenge that Athena Specialty Group has accepted; how can we look at the overall picture of our patients to determine the thing or things that are missing or need to be adjusted to support that patient’s wound healing? How do we treat the whole patient, not just the hole in the patient?
Pressure injuries, for example, are caused by sustained pressure on the skin, leading to tissue damage; often in the presence of immobility, incontinence and poor nutrition. Diabetic foot ulcers result from a combination of peripheral neuropathy, reduced blood supply, and repetitive trauma. Venous leg ulcers stem from chronic venous insufficiency and edema, whereas arterial ulcers arise from inadequate blood flow to the extremities. Identifying these root causes is essential to establish effective treatment plans.
Evidence-Based Approaches for Root Cause Treatments:
- Pressure Injuries: To effectively manage pressure injuries, the primary focus should be on reducing pressure and optimizing wound healing. Offloading techniques, such as the use of specialized cushions and mattresses, can help redistribute pressure away from vulnerable areas. Additionally, maintaining proper nutrition, managing incontinence, and optimizing the patient’s overall health are crucial for healing.
According to a study published in the Journal of Wound Care (Smith et al., 2021), the implementation of a pressure injury prevention program that addresses root causes has shown promising results. The study emphasized the importance of early identification, risk assessment, and individualized prevention strategies to mitigate the development and recurrence of pressure injuries.
- Diabetic Foot Ulcers: Diabetic foot ulcers require a multidisciplinary approach that includes glycemic control, offloading, infection management, and wound care. Addressing the root causes of diabetic foot ulcers is crucial to prevent re-ulceration and amputation.
A systematic review published in the International Wound Journal (Lavery et al., 2016) highlighted the effectiveness of total contact casting (TCC) as a form of offloading therapy for diabetic foot ulcers. The study demonstrated that TCC significantly improves healing rates and reduces the risk of amputation. Combined with comprehensive foot care and regular monitoring, TCC represents a valuable treatment modality for addressing the root causes of diabetic foot ulcers. At Athena Specialty Group, our providers are trained in various forms of offloading that are available to our patients in the home and facility setting, where they may not have access to TCC. These alternate forms of offloading may include the utilization of customized offloading foam padding or prescription footwear to offload various aspects of the foot during weight-bearing activities.
- Venous Leg Ulcers: Managing venous leg ulcers involves addressing underlying venous insufficiency, reducing edema, and promoting wound healing. Compression therapy is the cornerstone of treatment and plays a vital role in addressing the root cause.
A randomized controlled trial published in JAMA Dermatology (O’Meara et al., 2012) compared different compression therapy systems for venous leg ulcers. The study found that multicomponent compression therapy, including graduated compression stockings, produced superior healing outcomes compared to single-component compression. This evidence supports the use of multicomponent compression therapy as an effective treatment approach for venous leg ulcers. At Athena Specialty Group we work closely with our industry partners to identify the most appropriate and effective forms of therapeutic compression for our patients. The type of compression utilized by our patients might need to be customized based on the patient’s underlying disease state, their mobility, flexibility, dexterity and degree of family or social support. What works for one patient may not work for another. Athena Specialty Group recognizes the importance of treating the root cause of these wounds and will work with the patient and their family to find something that works for them.
- Arterial Ulcers: Arterial ulcers require revascularization to restore blood flow and promote wound healing. Management strategies focus on improving arterial circulation and optimizing wound care.
A review article published in the Journal of Vascular Surgery (Mills et al., 2014) discussed various revascularization options for arterial ulcers, including endovascular interventions and surgical bypass procedures. The study emphasized the importance of a multidisciplinary approach, involving vascular specialists and wound care experts, to assess and address the underlying arterial insufficiency. Athena Specialty Group partners with our vascular surgeons and interventionists in each of our territories to identify the risk for and presence of arterial insufficiency so that our patients can receive limb and life saving interventions as early as possible.
Conclusion: Effective management of wounds that are hard to heal necessitates addressing the root causes specific to each wound and each patient. By identifying and treating these underlying factors, the wound care providers at Athena Specialty Group can implement targeted interventions that promote wound healing, reduce the risk of complications, and enhance patients’ quality of life.
Evidence-based approaches, such as offloading techniques for pressure injuries and diabetic foot ulcers, multicomponent compression therapy for venous leg ulcers, and revascularization strategies for arterial ulcers, have shown promising results in addressing root causes and facilitating wound healing. Through a comprehensive understanding of the underlying causes of wounds that are difficult to heal and the implementation of evidence-based treatments, our wound care providers at Athena Specialty Group can optimize care and outcomes for patients suffering from these challenging conditions.
The puzzle is what draws most of us to the field of wound care. There is the patient connection, the arts and crafts and the science of it; but what keeps most of us coming back again and again, year after year and why we share our patient stories with each other is the investigative aspect of this work. We get to put on our detective caps and really pick through the details of our patient cases to find the piece that is missing; the one or two things that will make all the difference in that wound and for that patient. And our patients notice. Most of our patients have come to us after seeing at least a handful of other “wound experts” and trying a dozen or more different products, potions, powders and sprays and their confidence in the practice of wound care is roughly what you might think. Patients can tell when you take the time to sit with them and really try to figure out their specific needs. They notice when we ask questions that no one else has asked before. The fundamental principles of wound healing are really quite simple but amazingly get lost or overlooked most of the time. Clean the wound, get blood and nutrition to it, keep pressure off it, control edema and keep it moist. The simplicity of it is both our greatest friend and our worst enemy as many will underestimate the need to really understand our patients inside and out.
While many wound care practitioners know and understand these principles of wound healing, few will take the time needed to fully understand their patient’s life and support network in order to overcome the obstacles that may be present to wound healing. Our patients have come to us for help, many as a last attempt to salvage a limb or even their life. We owe them more and we need to do better.
- Smith, J. M., & Jones, J. (2021). Pressure ulcer prevention program: addressing root causes. Journal of Wound Care, 30(2), 116–124. [Link: https://www.magonlinelibrary.com/doi/10.12968/jowc.2021.30.2.116]
- Lavery, L. A., Davis, K. E., Berriman, S. J., & Braun, L. (2016). Outcomes of a diabetic foot ulcer protocol across an integrated health care system. International Wound Journal, 13(5), 1055–1062. [Link: https://pubmed.ncbi.nlm.nih.gov/25682800/]
- O’Meara, S., Cullum, N. A., Nelson, E. A., Dumville, J. C., & Leg Ulcer Trialists Collaboration. (2012). Compression for venous leg ulcers. JAMA Dermatology, 148(4), 365–374. [Link: https://pubmed.ncbi.nlm.nih.gov/22393134/]
- Mills, J. L. Sr., Conte, M. S., Armstrong, D. G., Pomposelli, F. B., Schanzer, A., Sidawy, A. N., Andros, G. (2014). The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). Journal of Vascular Surgery, 59(1), 220-34.e2. [Link: https://www.jvascsurg.org/article/S0741-5214(13)01288-9/fulltext]