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Eaten alive
Monday September 3, 2012


When news spread in May about a Georgia college student who had lost her left leg, right foot and both hands to necrotizing fasciitis, Megan Clark, PT, DPT, knew all too well the course of this devastating disease.

Clark is the supervisor of Burn Physical Medicine at Doctors Hospital in Augusta, Ga., where the student — Aimee Copeland — spent two months fighting for her life. Copeland contracted the "flesh-eating" bacteria when she cut her leg during a zip lining accident. She received 22 staples to close the wound, but returned in severe pain the next day and was diagnosed.

The bacteria can destroy fat, skin and muscle rapidly, and in more serious cases — such as Copelandís — it creates toxins that enter the bloodstream and cause organ failure, explained Walter Ingram, MD, medical director of the Grady Burn Center in Atlanta. Amputations of the affected areas are sometimes necessary.

"We actually see these cases all the time," Clark said. "The recommendation is for them to be seen at a burn center due to the extensive debriding and skin grafting. These patients are usually medically unstable and lying in bed for a while, so it requires a lot of work just to get them to stand."

For the patients who survive — 20% die according to the Centers for Disease Control — physical therapy plays a critical role in helping them regain the ability to function.

Back from the brink

Although Copelandís necrotizing fasciitis was caused by Aeromonas hydrophila, a bacterium that survives in fresh or brackish water in warm climates, the disease is more commonly caused by bacteria that can be found on human skin, Ingram said. Usually the bodyís immune system destroys the bacteria, but people with immune deficiency disorders — such as diabetes or kidney disease — can be more at risk. In these cases, the necrotizing fasciitis often will enter the body on an area of skin that is more likely to collect bacteria, such as the buttocks, perineum or folds of fat in obese people, Ingram said.

Sandy Moss, PT, who works in the Grossman Burn Center at West Hills Hospital & Medical Center in San Jose, Calif., remembers a diabetic man in his 70s who suffered from severe necrotizing fasciitis due to an infection caused by an ingrown hair on his buttocks. The disease destroyed the skin on his torso, neck, upper legs and parts of his arms, and as a result he required dozens of debridement and grafting procedures over the course of several months.

"It is amazing that he lived," Moss said. "These patients are oftentimes put in an induced coma due to the pain, and they require a ventilator, feeding machines, rectal tubes and multiple IVs. This patient went in and out of being conscious over months of time."

Moss begins treating these patients in the burn unitís ICU where she will start with passive range of motion and bed exercises. Over time, she progresses to helping patients with sitting on the edge of the bed, sit-to-stand transfers and then gait training with a walker.

"Typically, the patients are on tremendous amounts of pain medication, and this can decrease blood pressure, so they are at risk of passing out," she said. "I am constantly watching to see if they become clammy, sweaty or if they stop talking."

In more severe cases of necrotizing fasciitis, keeping patients motivated is a vital part of their recovery. For the man in his 70s, at one of his low points he said he wished he had died rather than face the grueling path to recovery. Moss discovered that he enjoyed talking about Motown music and sports, and these conversations during therapy rekindled his desire to press through his pain.

Because PTs may work with these patients daily for weeks and months, patients often will confide in them. "Body image issues will sometimes come up," Clark said. "They know that their bodies are changed forever, and I encourage them that it doesnít mean life will be bad — just different."

Wound care

Although surviving and learning to stand again are miracles in themselves for those who have suffered a severe bout of necrotizing fasciitis, rehabilitation after they leave the hospital is critical for patients who want to regain independence.

In some cases, patients may be discharged between grafting procedures, and PTs perform the outpatient wound care to prepare them for the next surgery. Trudy Mudrak, PT, CWS, a senior therapist in the wound management department Santa Clara Valley Medical Center in California, specializes in wound care. "Necrotizing fasciitis creates a very large wound that needs to close," she said.

She performs negative pressure wound therapy, which involves using a suctioning machine that applies negative pressure to pull fluid out of the wound. This also stimulates the wound to fill with granulation tissue.

"For patients, it can be initially terrifying to see a hole in their body that is not supposed to be there, but then they can see measurable differences in the wound size and depth as their body takes over the healing process," Mudrak said.

In some cases, the wound heals thoroughly. For those who still require grafting, physical therapy after these procedures is critical. Maria Saade-Daoud, PT, a therapist in the burn unit at Santa Clara Valley, performs stretching, range-of-motion exercises and scar massage to keep the scars supple. She explains to patients that their scars often are more mottled, thick and discolored within the first year, but then improve in appearance over time — especially if they continue their physical therapy regimen.

PTs who work with this population attest to the tremendous strides patients make during their courses of their treatment. "I see patients so debilitated that they cannot lift their head off the pillow, and eventually they can walk out of here and eventually ride a bike to their appointments," Saade-Daoud said. "It is really rewarding to watch this happen, and they are so grateful to move again." •

Heather Stringer is a freelance writer.

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Monday September 3, 2012
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