EFFECT OF INFRARED LASER VERSUS ZINC IONTOPHORESIS ON WOUND HEALING IN

BURNT CHILDREN

Reda Sayed Mohamad Sarhan. PTD. * Dept. of Physical Therapy for Pediatrics and Pediatric Surgery, Faculty of Physical Therapy, Cairo University.

Abstract: The purpose of this study was to compare between the effect of both Infrared (IR) laser bio-stimulation and the effect of zinc iontophoresis on the accelerating rate of healing of burnt children. Thirty burnt patients from both sexes (20 males and 10 Females), participated in this study were selected randomly from King Abdul-Aziz University Hospital Burns Unit, Jeddah, Saudi Arabia, having burn in their lower extremities, anterior surface of the leg, ranging in age between 5 and 9 years participated in the study. They were randomly divided into two Study groups of equal number, group A (n=15) were 10 males and 5 females) and group B (n=15) were10 males and 5 females). Patients in both groups received daily treatment of physical therapy program, comprising positioning, stretching and remedial exercises. Patients belonging to the group (A) were subjected to IR laser for the burnt area for 10 minutes in each session. On the other hand, patients belonging to the group (B) were subjected to zinc Ionto-phoresis for the burnt area for10 minutes in each session. Treatment continued for both groups of patients for three times/week / twelve successive weeks. The wound surface area was assessed before and after the

suggested period of treatment, using the metric graph paper method. The wound area was calculated from the product of cross-diameters of the wound sites. The curative effect was expressed as the percentile of wound area compared with that on day 0 (100%). The passive range of foot dorsi-flexion was also assessed, using a LCD goniometry. Furthermore, the present pain intensity scores were assessed. The collected data after termination of the suggested period of treatment of both groups revealed significant improvement in the group(A), utilizing the IR laser therapy, compared to those of the group(B),utilizing zinc Iontophoresis. Furthermore, a similar improvement was also noted in comparing the results of each Study group, before and after treatment. Such an improvement included reduction of the wound area and pain intensity scores in addition to an increase in the foot dorsi-flexion ROM. So, it should be stressed that utilization of IR laser irradiation in combination with the traditional physical therapy modalities. In vitro this study suggest that (IR) laser bio-stimulation might have promotive effects on burn wound healing and

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more effective in treating burnt areas than using zinc iontophoresis.

Introduction The skin is the largest organ of the human body. Burn injury causes destruction and disturbance of normal physiologic functions of the skin. It is difficult to estimate the problems of burnt patient, especially psychological and economical problems (28). Burns often happen unexpectedly and have the potential to cause death. Lifelong disfigurement and dysfunction. A critical part of burn management is assessing the depth and extent of injury. A systemic approach to burn care focuses on the six "Cs". Clothing, cooling, cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief) . Complication of burns include slow healing, scar formation and contracture. The extent of burn is expressed as the total percentage of body surface area (TBSA) affected by the injury. Accurate estimation of the TBSA of a burn is essential to guide management. Conventional methods for treating soft tissue wounds include applications of various ointments or medications to aid the natural body healing process. However, it has been found that some wounds, including chronic wounds, do not respond to conventional treatment method, and resist healing. Maintaining joint movement and maximizing functional ability in patient with a major burn presents a

formidable challenge to physical therapists. A comprehensive team approach to burn and early therapeutic intervention can reduce the possibility of joint dysfunction (13). Physical therapists identified a variety of wounds, which respond well to different types of commonly used electro-therapeutic modalities such as interferential, short wave and most notably ultrasound and Laser therapy 4). Bio-stimulated fibroblast cultures, taken from human embryo, have been treated with He Ne laser or. The fibroblast cell, when stimulated four times at 24-hour interval, showed increased bending ability to the lectin, which emphasized laser bio-stimulation (18) Infrared laser therapy is the application of red and near infrared light over injuries or wounds to improve soft tissue healing and relieve both acute and chronic pain, Low-level Laser therapy uses cold (subthermal) laser light energy to direct bio-stimulative light energy to the body s cells without injuring or damaging them by any way. The energy range of low level laser light lies between 1 and 500 mW (mill watts). Iontophoresis is the transfer of ions across the skin (transdermal) by use of continues direct current; iontophoresis is based on the principle that an electrically charged electrode will repel a similarly

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charged ion (first reported by LeDue in 1903) . In iontophoriesis , a weak current carrying drug ions through the skin to cause vasodilatation and increased blood perfusion. Zinc has been reported to be necessary for active growth and repair of tissue. Some investigators have thought that zinc promotes resynthesis of protein and nucleic acid at the wound site by incorporating itself into certain enzymes. The zinc ion, when introduced into body tissues by iontophoresis, has also been documented to have anti bacterial effect. Aim of the work: To investigate quantitatively the effect of both infra red laser therapy and zinc iontophoresis on the enhancement of recovery of wounds and pain reduction in burnt children.

Subjects, materials and methods Subjects: Thirty children from both sexes (20 males and 10 females), with age ranged from 5 to 9 years were included in this study. They were collected randomly from the burn unit in King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia as having burn in their lower extremities (in the anterior aspect of the leg). As a result of their burn, they were suffering from a decrease in foot dorsi-flexion ROM and pain. All patients were examined clinically by medical specialist before the study. None of them reported a history of other skin abnormalities in the area to be

treated. No associated injuries, anemia or pathological conditions have been identified. All of the patients were diagnosed as having direct flame or scald injuries mixed burn (superficial or deep dermal burns). They were randomly classified into two Study groups, each comprised 15patients: group A (10males and 5 females) and group B (10males and 5 females). Materials: 1) For treatment:

BTL – 5840 SLCombi Unit: (Combined Electrotherapy, Ultrasound and Laser unit). The main features include: - Black and white touch screen. - Full range of low and medium waveforms and their modifications. - Constant current and current

voltage modes (CC/CV) - Reversal of polarity of electrodes. - Multi frequency ergonomic ultrasound heads of 1 and 4cm" with a visual indicator of contact control on the head. - 1 and 3 MHz frequency that can be used with any ultrasound head. - Continuous and pulse ultrasound operation in the range of 10- 150Hz. Adjustable in 14 steps. - Continuous and pulse laser therapy (

frequency modulation ) –500 Hz. - Red probes of 685 nm

wavelength and 30 – 50 mW powe output.

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Infrared probes of 830 nm wavelength and 50 – 400 mW power output. - Acupuncture set for laser

acupuncture. - Sound volume adjustment.

Display color and brightness setting,

Screen saver, auto switch – off.

The unit is a product, under the existing requirements of the US Food and Drug Association Regulation. It is manufactured by BLT Technology Ltd., Electronic Corp, USA.

2) For evaluation:

a. Sterilized transparency film. b. Fine tipped transparency marker. c. Carbon papers. d. Metric graph papers (1mm²). e. White papers. f. LCD goniometer. g. Present pain intensity

scale (Form 1).

Form (1): Shows the Present pain intensity scale Grade Definition

0 No pain 1 Mild pain 2 Moderate pain 3 Severe pain 4 Unbearable pain

Adopted from Sriwatanabul et al (1982) (27)

Methods: For evaluation: • The measurements of burn

wound surface area were conducted before and after 12 weeks of treatment. The investigator placed a plastic sheet over the burn (after being cleaned with anti-septic solution) and traced the burn’s parameters with a fine tipped transparency marker. The carbon paper was placed over the metric graph paper, and then traced transparency film was placed over a carbon paper, with a white paper in between. The tracing was transcribed onto the metric graph paper and

the number of square mm on the metric graph paper was calculated, within the wound tracing. The measurement for each wound was repeated for three times and the mean value was recorded as the actual reading.

• The measurement of foot dorsi-flexion ROM was achieved while the patient was in supine lying position with the heel outside the treatment table. The fixed arm of the goniometry was placed parallel to the tibial side. The wrist joint was moved passively, within the limit of pain, to the maximum available dorsi-

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flexion range. Then, the degree of foot dorsi-flexion was recorded.

• Assessment of the present pain intensity (PPI) for each subject was done before and after treatment for both groups through the PPI scales (Form1) (27).

For treatment: • Patients belonging to group A

patients received a physical therapy program, which comprised positioning, splinting and remedial exercises, in addition to IR laser bio-stimulation for the burnt area, aiming for relieving pain, decreasing muscle spasm and preventing contractures. The patient was placed in the supine position with his heels out side the treatment table. The investigator stood beside the patient and the unit head was placed perpendicular to the burn area. The head of laser unit was cleaned with sterilized solution before and after application for each patient. The burn area was divided into equal zones. The main power switch was turned on. The Hi/Lo power switch was turned to Hi position. Time of treatment was 10 minuets for each zone.

• On the other hand, patient belonging to group B patients were exposed to the same line of treatment in addition to iontophoresis with a zinc oxide solution for the burnt area. The patient was placed in the supine position with his heels out side, the investigator stood beside the patient. The current generator

was set on, power switch was turned to 400 micro amp current with a pulse rate of 100 pulses per second. The current generator was applied to the patient s burn wound by two probes, each of the probes consists of a handle portion made of an insulating material, and head portion and a probe tip which screws into the head portion. Thus, the probe tip can be removed for cleaning and sterilization. The probes are connected to the current generator by wires. In use, cotton swabs are wetted with an Electrolyte solution (zinc oxide solution) and inserted into the probe tips. After each treatment, the swabs are disposed of and new swabs are inserted before treating the next patient. the burn area was divided into equal zones, the probes were placed closely adjacent the outer boundaries of burn zone on the laterally opposite sides along a line perpendicular to an imaginary line which generally bi-sects the wound. The probes were held in place for one minute to apply an electrical current to this burn zone, and then the probes were moved down the sides of the bun wound at approximately one centimeter increments. At each stop, the probes were held in place approximately one minute while the current are applied. This process was repeated as many times as necessary to cover the entire length of the burnt area.

• The duration of each session for all patients lasted for an hour, all

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of them were treated for three days per week, for 12 successive

weeks, and received equivalent nursing care.

Results

The collected data were statistically treated to show the mean, standard deviation and standard error of the mean for both groups. The student test was then utilized to examine the significance of treatment in each group. It revealed no significant difference between both groups before the application of treatment (t < 0.05), which insures homogenous sampling. As shown from table (1) and Fig. (1), the mean values of wound surface area in the Study group (A) before treatment with Infrared (IR) laser bio-stimulation was 138.46 ± 24.6 mm², which decreased after 12 weeks of the combined treatment to

106.2 ± 20.73 mm². The mean difference was 32.27 mm², representing a percentage of change of 23.3 %, suggesting a highly significant improvement (t = 21.147 < 0.001). Concerning the Study group (B), the mean value of wound surface area was 132.53 ± 26.49 mm² before treatment, which decreased to 123.53 ± 26.69 mm² after treatment with zinc iontophoresis, with a mean difference of 9 mm². The percentage of change was 13.66 %, which suggests a highly significant improvement (t = 7.4 < 0.001).

Table (1): The mean values of wound surface area in both groups (in square mm) before and

after twelve weeks of treatment as well as the percentage of change.

Study Group (A) Study Group (B) Comparison Before After Before After

Mean 138.4667 106.200 132.533 123.533 SD ± 24.6167 ± 20.7337 ± 26.4949 ± 26.6937 MD 6.3560 9

% of Change 23.3% 13.66% t 21.147 7.407 P

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Fig. (1): The mean values of wound surface area in both groups before and after treatment

The results obtained from table (2) and Fig. (2), present the mean value of foot dorsi-flexion ROM in the Study group (A). It was 15.53 ± 5.194º before treatment with Infrared (IR) laser bio-stimulation, which increased after the suggested period of treatment to 25.4 ± 3.24, with a mean difference of 9.867. Such an increase had a percentage of change of 1.57 %, which indicated a highly significant

difference (t = 13.64 < 0.001). The mean values of foot dorsi-flexion ROM in the experimental Study group (B) increased also from 16.93 ± 4.41º before treatment with zinc iontophoresis to 22.53 ± 2.94º after treatment, forming a mean difference of 5.6 and a percentage of change of 3.02 %, suggesting a significant difference (t = 11.762 < 0.02).

Table(2): The mean values of wrist dorsi-flexion ROM in both groups (In degrees) before and after twelve weeks of treatment

Study Group (A) Study Group (B) Comparison

Before After Before After Mean 15.5333 25.4000 16.933 22.5333

SD ± 5.1943 ± 3.2470 ± 4.4153 ± 2.9488 MD -9.8667 -5.600

% of Change 1.57% 3.02% t -9.8667 -11.762 p < 0.05 < 0.05

020406080

100120140

Wound surface area (mm2)

Study G.A Study G.B

PrePost

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Fig. (2): Shows the mean values of foot dorsi-flexion ROM in both groups (in degrees) before and after treatment.

As shown from table (3) and Fig. (3), the mean value of PPI score in the Study group (A). It was 3.2 ± .676 before treatment with Infrared (IR) laser bio-stimulation, which decreased after the suggested period of treatment to 1.8 ± 0676, with a mean difference of 1.4. Such an decrease had a percentage of change of 2.285 %, which indicated a highly significant difference (t =

10.693 < 0.001). The mean value of PPI score in the Study group (B) decreased also from 3.133 ± .6399 before treatment with zinc iontophoresis to 2.267 ± .457after treatment, forming a mean differrence of .8667 and a percentage of change of 3.61 %, suggesting a significant difference (t = 9.539 < 0.02).

Table(3): The mean values of present pain intensity (PPI) in both groups

(in grades) before and after eight weeks of treatment

Study Group (A) Study Group (B) Comparison Before After Before After

Mean 3.2 1.8 3.133 2.2667 SD 0.6761 0.6761 0.6399 0..4577 MD 1.4 0.1182

% of Change 2.285% 3.61% t 10.693 9.539 p < 0.05 < 0.05

Fig. (3): The mean values of present pain intensity (PPI) in both groups (in grades) before and after treatment.

00.5

11.5

22.5

33.5

PPI (Grades)

Study G.A Study G B

Pre Post

05

1015

202530

ROM (0)

Study G.A. Study G.B.

PrePost

Discussion Healing of wounds is the main problem for the physical therapist, which deals with many functional problems of burnt patients. The ultimate goals of wound management are to allow a wound to close as rapidly as possible, to resemble the original tissue as near as possible and to produce the least amount of scarring (3,7,13,26) .Laser may be an effective adjunct modality to promote wound healing. Increased rates of epidermal regeneration, collagen synthesis, granulation tissue formation and wound closure have been reported with low intensity laser application on wounds and burns (12,21 ,22,25). Several researchers investigated the bio-stimulation effect of laser and revealed many positive effects of the rays, including acceleration of wound healing (8,35)

Iontophoresis is the process by which drugs are introduced into a joint or small body part via electric current. It is non-invasive, painless and it eliminates potential side effects and adverse reaction which can occur with medications delivered orally or by injection (2,4,5,16 ). It would be expected that the perception of pain would be reduced by techniques aimed at increasing the concentration of inhibitory neuro-transmitters and/or reducing the concentrations of excitatory neuro-transmitters(37). It was also reported that infra-red laser stimulates the gate control to inhibit pain pathways (1,23) .

The findings of this study indicated considerable differences in measuring mean values of burn size in the control group patients after treatment, as compared with the pre-treatment values. A significant difference was also recorded between the mean values of both the study and control groups at the end of treatment. The results of the present study came in agreement with the results of Agren M.S., Engel M.A., and Martz (1994) .They stated that epithelialization of the second-degree burn wound was accelerated by topical treatment with hydrogel dressing and further enhanced by electrical stimulation compared with no treatment (air exposure) Balogun and co-workers (1999) in their case study reported that by the application of Zinc iontophoresis in the management of bacterial colonized wounds the rate of epidermal regeneration and granulation tissue formation were accelarated. Bgie K.M., Reger S.I., Levine S.P., and Sahgal (2000) Stated that electrical stimulation for wound healing and pressure sore prevention could increase the rate of healing by more 50% than that treated by traditional topical treatment. The present results also came in agreement with those stated by Gudeman and co-workers (1997) in their study they investigated the effect of iontophoresis in conjunction with other traditional modalities and they came in conclusion that iontophoresis in conjunction with traditional modalities provides more

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immediate pain relieve than the traditional modalities alone. The results of the present piece of work coincide with those reported by Neeter et al (2003) who evaluated the effect of iontophoresis with dexamethasone to the effect of iontophoresis with saline solution; they concluded that iontophoresis with dexamethasone were found to have a positive effect in the treatment of patient with acute Achilles tendon pain. The results of the present piece of work coincide with those reported by Hardy et al (1967)(12), Lam et al (1986)(19), Abergel et al (1987)(1), Patterson and Blaylock (1987)(22) and Baxter et al (1991)(5). In their study, increased tensile strength was recorded in skin wounds of rabbits, bio-stimulated daily with pulsed IR laser for a period of 21 days. However, non-stimulated wounds on the contra-lateral side in the same animal also showed an increase in tensile strength (6). The present results also came in agreement with the results ofHunter et al (1984) (14) and Basford et al (1986) (3). They stated that enhanced rates of wound and burn healing were reported in rats and guinea pigs with low-intensity laser therapy. Averabakh et al (1988)(2)

attributed the effect of laser therapy in promoting wound healing to be due to an increase in fibroblast proliferation (fibroplasia) and faster collagen synthesis. The promoted wound healing in the present study may be due to the ability of immune cells to combat invading pathogens.

Baxter (1995)(4) stated that the immune system is an important and integral part of the healing process. The lymphocytes, in particular, are responsible for the release of soluble mediators of immunity and of tissue repair. Another factor, which might have affected the burn size and rate of healing, is the formation of the prostaglandin (PG). This explanation was an observation reported by Hunter et al (1984)(14). In 1988, Enwemexa (8) added that such an improvement might be attributed to increasing ATP synthesis by enhancing electron transfer in the inner membrane of the mitochondria. The mechanism for the acceleration of wound healing with low-energy laser bio-stimulation involved acceleration of the messenger ribo-nucleic acid (mRNA) transcription rate of the collagen gene or other enzymatic changes, following bio-stimulation (1). It has been revealed that bio-stimulated full thickness skin wounds daily in rats with ruby and He Ne laser caused faster healing of wounds. They also found an increased collagen in wounds, treated with He Ne laser compared to wounds treated with ruby laser. The maximum effect was observed at an energy density of 4 J/cm (15). On the contrary, the results of this piece of work disagreed with those of Santoianni et al (1984)(25) and Hallman et al (1988)(11), who failed to find, accelerated, wound healing after laser application.

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Conclusion From the results of this study, it can be concluded that the application of IR laser therapy is a more valuable method for treating and improving the healing process

and the subsequent pain reduction among patients, suffering from superficial and deep thermal burns than the application of zinc Iontophoresis.

References 1. Airakasinen O.,et al (1988): Effects of infra-red laser irradiation at trigger point. Acupunct. Electrother.Res. 14: 9-14

2. Averbakh MM, Sorokin ML and Dobkiy VG et al (1988): The influence of He Ne laser on the healing of aseptic experimental wounds. J.Ortho.Sports Phys.Ther. 9: 333-338.

3. Balogun JA, Abidoye AB, Akala EO.(1990): Zinc iontophoresis in the management of bacterial colonized wounds: a case report. Physiotherapy Canada.;42:147-15.

4.Banga AK, Panus PC.(1998): Clinical application of iontophoresis devices in rehabilitation medicine. Critical review in physical and rehabilitation medicine.10: 147-179. 5.Bertalolucci LE.(1982): Introduction of Anti-inflammatory drugs by iontophoresis: double blind study. J Orth Sports Phys Therapy. 6.Baxter GD (1995): Therapeutic laser: Theory and practice. 2nd ed. Longman Company, Singapore. pp.: 26-114.

7. Baxter GD, Bell AJ and Allen J et al (1991): Low level laser therapy: Current clinical practice in Northern Ireland. Physiotherapy, 77: 71-178. 8. Braverman B Mc Carthy RJ and Vankovid AD et al (1989): Effect of He Ne and IR laser irradiation on wound healing in rabbits. Lasers Surg.Med. 9: 50-58. 9.Carley,P.J.et al (1985: "Electrotherapy for acceleration of wound Healing: Low Intensity Direct Current", Arch. Phys. Med. Rehabil, vol.66. 10.Chang K, Tarjan P.P., (1993):Theoretical studyof rectangular pulse electrical stimulation(RPES) on skin cells (in vivo) under conforming electrodes .Biomed.Sci Instrum. 29.349-354. 11Dobbs ER (1979): Physical therapy: Burns. W.B. Saunders Company, Philadelphia, pp.: 492-499. 12.Danno K, Mori NToda K Kobayashi T, Utani A(2000) :Near- infrared irradiation stimulates cutaneous wound repair: laboratory experiments on possible mechanisms, Photodermal photoimmunal photomed 17: 261-265. 13.Enwemeka CS (1988): Laser bio-stimulation of healing wounds:

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Specific effects and mechanisms of action. JOSPT. 10: 333-338. 14.Fleischli J.G., and Laughlin T.J., (1997) :Electrical stimulation in wound healing.J.Foot Ankle Surg. 36.457-461. 15.Gardner S.E., Frantz R.A., And Schmidt F.L.(1999) : Effect of electrical stimulation on chronic wound healing: a meta-analysis. Wound Repair regen.7.495-503. 16.Gentzkow G.D., and Miller K. H. (1991) : Electrical stimulation for dermal wound healing. Clin. Podiatr. Med. Surg. 8.827-841. 17.Grossmann M, Jamiesson MJ, Kellogg DL et al (1995): The effect of iontophoresis on the cutaneous vasculature: evidence for current-induced hyperemia. Microvasc Res. 50: 444-452 18.Hallman HO, Bosford JR and O’Brein JF et al (1988): Does low-energy He Ne laser irradiation alter in vitro replication of human fibroblast. Lasers Surg.Med. 8: 125-129. 19. Hardy LB, Hardy FS and Fine S et al (1967): Effect of ruby laser radiation on mouse fibroblast culture. Fed.Proc. 26: 668. 20.Helm AA, Kevorllian CG and Lushbangh M et al (1982): Burn injury: Rehabilitation management. Arch.Phys.Med.Rehabil. 63: 6-16. 21.Hunter J, Leonard L and Wilson et al (1984): Effect of low-energy laser on wound healing in a porcine model. Lasers Surg.Med. 3: 285-290. 22.Kana JS Hutsch eneiter G and Heina D et al (1981): Effect of low-power density laser radiation on healing of open skin wounds in rats. Lasers Surg.Med. 116: 273-296.

23.Kevin Moore(1992): Laser Therapy. 9:145-149. 24.Kramis R, Robert W and Gillette R (1996): Non-nociceptive aspect of persistent musculo-skeletal pain. LOSPT, (24) 4: 255-265. 25.Kubasova T, Kovacs L and Somosy et al (1984): Biological effect of He Ne laser. Investigations on functional and micro-morphological alteration of cell membranes in vitro. Lasers Surg.Med. 4: 381-388. 26.Lam TS, Abergel RP and Castel JC et al (1986): Laser stimulation of collagen synthesis in human skin fibroblast cultures. Laser Life Sci. 1: 61-77. 27.Lyons RF, Abergel RP, White RA, Dwyer RM, Castel JC,Uitto J (1987) :Biostimulation of wound healing in vivo by a helium –neon laser. Ann Plast Surg 18:47-50. 28.McWhorter, Luther S.; Chndler,Mark H (1992): Method of treatment of soft tissue wounds by electrical stimulation. 29. Mester AF and Mester A (1987): Clinical data of laser bio-stimulation in wound healing. Lasers Surg.Med. 6: 78. 30.Mester E (1985): The biomedical effects of laser application. Lasers Surg.Med. 5: 31-39. 31.Patterson JW and Bloylock WK (1987): Dermatology. Medical Examination Publishing, New York, pp.: 1-15. 32.Peedar J.A.,Kloth L.C., and Gentzkow G.D.(1991): Chronic dermal ulcer healing enhanced with monophasic pulse electrical stimulation. Phys. Ther. 71.639-649

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33.Richard RL and Staly MJ (1994): Pathologic manifestations of burn injury. 1st ed. F.A. Davis Company, Philadelphia. pp.: 30-79. 34.Rochkind S., Rousso M., Nissan M, Villareal M, Barr-Neal L. and Rees DC (1989): Systemic effects of low power laser irradiation on the peripheral and central nervous system, cutaneous wounds, and burns., Laser Surg. Med., 1(2): 174-82. 36.Salcido Tand Richard J (2004) :Advances in skin and wound care.17(3):100 37.Santoianni P, Monfrecola G and Martellota D et al (1984): Inadequate effect of He Ne laser on venous leg ulcers. Photo-dermatology. I: 245-249.

38.Schlager A, Oehler k,Schmuth M,Spoel L(2000).: Healing of burns after treatment with 670-nanometer low-power laser light.Plast Reconstr Surg 105: 1635-1639 39.Sriwatanabul K, Kelvie W and Lasagena L (1982): The quantification of pain: An analysis of wounds used to decrease pain and analgesia in clinical trials. Chin. Pharmacol Ther., 32 (2): 143. 40.Weiss DS, Kirsner R and Eaglastein WH (1990): Electrical stimulation and wound healing. Arch.Dermat. 126(2): 222-225.

تأثير أشعة الليزر تحت الحمراء و التأين الكهربائى للزنك

على التئام جروح الحروق عند األطفال رضا سرحان/ د

قسم العالج الطبيعى مستشفى الحسين الجامعى

جامعة االزهر

أثير ويم ت ى تق ة إل ذه الدراس دف ه تهراء زر تحت الحم ائى أشعة اللي أين الكهرب و الت

ف روق وتخفي روح الح ام ج ى التئ ك عل للزنون ى ثالث ث عل ذا البح راء ه م إج د ت م، فق األلارهم روق تراوحت أعم ن مرضى الح ال م طف

ى ٥من ى ٩ إل ة عشوائيا إل سمت العين ا، ق عامسة ة خم ل مجموع وعتين ضمت آ شر مجم ع

ى ت : مرض ث ، عولج ل البح ة مح ة المجموعى ة األول ث أ (المجموع ل ابح تخدام ) مح باس

زر تحت العالج التقليدي مع استخدام أشعة الليذه الحاالت وهو يتكون من ل ه الحمراء في مثافة ق باإلض ة و التعلي اع العالجي بعض األوضالج م ع ا ت ة، بينم ات العالجي ى التمرين إل

ة األخرى ل البحث ب(المجموع طة ) مح بواسأين تخدام الت ع اس سابقة م اليب ال س األس نفم د ت رح، وق ان الج ى مك ك عل ائى للزن الكهرب

اس وعتين لقي إجراء االختبارات المناسبة للمجممساحة المنطقة المصابة باستخدام طريقة الرسم البياني مع قياس مدى حرآة فرد مفصل الرسغ

م دة األل اس مدى ش ى قي د باإلضافة ال ل و بع قبد أظهرت صلة من العالج، وق ابيع مت ثمانية أسي صائية ف ة إح سن ذو دالل دوث تح ائج ح النترة العالج ، اء فت د انته وعتين بع مرضى المجمة صالح المجموع حة ل روق واض ود ف ع وج م

وبذلك يعد العالج باستخدام أشعة . محل البحث أ ساعدة في اال للم الليزر تحت الحمراء عالجا فع

ام الجروح وتخفيف األلم الناجم من الحروق التئ .لدى األطفال

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Appendix

Table (1) shows the mean values of wound surface area in the experimental group A before and after twelve weeks of treatment.

Subject no. Before After

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

160 132 146 152 113 171 163 132 87 103 160 139 162 140 117

120 105 115 125 90 132 125 105 60 75 120 100 125 110 86

X 138.4667 106.2 SD ±24.6167 ±20.7337 SE 6.3560 5.3536 MD 32.2667

% of change23.3% t 21.147 < 0.05

Table(2)

shows the mean values of wound surface area in the experimental group B before and after twelve weeks of treatment.

Subject no. Before After

١٥

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

130 91 160 110 145 150 125 180 105 170 132 126 100 152 112

119 80 154 102 135 142 120 170 98 165 128 105 95 135 105

X 132.533 123.533 SD ±26.4949 ±26.6937 SE 6.3560 5.3536 MD 9

% of change13.66% t 7.407 < 0.05

Table (3) shows the mean values of wound surface area in both the experimental groups Before twelve weeks of treatment.

Subject no. Experimental group A Experimental group B

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

160 132 146 152 113 171 163 132 87 103 160 139 162 140 117

130 91 160 110 145 150 125 180 105 170 132 126 100 152 112

X 138.4667 132.533 SD ±24.6167 ±26.4449 SE 6.3580 6.8410 MD 5.9333

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% of change23.3% t .624 > 0.05

Table (4) shows the mean values of wound surface area in both the experimental groups after twelve weeks of treatment.

Subject no. Experimental group A Experimental group B

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

120 105 115 125 90 132 125 105 60 75 120 100 125 110 86

119 80 154 102 135 142 120 170 98 165 128 105 95 135 105

X 106.2 123.533 SD ±20.7337 ±26.6937 SE 5.3534 6.8923 MD 17.3333

% of change6.1% t 1.982 < 0.05

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Table (5) shows the mean values of present pain intensity in the experimental group (A) before and after twelve weeks of treatment.

Subject no. Before After

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

3 4 2 3 3 4 3 4 3 4 3 4 2 3 3

2 2 1 2 2 3 2 2 1 2 1 3 1 2 1

X 3.2 1.8 SD ±.6761 ±.6761 SE .1746 .1746 MD 1.4000

% of change2.285% t 10.693 < 0. 05

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Table (6) shows the mean values of present pain intensity in the experimental group (B) before and after twelve weeks of treatment.

Subject no. Before After

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

4 3 3 4 3 2 4 3 3 4 3 2 3 3 3

3 2 2 3 2 2 3 2 2 3 2 2 2 2 2

X 3.133 2.2667 SD ±.6399 ±.4577 SE 1.14 .1182 MD .8667

% of change3.61%

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t 9.539 < 0.05

Table (7)

shows the mean values of present pain intensity in the experimental group (A) and experimental group (B) before twelve weeks of treatment.

Subject no. experimental group (A) experimental group (B)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

3 4 2 3 3 4 3 4 3 4 3 4 2 3 3

4 3 3 4 3 2 4 3 3 4 3 2 3 3 3

X 3.2 3.1 SD ±.6761 ±.6399 SE .1746 .16526 MD 6.667

% of change.479%

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t .250 > 0.05

Table (8) shows the mean values present pain intensity in the experimental group (A) and experimental group (B) after twelve weeks of treatment.

Subject no. experimental group (A) experimental group (B)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

2 2 1 2 2 3 2 2 1 2 1 3 1 2 1

3 2 2 3 2 2 3 2 2 3 2 2 2 2 2

X 1.8 2.2667 SD ±.6761 ±.4577 SE .1746 .1182 MD .4667

% of change3.856%

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t 2.432 < 0.05

Table (9) shows the mean values of foot dorsi-flexion in the experimental group (A) before and after twelve weeks of treatment.

Subject no. Before After

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

15 21 13 21 18 10 19 8 7 9 18 21 13 18 22

25 30 23 28 25 22 25 22 20 25 28 30 22 26 30

X 15.5333 25.4 SD ±5.1943 ±3.2470 SE 1.3412 .8384 MD 9.8667

% of change1.57% t 13.649 < 0. 05

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Table (10) shows the mean values of foot dorsi-flexion in the experimental group (B) before and after twelve weeks of treatment.

Subject no. Before After

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

15 23 13 23 16 10 14 13 19 13 23 16 14 19 23

20 26 20 26 22 18 23 26 23 20 28 22 20 24 26

X 16.933 22.5333 SD ±4.4153 ±2.9488 SE 1.14 .7618 MD 5.6

% of change3.02% t 11.762 < 0. 05

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Table (11) shows the mean values of foot dorsi-flexion in the experimental group (A) and experimental group (B) before twelve weeks of treatment.

Subject no. experimental group (A) experimental group (B)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

15 21 13 21 18 10 19 8 7 9 18 21 13 18 22

15 23 13 23 16 10 14 13 19 13 23 16 14 19 23

X 15.5333 16.9333 SD ±5.1943 ±4.4153 SE 1.3412 1.14 MD 1.4

% of change11.095% t 1.295 > 0. 05

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Table (12)

shows the mean values of foot dorsi-flexion in the experimental group (A) and experimental group (B) after twelve weeks of treatment.

Subject no. experimental group (A) experimental group (B)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

25 30 23 28 25 22 25 22 20 25 28 30 22 26 30

20 26 20 26 22 18 23 20 23 20 28 22 20 24 26

X 25.4 22.5333 SD ±3.2470 ±2.9488 SE .8384 .7614 MD 2.8667

% of change8.86% t 4.487 < 0. 05

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WOUND ASSESSMENT

____________________________________________________________________________________________

Complete the rating sheet to assess wound status. Evaluate each item by picking the response that best describes the wound and entering the number in the item column for the appropriate date. See "Instructions for Use" to guide you in completing the rating form. Use a separate form for each wound.

Location: Anatomic site. Circle, identify right (R) or left (L) and use "X" to mark site on body diagrams or draw incision on body:

_____ Sacrum and coccyx _____ Ischial tuberosity _____Lateral ankle _____ Incision site

_____ Trochanter _____ Heel _____ Medial ankle _____________ Other site

Shape: Overall wound pattern; assess by observing perimeter and depth.

Circle and date appropriate description:

_____ Irregular _____ Linear or elongated _____ Square/rectangle _____ Butterfly

_____ Round/oval _____ Bowl/boat ___________________Other site

Dressing Order: (include cleansing, product name, size, if it is a border, rope or gauze product, frequency)_________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Dressing Order Change: ______________________ _________________________________________ _________________________________________

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_________________________________________ _________________________________________

6. Exudate Type & Amount Indicate type and amount by placing a number from each column in date column 1 = Bloody 1 = None 2 = Serosanguinous 2 = Scant 3 = Serous * 3 = Small 4 = Purulent * 4 = Moderate 5 = Foul purulent* 5 = Large 6 = None

7. Skin Color Surrounding Wound

1 = Pink or normal for ethnic group 2 = Bright red &/ or blanches to touch 3 = White or gray pallor or hypopigmented 4 = Dark red or purple &/ or non-blanchable* 5 = Black or hyperpigmented

ITEM ASSESSMENT Date Date Date Date Date

1. Size Measure length x width and record in the date column in centimeters

2. Depth Measure in centimeters

3. Edges 1 = Indistinct, diffuse, not clearly visible 2 = Distinct, outline clearly visible, attached, even with wound base 3 = Defined, not attached to wound base 4 = Defined, not attached to base, rolled under, thickened 5 = Defined, fibrotic, scarred, or hyperkeratonic

4. Undermining 1 = < 2 cm in any area 2 = 2 to 4 cm involving < 50% margins 3 = 2 to 4 cm involving > 50% margins 4 = > 4 cm in any area 5 = Tunneling &/or sinus tract formation

5. Necrotic Tissue Type and Amount

1 = None visible INDICATE % OF WOUND INVOLVED NEXT TO NO. IN DATE COLUMN: 2 = White/gray non-viable tissue &/or non-adherent yellow slough 3 = Loosely adherent yellow slough 4 = Adherent, soft black eschar 5 = Firmly adherent, hard black eschar

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8. Peripheral Tissue Edema 1 = Same 2 = Non-pitting edema extends < 4 cm around wound 3 = Non-pitting edema extends > 4 cm around wound 4 = Pitting edema extends < 4 cm around wound 5 = Crepitus &/or pitting edema extends > 4 cm

9. Peripheral Tissue Induration 1 = Minimal firmness around wound 2 = Induration < 2 cm around wound 3 = Induration 2 to 4 cm extending < 50% around wound 4 = Induration 2 to 4 cm extending > 50%around wound 5 = Induration > 4 cm in any area*

10. Granulation Tissue 1 = Skin intact 2 = Bright beefy red with tissue overgrowth 3 = Bright beefy red 4 = Pink &/or dull; dusky red 5 = No granulation tissue present

11. Infection (must be reflected in other items)

1 = None 2 = Four of the following: a. Heat d. Tenderness/Pain b. Fever e. Serous drainage c. Induration f. Redness of skin 3 = Pus

12. Discomfort: (Record both No. & letter in column)

Scale: 0-5 with 0 being no pain* a. During treatment b. All the time c. During exertion d. When elevated

13. Wound Status 1 = Healing 2 = Unchanged 3 = Deteriorating

14. Stage Record stage I, II, III or IV for pressure ulcers Only

INITIALS:

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