Modalities & Wound Care

7/29/2019 Modalities & Wound Care

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Modalities & Wound Care

by

Vince Lepak, PT, MPH, CWS

Objective

• Students will have the guidelines for safe and

appropriate application of the following modalitiesto promote wound healing:

– Hydrotherapy

– Ultrasound

– Electrical Stimulation

– Hyperbaric Oxygen

– Laser

– Compression pumps

Whirlpool• Carrie Sussman (1998) stated that the lack

of well designed clinical trials for the use of whirlpool with open wounds should

encourage the clinician apply this modality

with careful thought.

• Three main reputed effects are:

– controlling infection through the removal of

debris and exudate

– increased perfusion to local tissues

– neuronal effects that produce analgesia

Whirlpool Controls Infection?

• Sussman (1998) indicates that uses of whirlpool to reduce the rate of infection inthe literature is questionable.

• She then sites literature that implicateswhirlpool as a cause of nosocomialinfections in patients with burns.

• Many clinicians continue to use whirlpooleven when it is not appropriate.



Whirlpool Increases Circulation?

• The benefits of increasing circulation

include: – improved delivery of oxygen, nutrients,

luekocytes, systemic antibiotics to tissues and

removal of metabolites.

Whirlpool Induces Analgesia?

• calming

• analgesia

• gate effect

• sedation of warmth

Whirlpool Indications

• Hecox (1994), Sussman (1998), and Loehne(2002, p.214) support the use of whirlpool

with:

– wounds with necrosis (nekros Gr.. dead)

– wounds with adherent dressings

– wounds that are dirty from trauma – wounds with residual from topical agents

Whirlpool Contraindications – Hecox (1994)

• hypotensive or

dopamine(vasoconstrictor)

• advanced arterial disease(Burger's

Allen)

• hemorrhage tendency

• incontinence

• acute deep vein thrombosis(DVT)

• acute pulmonary embolus(PE)

• deep abdominal/chest wounds

• acute myocardial infarction• wet gangrene

• pregnancy -- temperature must be

less than 1000f

– Sussman (1998)• moderate to severe

edema

• lethargy

• unresponsiveness

• maceration

• febrile conditions

• compromised

cardiovascular or

pulmonary system

• acute phlebitis• renal failure

• dry gangrene

• incontinence



Whirlpool Precautions

• Sussman (1998) &

Loehne (2002, p.214)

– clean granulatingwounds

– epthelializing wounds

– new skin grafts

– new tissue flaps

– non-necrotic ulcers

secondary to diabetic

neuropathy

• Agency for HealthCare Policy and

Research (AHCPR,1994)

– Heel ulcers with dryescar should not bedebrided unless thereare signs of infection,fluctuant, or drainage.

– Whirlpool discontinued

when ulcer is clean

Whirlpool Procedures

• Sussman (1998) – frequency and duration

• no clear guidelines – water temperature

• 37 degree Celsius or 98 oF (Sussman) – too high for largeimmersions

• (Loehne, 2002, p.213; Cameron, 1999, p.199)

– tepid/nonthermal 80-92 oF (26.6-33.3 oC)

– neutral 92-96 oF (33.3-35.5 oC)

– thermal 96-104 oF (35.5-40 oC) – causes stress on cardiopulmonaryand nervous system – limited body area with no medical complications

– monitor vital signs (HR, BP, RR)• Hx: cardiopulmonary or cardiac disease, cerebrovascular accident, or

hypertension

Ultrasound• Cameron (1999) states that mixed evidence

exists on the efficacy of ultrasound

accelerating wound healing – Positive wound healing studies with ultrasound

– Dyson & Suckling (1978); pulsed 20% duty cycle, 1.0

W/cm2, 3 MHz, 5-10 minutes, on the wound’s perimeter,

on venous stasis ulcerations

– McDiarmid, Burns, Lewith, et al (1985); similar

application on infected pressure ulcers as the Dyson &

Suckling study

– No beneficial effect with wound healing – Lundeberg, Nordstrom, Brodda-Jansen, et al (1990)

– Eriksson, Lundeberg, Malm (1991)

– TerRiet, Kessels, Knipschild (1996)



Reported Physiological Effects of

Ultrasound

• physiological effects (Dyson, 1995)

– increase fibroblastic activity – increase capillary permeability which increases

calcium uptake

– accelerate mast cell and macrophage releases

– increase oxygen uptake with thermal effects

– increase angiogenesis

Recommended Treatment

Procedures

• Cameron (1999, p.283-285) & Kloth (2002,

p.356-366) – 20% duty cycle

– 0.5-1.0 W/cm2 – reparative to remodeling

– 1-3 MHz

– 5-10 minutes

– direct, indirect, or perimeter technique

Strength of Evidence for US

• Conflicting results in the literature

• Strength of evidence = “C”

(Kloth, 2002, p.359-365)

I t t t



Is t appropr ate to useelectrical stimulation (ES) for

tissue healing?• YES, however it has been difficult to gain

acceptance as a viable treatment.• In 1994, The Clinical Practice Guidelines for

the Treatment of Pressure Ulcers developed by

the Agency for Health Care Policy and

Research (AHCPR) recommends the use of ES

on Stage III and IV pressure ulcers that are not

responsive to conventional treatment.• Their recommendations are based on a B

“Strength-of-Evidence Ratings.”

AHCPR’s Evidence

• Carley and Wainapel, 1985

• Feedar, Kloth, and Gentzkow, 1991• Gentzkow, Pollack, Kloth, and Stubbs, 1991

• Griffin, Tooms, Mendius, et al., 1991

• Kloth and Feedar, 1988

Proposed Theories(Brown, 1995; McCulloch, Kloth, & Feedar, 1995;Unger, 1992)

• Increased microcirculation• Edema reduction/prevention

• Antibacterial effects

• Bio electric effects

– Galvanotaxis

– Injury Potential

• Cellular effects

Protocols (slide 1 of 3)

• CMDC (Continuous Microamperage Direct Current

– 200 - 1,000 microamperes

2 - 4 hours a day; 3 - 7 days a week

cathodal 3 -5 treatments to reduce bacteria

anodal until healed; initiate only when wound free

of infection; if cessation of healing occurs, the polarity should be switched




• HVPC (High Volt Pulsed Current)

– 75 - 200 volts80 - 100 pps

45 - 60 minutes; 3 - 7 days a week

cathodal 3 - 5 days for infection

anodal to heal, if plateau occurs, alter daily


• Low Voltage Pulsed Microamperage Current or MENS

[Microamperage Electrical Neuromuscular Stimulation]

– Arndt - Schulz Law - Weak stimuli increase physiological

activity and very strong stimuli inhibits or abolishes activity.

– monophasic or biphasic square wave – pulse duration up to 0.5 sec

– freq. 0.1 - 99 Hz

– peak intensity 990 microamperages

– suggested uses

• pain relief

• edema

• wound healing

– two double-blind studies in 1994 - no improvement

ELECTRODE PLACEMENT(McCulloch, Kloth, & Feedar, 1995)

This placement takes advantage of the“Current of Injury Theory.”

• cathode over the wound, with the anodeapproximately 15cm proximal or closer tothe spinal cord

• anode over the wound, with the cathode

approximately 15cm caudal or farther away from the spinal cord

Electro Summary

• Electrical stimulation augments the body’s

endogenous biochemical system.

• It should be applied if there are no clinical

signs of healing in 14 days.

• Contraindications are the same as any

electrical modality with the addition of:

– osteomyelitis

– heavy metal residue



Hyperberic Oxygen(Gogia, 1995)

• increased phagocytosis

• decreased infection• increased fibroblast proliferation

• increased epithelial proliferation

• promotes collagen synthesis

• increased angiogenesis

Indications for Nonhealing

Wounds• Ischemic lesions

• Venous stasis• Decubiti

• Burns

• DM

• Cellulitis

• Osteomyelitis• Pyoderma gangrenosum

• Skin flaps in danger of ischemia

Contraindications and

Precautions

• aerobic bacteria

• thrombophlebitis

• large vessel occlusion

• severe ischemia

S h f id



Strength of Evidence

for

HBO

• Venous ulcers – one small RCT and twocase series = rating of “C”

• DM foot ulcers – one RCT and two

controlled trials = rating of “B”

(Kloth, 2002, p.350-353)

HBO

• Ciaravino et al., stated that the average cost

of 30 HBO treatments was $14K.

(Kloth, 2002, p.352)

Laser (Gogia, 1995)

• He-Ne• Stimulate ATP formation

• Increase immune system

• Increase collagen synthesis

– Treatment

• 90 seconds of irradiation per cm2 @80 pps @ 4

J/cm2



Normothermic Treatment

• 37 + 1 oC (96.8 - 98.6 - 100.4 oF)

• Infrared source of heat• semiocclusive – moisture retentive dressing

• Proposed impact on the wound: – increase blood flow, tissue oxygenation, bacteriocidial,

fibroblast proliferation, and increase the wound healingrate

• Evidence: one RCT, a controlled study, a pilot

study, and one prospective study = “B”• Follow the protocol (Kloth, 2002, p.321-322)

(Kloth, 2002, p.316-326)

References• Brown, M. (1995). Electrical stimulation for wound management. In P. P. Gogia (Ed.), Clinical wound

management (pp. 175-183). Thorofare, NJ: SLACK

• Cameron, M. H. (1999). Hydrotherapy. In (Ed.), Physical agents in rehabilitation: From research to practice (pp.174-216). Philadelphia: W. B. Saunders.

• Dyson, M. (1995). Ultrasound management for wound management. In P. P. Gogia (Ed.), Clinical wound

management (pp. 197-204). Thorofare, NJ: SLACK.• Gogia, P. P. (1995). Low-energy laser in wound management. In (Ed.), Clinical wound management (pp.

165-172). Thorofare, NJ: SLACK.

• Gogia, P. P. (1995). Oxygen therapy for wound management. In (Ed.), Clinical wound management (pp.186-195). Thorofare, NJ: SLACK.

• Hecox, B., Mehreteab, T. A., & Weisberg, J. (1994). Physical agents: A comprehensive text for physicaltherapists. Norwalk, CT: Appleton & Lange.

• Kloth, L. C. (2002). Adjunctive interventions for wound healing. In L. C. Kloth & J. M. McCulloch(Eds.), Wound healing alternatives in management (3rd ed., pp. 316-382). Philadelphia, PA: F.A. Davis.

• Loehne, H. B. (2002). Wound debridement and irrigation. In L. C. Kloth & J. M. McCulloch (Eds.),Wound healing alternatives in management (3rd ed., pp. 203-231). Philadelphia, PA: F.A. Davis.

• McCulloch, J. M., Kloth, L. C., & Feedar, J. A. (Eds.). (1995). Wound healing alternatives inmanagement (2nd ed.). Philadelphia, PA: F.A. Davis.

• Sussman, C., & Bates-Jensen. (1998). Wound care: a collaborative practice manual for physicaltherapists and nurses, Gaithersburg, MA: Aspen.

• Unger, P.G. (1992). Electrical enhancement of wound repair. Physical Therapy, 41-49.

• U. S. Department of Health and Human Services. (1994). Treatment of pressure ulcers (AHCPR Publication No. 95-0652). Rockville, MD: Author.

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Modalities & Wound Care