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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.
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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
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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)
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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
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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
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Protocols (slide 2 of 3)
• 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
Protocols (slide 3 of 3)
• 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
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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
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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
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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.