Modalities Wound Care

1. Modalities & Wound Care by Vince Lepak, PT, MPH, CWS

2. Objective Students will have the guidelines for safe and appropriate application of the following modalities to promote wound healing: Hydrotherapy Ultrasound Electrical Stimulation Hyperbaric Oxygen Laser Compression pumps

3. 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

4. Whirlpool Controls Infection? Sussman (1998) indicates that uses of whirlpool to reduce the rate of infection in the literature is questionable. She then sites literature that implicates whirlpool as a cause of nosocomial infections in patients with burns. Many clinicians continue to use whirlpool even when it is not appropriate.

5. Whirlpool Increases Circulation? The benefits of increasing circulation include: improved delivery of oxygen, nutrients, luekocytes, systemic antibiotics to tissues and removal of metabolites.

6. Whirlpool Induces Analgesia? calming analgesia gate effect sedation of warmth

7. 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

8. 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

9. Whirlpool Precautions Sussman (1998) & Loehne (2002, p.214) clean granulating wounds epthelializing wounds new skin grafts new tissue flaps non-necrotic ulcers secondary to diabetic neuropathy Agency for Health Care Policy and Research (AHCPR, 1994) Heel ulcers with dry escar should not be debrided unless there are signs of infection, fluctuant, or drainage. Whirlpool discontinued when ulcer is clean

10. Whirlpool Procedures Sussman (1998) frequency and duration no clear guidelines water temperature 37 degree Celsius or 98 oF (Sussman) � too high for large immersions (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 cardiopulmonary and nervous system � limited body area with no medical complications monitor vital signs (HR, BP, RR) Hx: cardiopulmonary or cardiac disease, cerebrovascular accident, or hypertension full tank requires 425 gallons 1608.8 liters low boy 95 gallons or 359.6 liters small tank 30 gallons or 113.5 liters The PSI exerted are unknown but likely exceed 4-15 PSIfull tank requires 425 gallons 1608.8 liters low boy 95 gallons or 359.6 liters small tank 30 gallons or 113.5 liters The PSI exerted are unknown but likely exceed 4-15 PSI

12. 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)

13. 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

14. 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

15. Strength of Evidence for US Conflicting results in the literature Strength of evidence = �C�

17. Is it appropriate to use electrical 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.� "Strength-of-Evidence Ratings" A - Results of two or more randomized controlled clinical trails on pressure ulcers in humans provide support. B - Results of two or more controlled clinical trials on pressure ulcers in humans provide support, or when appropriate, results of two or more controlled trails in animals provide indirect support. C - One controlled clinical trail or results of at least two case series/descriptive studies on pressure ulcers in humans or expert opinion. "Strength-of-Evidence Ratings" A - Results of two or more randomized controlled clinical trails on pressure ulcers in humans provide support. B - Results of two or more controlled clinical trials on pressure ulcers in humans provide support, or when appropriate, results of two or more controlled trails in animals provide indirect support. C - One controlled clinical trail or results of at least two case series/descriptive studies on pressure ulcers in humans or expert opinion.

18. 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 #Carley & Wainapel (1988) They looked at 30 hospital inpatients and compared LIDC/W to D/hydrotherapy. 15 patients received 300-700microA/2hrs BID/5days a week. Anode was used after 3 days of cathode, if plateau existed then the polarity was reversed for three days. The treatment group healed 1.5 to 2.5 times faster. #Feeder/Kloth/Gentzkow (1991) They used a double blind randomized study to look a 50 pressure ulcer (II-2, III-39, IV-9) There were 26(rx) and 24(control). They used a monophasic pulsed current (square) @ 128 & 64pps, 29.2V (both groups reported a tingling sensation), for 30 min/BID/ 7days a week altering polarity daily. Results: 14% healing per week (rx) vs.. 8.25% (sham). 4sham that were healing at 2.9% were switched over to (rx) and healing rate changed to 12.8%. #Gentzkow et al. (1991) used a double blind randomized clinical study on 37 patients with 40 pressure ulcers (19 sham & 21 rx). They used the same machine and protocol as Feedar, Kloth, & Gentzkow (1991) and demonstrated a 47.9% (rx) v. 13.4% (sham) healing rate. They then crossed over 15 ulcers from sham and demonstrated a 49.9% healing rate once estim was applied. #Griffin,Tooms, Medius,et al. (1991) used HVS with SCI. 17 patients randomly assigned to HVS or Sham. 60 min/daily for twenty days. Twin peak monophasic 100pps @ 200V- no evoked muscle response or pain. Negative polarity over wound. HVS more effective than placebo. #Kloth & Feedar (1988) Twin peak monophasic @ 105pps @ 100-175V (strong sensory stimulus)for 45 min daily, 5 days per week. Randomized 16 subjects (9rx & 7control) with stage IV. Rx healed at 44% per week versus the control 11.6% per week. Anode was used unless a plateau was reach then switch to negative until the next plateau then altered daily.#Carley & Wainapel (1988) They looked at 30 hospital inpatients and compared LIDC/W to D/hydrotherapy. 15 patients received 300-700microA/2hrs BID/5days a week. Anode was used after 3 days of cathode, if plateau existed then the polarity was reversed for three days. The treatment group healed 1.5 to 2.5 times faster. #Feeder/Kloth/Gentzkow (1991) They used a double blind randomized study to look a 50 pressure ulcer (II-2, III-39, IV-9) There were 26(rx) and 24(control). They used a monophasic pulsed current (square) @ 128 & 64pps, 29.2V (both groups reported a tingling sensation), for 30 min/BID/ 7days a week altering polarity daily. Results: 14% healing per week (rx) vs.. 8.25% (sham). 4sham that were healing at 2.9% were switched over to (rx) and healing rate changed to 12.8%. #Gentzkow et al. (1991) used a double blind randomized clinical study on 37 patients with 40 pressure ulcers (19 sham & 21 rx). They used the same machine and protocol as Feedar, Kloth, & Gentzkow (1991) and demonstrated a 47.9% (rx) v. 13.4% (sham) healing rate. They then crossed over 15 ulcers from sham and demonstrated a 49.9% healing rate once estim was applied. #Griffin,Tooms, Medius,et al. (1991) used HVS with SCI. 17 patients randomly assigned to HVS or Sham. 60 min/daily for twenty days. Twin peak monophasic 100pps @ 200V- no evoked muscle response or pain. Negative polarity over wound. HVS more effective than placebo. #Kloth & Feedar (1988) Twin peak monophasic @ 105pps @ 100-175V (strong sensory stimulus)for 45 min daily, 5 days per week. Randomized 16 subjects (9rx & 7control) with stage IV. Rx healed at 44% per week versus the control 11.6% per week. Anode was used unless a plateau was reach then switch to negative until the next plateau then altered daily.

19. 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

20. Protocols (slide 1 of 3) CMDC (Continuous Microamperage Direct Current 200 - 1,000 microamperes2 - 4 hours a day; 3 - 7 days a weekcathodal 3 -5 treatments to reduce bacteriaanodal until healed; initiate only when wound free of infection; if cessation of healing occurs, the polarity should be switched

21. Protocols (slide 2 of 3) HVPC (High Volt Pulsed Current) 75 - 200 volts80 - 100 pps45 - 60 minutes; 3 - 7 days a week cathodal 3 - 5 days for infectionanodal to heal, if plateau occurs, alter daily

22. 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

23. ELECTRODE PLACEMENT (McCulloch, Kloth, & Feedar, 1995) This placement takes advantage of the �Current of Injury Theory.� cathode over the wound, with the anode approximately 15cm proximal or closer to the spinal cord anode over the wound, with the cathode approximately 15cm caudal or farther away from the spinal cord

24. 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

26. Hyperberic Oxygen(Gogia, 1995) increased phagocytosis decreased infection increased fibroblast proliferation increased epithelial proliferation promotes collagen synthesis increased angiogenesis

27. Indications for Nonhealing Wounds Ischemic lesions Venous stasis Decubiti Burns DM Cellulitis Osteomyelitis Pyoderma gangrenosum Skin flaps in danger of ischemia

28. Contraindications and Precautions aerobic bacteria thrombophlebitis large vessel occlusion severe ischemia

29. Strength of EvidenceforHBO Venous ulcers � one small RCT and two case series = rating of �C� DM foot ulcers � one RCT and two controlled trials = rating of �B�

30. HBO Ciaravino et al., stated that the average cost of 30 HBO treatments was $14K.

32. 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

34. 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 healing rate Evidence: one RCT, a controlled study, a pilot study, and one prospective study = �B� Follow the protocol (Kloth, 2002, p.321-322)

35. 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 physical therapists. 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 in management (2nd ed.). Philadelphia, PA: F.A. Davis. Sussman, C., & Bates-Jensen. (1998). Wound care: a collaborative practice manual for physical therapists 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.