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Modalities
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Whirlpool
Pulsatile Lavage with Suction
Ultrasound
Normothermia Therapy
Negative Pressure Wound Therapy
Hyperbaric Oxygen
Electrical Stimulation
Whirlpool
• Hydrotherapy
• Standard treatment for many years
Effects of Whirlpool
• Cleanses wound
• Removes debris & exudate through
mechanical debridement
• Softens hard eschar
• Non-selective debridement
• Hydrates wound
• Thermal effect
• Neuronal effects
In Vivo
• Increased healing with whirlpool
vs. wet-moist dressings, but a large
number of deteriorating wounds in
both groups
• Burke DT et al American Journal
Physical and Medical Rehabilitation
1998;77(5):394-398.
Indications for use
• Wounds with loosely adherent
necrotic tissue
• Exudate
• Debris
• Extensive psoriasis or burns
Contraindications
• Evidence of healthy granulating wound bed
• Compromised cardiovascular or pulmonary
function
• Plebitis, Renal failure
• Temperature 101.9°F or greater
• Lethargic
• Venous ulcer/position
• Arterial insufficiency/burns
• Neuropathic foot ulcer
• Dry gangrene
• Lower extremity edema
Therapy Protocol
• 5-20 minutes
• 1x daily
• 8-15 psi - irrigation > can damage
tissue
Pulsatile Lavage with
Suction (PLWS)
Simpulse Varicare
System Unit
Davol, Inc.
Historical Perspective
• Jet lavage used in Vietnam
by oral surgeons
• PLWS - suction and PSI controlled
Effects of PLWS
• Cleansing
• Debridement
• Suction = negative pressure
• Impact pressure
In Vivo
• 2.5x granulation with PLWS vs.
whirlpool
• Greater wound closure
– 2 hospitals - 1 housed controls and
other PLWS subjects
– Haynes LJ et al, 1994
• Cleansing - # of anecdotal and
observational reports with mixed
results
Indications for use
• Infection
• Loose debris
Contraindications
• Sterile process is required
• No value - if eschar is yellow,
adherent collagenous
• Stop if
– no increase in granulation after 1 week
– no decrease in necrotic tissue after
1 week
Therapy Protocol
• 4-15 psi
– 8 psi bacterial reduction studies
– 13 psi inflammation studies
• 1x daily
Ultrasound
• Mechanical vibration
transmitted >20 kHz
• US needs water or tissues to
conduct/transport vibration
Historical Perspective
• 1950’s US used to treat
a number of disorders
Effects of US
• Thermal
– Heat tissue
• Cavitation bubbles
• Acoustic Streaming
– Enhances circulatory flow
– Possibly alters cell membranes
– May stimulate protein synthesis
– Stimulates fibroblasts & macrophages
– Promotes angiogenesis
– May accelerate inflammatory phase
In Vivo
• Pulsed US increased granulation tissue in
rabbits
– Dyson M et al
• Increased tensile strength in animal model
wounds
– Byl N et al, Orthop Sports Phys Ther, 1993
• 4 week study
– Controlled, 25 subjects
– Venous ulcers decreased in size
– No information about baseline groups
– Dyson M et al, Ultrasonics 14:232,1976
Indications for use
• Chronic diabetic foot ulcers &
pressure ulcers
– With absence of inflammatory
phase
Contraindications
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Pregnancy
Malignancies
Vascular abnormalities
Deep thrombosis
Emboli
Acute wound inflammation
Fractures
Therapy Protocol
• 0.5 W/cm2, 3 MHz
• Pulse 2 msec on/8 msec off
• 5 minute duration
• 3x/week
• 2 weeks
Ultraviolet Radiation
Therapy
• Radiant energy between visible
light & x-rays (400 - 180 nm)
Historical Perspective
• Sun worshipping/
healing
• Hippocrates 460 -370 BC
– Prescribed sunbath
• 1877 bacteriocidal properties of light
demonstrated
 UVA - 315-400 nm tanning
 UVB - 290-315 nm sunburn, blistering,
hyperplasia,
carcinogenesis
 UVC - 180-290 nm germicidal, filtered
out by ozone layer
Penetration into skin increases
with longer wavelength
Effects of UV Radiation
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Induces inflammatory response
Stimulates epithelialization
Increases epidermal turnover
Increases epidermal thickness stratum
corneum (hyperplasia)
Enhances granulation tissue formation
Increases blood flow to wounds
Latent erythema
Bacteriocidal effects
In Vitro Studies
• UVA, UVB, UVC
• Shown to kill microorganisms
– Serum sterilization
– Surgical theater decontamination
– Some 99.99% kill rate in antibiotic
resistant bacterial pathogens
(MRSA)
In Vivo Studies
• Some antibiotic resistant pathogens killed
• Rat & rabbit showed increased healing,
decreased healing in guinea pig
– Mechanical wounds - not chronic
• In humans small number of studies positive results in superficial wounds,
and in studies combined with US
– Nussbaum E et al Phys Ther 1994;78:812
Indications for use
• Slow or non-healing wounds
• Necrotic wounds
• Purulent, infected wounds
Contraindications
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Pulmonary tuberculosis
Cardiac, liver, or renal disease, lupus
Wound carcinoma
Fever
Eczema, psoriasis
Hyperthyroidism
Severe diabetes
Therapy Protocol
• Apply sunblock (SPF 30 or >) to
periwound or drape
• Exposure time varies with infection
1-2x daily 45-120 seconds
Normothermic Wound
Therapy
• 37 +/- 1C
• Cellular function & enzymatic and
biochemical reactions are optimized
at normal body temperatures
Historical Perspective
• Hippocrates 460-370
“Wounds love warm…”
• Mid 1900’s - radiant heat from
infrared lamps too dry
Wound Bed
• Wounds are hypothermic (25-32C)
• Vasoconstrictive
• Depressed neutrophil activity
• Increased risk of infection
Warm-Up
Active Wound Therapy
Augustine Medical, Inc
Normothermia effects
• Skin and subcutaneous tissue
warmed
• Increases blood perfusion
• Increases local tissue metabolism
• Decreases affinity of O2 to Hb
• Increases neutrophil activity
• Decreases vulnerability to infection
In Vitro
• Neonatal wound fluid heated &
applied to fibroblasts decreased
inhibitory effect of wound fluid on
fibroblasts
– Park H et al, Wounds 1998;10:189-192
In Vivo
• Normal subjects had increased skin
surface temperature, subcutaneous
temperature, and oxygen tension after
treatment with infrared heat plate effects last 3 hours after treatment
• Increased healing in rats with ischemic
wounds
• Clinical Studies
– Kloth LC et al, Adv Skin Wound Care 2000;13:69-74
Indications
• Stage III and IV pressure ulcers
• Venous leg ulcers that have not
responded to standard care
• Neuropathic foot ulcers that have not
responded to standard care
• Surgical
• Lower extremity ulcers, venous,
arterial, diabetic, neuropathic
Contraindications
• 3rd degree burns
Normothermic Wound
Therapy
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Prepare periwound tissue
Apply heat
Treat 1 hour, 3x per day
Change dressings PRN
Negative Pressure
Wound Therapy
• Open cell foam dressing in wound
cavity & applying controlled subatmospheric pressure 125 mm Hg
below ambient pressure
Historical Perspective
• Negative pressure increases tension
among adjacent cells
• Alters cell shapes, thereby
stimulating growth & division
• V.A.C., 1995
The V.A.C. (VacuumAssisted Closure)
Kinetic Concepts, Inc (KCI)
The Mini-V.A.C.
Negative Pressure
Wound Therapy Effects
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Increases vascular perfusion
Removes excess fluid
Decreases bacterial colonization
Removes inhibitory factors
Tension/deformation of cells
Increases rate of granulation
Enhances epithelial migration
Increases flap survival
In Vivo
• Animal studies (pigs)
– Granulate faster than saline
wet-to-moist
• Staph epidermis S Aureus
– 1000x compared to standard
• Small number of controlled studies small number of subjects
Indications for use
• Stage III, IV pressure ulcers
• Venous, arterial, neuropathic
• Subacute, acute — burns, dehisced
incisions, mesh skin flaps, grafts,
muscle flaps
Contraindications
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Necrotic tissue
Untreated osteomyelitis
Malignancy in wound
Fistulas to organs or body cavities
Precaution - bleeding, anticoagulant
use
Therapy Protocol
• 2 Foams
– Black - polyurethane - deep, burns, flaps
– White - soft, superficial, tunneling
• Irrigate & debride wound with each dressing
change (pulsed lavage & suction)
• Cut foam to fit wound
• Continuous or intermittent
• Dressing change
Hyperbaric oxygen
• 100% O2 at greater than ATA
pressure
Oxygen in Wounds
• Perfusion
• Collagen deposition
• Granulation
• Leukocyte function
• Bacteriocidal effects
Hypoxia vs Hyperoxia
Hypoxia
Hyperoxia
• increases
angiogenesis
• increases rate of
collagen synthesis
• accelerates healing
& epithelialization
Systemic vs. Topical
• Systemic
– 100% O2 at 1.5-3.0 ATA
– 1943 - US Navy - decompression
sickness and air embolism
– Crush injuries, radionecrosis,
osteomyelitis, skin flaps, etc.
– Contraindications
– Cost
– Accessibility
Topical
• Topical
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1.03-1.06 ATA
Direct contact with wound
Contraindications
Cost
Ease of use
Advanced Hyperbaric Technologies, Inc.
Chamber
• 50 mm Hg above atmospheric
pressure
• Pulsating (0 to 50 mm Hg)
• Latex sleeve
• Humidified oxygen
Advanced Hyperbaric Technologies, Inc.
Sacral Unit
• 22 mm Hg
• 2-3 liters of humidified O2/minute
• Constant pressure
• Seal holds unit to wound
In Vivo Studies
• 8 subjects
– Stage III or IV sacral pressure ulcers
• 34.4% wound reduction in 4 weeks
• Range of healing times 8-49 weeks
• Largest ulcers
– 87.75 cm2 - 16 weeks
– 52.64 cm2 - 22 weeks
Therapy Protocol
• 2 x 60 or 90-minute treatments/day
• 5 days/week
Electrical Stimulation
• Use of capacitive coupled
electrical current to transfer
energy to a wound
• Current is transferred through
wet pad in contact
Historical Perspective
• Gillbert, 1600’s - 1st publication
• Galvani, 1791 - Direct current
• Matteucci - Current of injury
• 1960’s - Use of electrical current to
heal wounds
Electrical Terms
• Anode = positive pole
• Cathode = negative pole
• DC = direct current or galvanic
Skin Battery Potential
• Outside of skin: electronegative
• Inside of skin: electropositive
• Current of Injury
– Shift in polarity
– Outside: electropositive
– Inside: electronegative
Galvanotaxic Effects
• Cells move along the path
of current flow
• Neutrophils, fibroblasts, epithelial
cells to cathode
• Macrophages to anode
• Mast cells repelled by anode
Summary Effects (polar)
Negative - Cathode
• Increase blood flow
• Attracts: neutrophils, epithelial cells, &
fibroblasts
• Stimulates proliferation in fibroblasts &
collagen production
• Enhances growth of granulation tissue
• Induces epidermal cell migration
• Stimulates neurite growth directionally
• Solubilizes necrotic tissue
• Decreases edema/inhibits edema
• Anti-microbial
Summary Effects (polar)
Positive - Anode
• Attracts macrophages
• Promotes epithelial growth and
organization
• Decreases mast cells in healing wounds
• Acts as a vasoconstrictor
• Decreases blood flow
• Anti-microbial
Stimulatory Effects
on Cells
• Increases proliferation of fibroblasts
• Increases calcium uptake
• Stimulates receptors for growth
factors
• Increases growth of neurite
• Increases ATP & AA transport
• Protein synthesis
Effects on Blood Flow
• Vasodilation
• Increases permeability
• Secondary response of galvanotaxis &
chemotaxis
• Increases vascularity
• Increases O2
• Decreases oxygen derived from free
radical damage
• Decreases metabolites
• Decreases necrosis
• Increases growth
Antibacterial Effects
Inhibition of
• Pseudomonas aeruginosa
• Staph aureus
• E. Coli
• Staph epidermis
Indications for Use
• Pressure ulcers
• Vascular ulcers
• Surgical wounds
• Neuropathic ulcers
Contraindications
• Basil or squamous cell
carcinoma
• Untreated osteomyelitis
Electrical Stimulation
Therapy
• DC, 1 mAmp/inch2 electrode
– 30-60 minutes/day
– 5 days/week
• HVPC, 150 V
– 120 pulse/sec, 255 ms pp
– 30 minutes/day
– 5 days/week
Clinical Modalities
Research
• Evaluate effectiveness of modality
• Why does it work?
• Interactions with other modalities
• What population does it work with?