Modalities & Wound Care

by
Vince Lepak, PT, MPH, CWS
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
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 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.
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 100
0
f
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 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
Whirlpool Procedures
Sussman (1998)
frequency and duration
no clear guidelines
water temperature
37 degree Celsius or 98
o
F (Sussman) too high for large
immersions
(Loehne, 2002, p.213; Cameron, 1999, p.199)
tepid/nonthermal 80-92
o
F (26.6-33.3
o
C)
neutral 92-96
o
F (33.3-35.5
o
C)
thermal 96-104
o
F (35.5-40
o
C) 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
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 wounds 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)
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.
AHCPRs 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
Protocols (slide 2 of 3)
HVPC (High Volt Pulsed Current)
75 - 200 volts
80 - 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 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
Electro Summary
Electrical stimulation augments the bodys
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
Strength of Evidence
for
HBO
Venous ulcers one small RCT and two
case 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 cm
2
@80 pps @ 4
J/cm
2
Normothermic Treatment
37 + 1
o
C (96.8 - 98.6 - 100.4
o
F)
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)
(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 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.