Modalities

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Modalities

• Whirlpool
• Pulsatile Lavage with Suction
• Ultrasound
• Normothermia Therapy
• Negative Pressure Wound Therapy
• Hyperbaric Oxygen
• Electrical Stimulation

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Whirlpool

• Hydrotherapy
• Standard treatment for many years

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Effects of Whirlpool

• Cleanses wound
• Removes debris exudate through mechanical
  debridement
• Softens hard eschar
• Non-selective debridement
• Hydrates wound
• Thermal effect
• Neuronal effects

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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 199877(5)394-398.

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Indications for use

• Wounds with loosely adherent necrotic tissue
• Exudate
• Debris
• Extensive psoriasis or burns

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Contraindications

• Evidence of healthy granulating wound bed
• Compromised cardiovascular or pulmonary function
• Plebitis, Renal failure
• Temperature 101.9F or greater
• Lethargic
• Venous ulcer/position
• Arterial insufficiency/burns
• Neuropathic foot ulcer
• Dry gangrene
• Lower extremity edema

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Therapy Protocol

• 5-20 minutes
• 1x daily
• 8-15 psi - irrigation gt can damage tissue

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Pulsatile Lavage with Suction (PLWS)
Simpulse Varicare System Unit Davol, Inc.
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Historical Perspective

• Jet lavage used in Vietnamby oral surgeons
• PLWS - suction and PSI controlled

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Effects of PLWS

• Cleansing
• Debridement
• Suction negative pressure
• Impact pressure

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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

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Indications for use

• Infection
• Loose debris

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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 after1 week

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Therapy Protocol

• 4-15 psi
• 8 psi bacterial reduction studies
• 13 psi inflammation studies
• 1x daily

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Ultrasound

• Mechanical vibration transmitted gt20 kHz
• US needs water or tissues to conduct/transport
  vibration

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Historical Perspective

• 1950s US used to treata number of disorders

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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

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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 14232,1976

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Indications for use

• Chronic diabetic foot ulcers pressure ulcers
• With absence of inflammatory phase

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Contraindications

• Pregnancy
• Malignancies
• Vascular abnormalities
• Deep thrombosis
• Emboli
• Acute wound inflammation
• Fractures

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Therapy Protocol

• 0.5 W/cm2, 3 MHz
• Pulse 2 msec on/8 msec off
• 5 minute duration
• 3x/week
• 2 weeks

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Ultraviolet Radiation Therapy

• Radiant energy between visible light x-rays
  (400 - 180 nm)

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Historical Perspective

• Sun worshipping/healing
• Hippocrates 460 -370 BC
• Prescribed sunbath
• 1877 bacteriocidal properties of light
  demonstrated

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• UVA - 315-400 nm - tanning
• UVB - 290-315 nm - sunburn, blistering,
  hyperplasia, carcinogenesis
• UVC - 180-290 nm - germicidal, filteredout by
  ozone layer

Penetration into skin increaseswith longer
wavelength
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Effects of UV Radiation

• 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

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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)

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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 199478812

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Indications for use

• Slow or non-healing wounds
• Necrotic wounds
• Purulent, infected wounds

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Contraindications

• Pulmonary tuberculosis
• Cardiac, liver, or renal disease, lupus
• Wound carcinoma
• Fever
• Eczema, psoriasis
• Hyperthyroidism
• Severe diabetes

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Therapy Protocol

• Apply sunblock (SPF 30 or gt) to periwound or
  drape
• Exposure time varies with infection 1-2x daily
  45-120 seconds

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Normothermic Wound Therapy

• 37 /- 1C
• Cellular function enzymatic and biochemical
  reactions are optimized at normal body
  temperatures

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Historical Perspective

• Hippocrates 460-370
• Wounds love warm
• Mid 1900s - radiant heat from infrared lamps
  too dry

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Wound Bed

• Wounds are hypothermic (25-32C)
• Vasoconstrictive
• Depressed neutrophil activity
• Increased risk of infection

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Warm-Up Active Wound Therapy
Augustine Medical, Inc
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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

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In Vitro

• Neonatal wound fluid heated applied to
  fibroblasts decreased inhibitory effect of wound
  fluid on fibroblasts
• Park H et al, Wounds 199810189-192

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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
  20001369-74

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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

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Contraindications

• 3rd degree burns

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Normothermic Wound Therapy

• Prepare periwound tissue
• Apply heat
• Treat 1 hour, 3x per day
• Change dressings PRN

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Negative Pressure Wound Therapy

• Open cell foam dressing in wound cavity
  applying controlled sub-atmospheric pressure 125
  mm Hg below ambient pressure

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Historical Perspective

• Negative pressure increases tension among
  adjacent cells
• Alters cell shapes, thereby stimulating growth
  division
• V.A.C., 1995

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The V.A.C. (Vacuum-Assisted Closure)
Kinetic Concepts, Inc (KCI)
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The Mini-V.A.C.
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Negative Pressure Wound Therapy Effects

• 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

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In Vivo

• Animal studies (pigs)
• Granulate faster than salinewet-to-moist
• Staph epidermis S Aureus
• 1000x compared to standard
• Small number of controlled studies - small number
  of subjects

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Indications for use

• Stage III, IV pressure ulcers
• Venous, arterial, neuropathic
• Subacute, acute burns, dehisced incisions, mesh
  skin flaps, grafts, muscle flaps

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Contraindications

• Necrotic tissue
• Untreated osteomyelitis
• Malignancy in wound
• Fistulas to organs or body cavities
• Precaution - bleeding, anticoagulant use

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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

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Hyperbaric oxygen

• 100 O2 at greater than ATA pressure

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Oxygen in Wounds

• Perfusion
• Collagen deposition
• Granulation
• Leukocyte function
• Bacteriocidal effects

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Hypoxia vs Hyperoxia

• Hypoxia
• increases angiogenesis

• Hyperoxia
• increases rate of collagen synthesis
• accelerates healing epithelialization

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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

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Topical

• Topical
• 1.03-1.06 ATA
• Direct contact with wound
• Contraindications
• Cost
• Ease of use

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Advanced Hyperbaric Technologies, Inc.
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Chamber

• 50 mm Hg above atmospheric pressure
• Pulsating (0 to 50 mm Hg)
• Latex sleeve
• Humidified oxygen

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Advanced Hyperbaric Technologies, Inc.
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Sacral Unit

• 22 mm Hg
• 2-3 liters of humidified O2/minute
• Constant pressure
• Seal holds unit to wound

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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

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Therapy Protocol

• 2 x 60 or 90-minute treatments/day
• 5 days/week

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Electrical Stimulation

• Use of capacitive coupledelectrical current to
  transferenergy to a wound
• Current is transferred throughwet pad in contact

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Historical Perspective

• Gillbert, 1600s - 1st publication
• Galvani, 1791 - Direct current
• Matteucci - Current of injury
• 1960s - Use of electrical current to heal wounds

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Electrical Terms

• Anode positive pole
• Cathode negative pole
• DC direct current or galvanic

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Skin Battery Potential

• Outside of skin electronegative
• Inside of skin electropositive
• Current of Injury
• Shift in polarity
• Outside electropositive
• Inside electronegative

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Galvanotaxic Effects

• Cells move along the pathof current flow
• Neutrophils, fibroblasts, epithelial cells to
  cathode
• Macrophages to anode
• Mast cells repelled by anode

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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

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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

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Stimulatory Effectson Cells

• Increases proliferation of fibroblasts
• Increases calcium uptake
• Stimulates receptors for growth factors
• Increases growth of neurite
• Increases ATP AA transport
• Protein synthesis

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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

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Antibacterial Effects

• Inhibition of
• Pseudomonas aeruginosa
• Staph aureus
• E. Coli
• Staph epidermis

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Indications for Use

• Pressure ulcers
• Vascular ulcers
• Surgical wounds
• Neuropathic ulcers

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Contraindications

• Basil or squamous cell carcinoma
• Untreated osteomyelitis

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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

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Clinical Modalities Research

• Evaluate effectiveness of modality
• Why does it work?
• Interactions with other modalities
• What population does it work with?

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