Modalities

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Modalities Wound Care

• by
• Vince Lepak, PT, MPH, CWS

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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

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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

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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.

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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.

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Whirlpool Induces Analgesia?

• calming
• analgesia
• gate effect
• sedation of warmth

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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

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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 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

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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

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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)

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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

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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

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Strength of Evidence for US

• Conflicting results in the literature
• Strength of evidence C

(Kloth, 2002, p.359-365)
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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.

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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

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Proposed Theories (Brown, 1995 McCulloch,
Kloth, Feedar, 1995Unger, 1992)

• Increased microcirculation
• Edema reduction/prevention
• Antibacterial effects
• Bio electric effects
• Galvanotaxis
• Injury Potential
• Cellular effects

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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

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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

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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

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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

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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

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Hyperberic Oxygen(Gogia, 1995)

• increased phagocytosis
• decreased infection
• increased fibroblast proliferation
• increased epithelial proliferation
• promotes collagen synthesis
• increased angiogenesis

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Indications for Nonhealing Wounds

• Ischemic lesions
• Venous stasis
• Decubiti
• Burns
• DM
• Cellulitis
• Osteomyelitis
• Pyoderma gangrenosum
• Skin flaps in danger of ischemia

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Contraindications and Precautions

• aerobic bacteria
• thrombophlebitis
• large vessel occlusion
• severe ischemia

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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

(Kloth, 2002, p.350-353)
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HBO

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

(Kloth, 2002, p.352)
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Laser(Gogia, 1995)

• He-Ne
• Stimulate ATP formation
• Increase immune system
• Increase collagen synthesis
• Treatment
• 90 seconds of irradiation per cm2 _at_80 pps _at_ 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 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)
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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.