Modalities

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

3. Whirlpool • Hydrotherapy • Standard treatment for many years

4. Effects of Whirlpool • Cleanses wound • Removes debris & exudate through mechanical debridement • Softens hard eschar • Non-selective debridement • Hydrates wound • Thermal effect • Neuronal effects

5. 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.

6. Indications for use • Wounds with loosely adherent necrotic tissue • Exudate • Debris • Extensive psoriasis or burns

7. 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

8. Therapy Protocol • 5-20 minutes • 1x daily • 8-15 psi - irrigation > can damage tissue

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

10. Historical Perspective • Jet lavage used in Vietnamby oral surgeons • PLWS - suction and PSI controlled

11. Effects of PLWS • Cleansing • Debridement • Suction = negative pressure • Impact pressure

12. 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

13. Indications for use • Infection • Loose debris

14. 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

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

16. Ultrasound • Mechanical vibration transmitted >20 kHz • US needs water or tissues to conduct/transport vibration

17. Historical Perspective • 1950’s US used to treata number of disorders

18. 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

19. 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

20. Indications for use • Chronic diabetic foot ulcers & pressure ulcers • With absence of inflammatory phase

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

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

23. Ultraviolet Radiation Therapy • Radiant energy between visible light & x-rays (400 - 180 nm)

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

25. 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

26. 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

27. 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)

28. 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

29. Indications for use • Slow or non-healing wounds • Necrotic wounds • Purulent, infected wounds

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

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

32. Normothermic Wound Therapy • 37 +/- 1C • Cellular function & enzymatic and biochemical reactions are optimized at normal body temperatures

33. Historical Perspective • Hippocrates 460-370 “Wounds love warm…” • Mid 1900’s - radiant heat from infrared lamps too dry

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

35. Warm-Up Active Wound Therapy Augustine Medical, Inc

36. 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

37. 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

38. 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

39. 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

40. Contraindications • 3rd degree burns

41. Normothermic Wound Therapy • Prepare periwound tissue • Apply heat • Treat 1 hour, 3x per day • Change dressings PRN

42. Negative Pressure Wound Therapy • Open cell foam dressing in wound cavity & applying controlled sub-atmospheric pressure 125 mm Hg below ambient pressure

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

44. The V.A.C. (Vacuum-Assisted Closure) Kinetic Concepts, Inc (KCI)

45. The Mini-V.A.C.

46. 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

47. 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

48. Indications for use • Stage III, IV pressure ulcers • Venous, arterial, neuropathic • Subacute, acute — burns, dehisced incisions, mesh skin flaps, grafts, muscle flaps

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

50. 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