Modalities

ModalitiesModalities

• Whirlpool

• Pulsatile Lavage with Suction

• Ultrasound

• Normothermia Therapy

• Negative Pressure Wound Therapy

• Hyperbaric Oxygen

• Electrical Stimulation

WhirlpoolWhirlpool

• Hydrotherapy

• Standard treatment for many years

Effects of WhirlpoolEffects of Whirlpool

• Cleanses wound

• Removes debris & exudate through mechanical debridement

• Softens hard eschar

• Non-selective debridement

• Hydrates wound

• Thermal effect

• Neuronal effects

In VivoIn 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 useIndications for use

• Wounds with loosely adherent necrotic tissue

• Exudate

• Debris

• Extensive psoriasis or burns

ContraindicationsContraindications

• 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 ProtocolTherapy Protocol

• 5-20 minutes

• 1x daily

• 8-15 psi - irrigation > can damage tissue

Pulsatile Lavage with Pulsatile Lavage with Suction (PLWS)Suction (PLWS)

Simpulse Varicare System Unit

Davol, Inc.

Historical PerspectiveHistorical Perspective

• Jet lavage used in Vietnamby oral surgeons

• PLWS - suction and PSI controlled

Effects of PLWSEffects of PLWS

• Cleansing

• Debridement

• Suction = negative pressure

• Impact pressure

In VivoIn 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


• Infection

• Loose debris


• 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


• 4-15 psi– 8 psi bacterial reduction studies– 13 psi inflammation studies

• 1x daily

UltrasoundUltrasound

• Mechanical vibration transmitted >20 kHz

• US needs water or tissues to conduct/transport vibration


• 1950’s US used to treata number of disorders

Effects of USEffects 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 VivoIn 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


• Chronic diabetic foot ulcers & pressure ulcers

– With absence of inflammatory phase


• Pregnancy

• Malignancies

• Vascular abnormalities

• Deep thrombosis

• Emboli

• Acute wound inflammation

• Fractures


• 0.5 W/cm2, 3 MHz

• Pulse 2 sec on/8 sec off

• 5 minute duration

• 3x/week

• 2 weeks

Ultraviolet Radiation Ultraviolet Radiation TherapyTherapy

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


• 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, filteredout by ozone layer

Penetration into skin increaseswith longer wavelength

Effects of UV RadiationEffects 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

In Vitro StudiesIn 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 StudiesIn 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


• Slow or non-healing wounds

• Necrotic wounds

• Purulent, infected wounds


• Pulmonary tuberculosis

• Cardiac, liver, or renal disease, lupus

• Wound carcinoma

• Fever

• Eczema, psoriasis

• Hyperthyroidism

• Severe diabetes


• Apply sunblock (SPF 30 or >) to periwound or drape

• Exposure time varies with infection 1-2x daily 45-120 seconds

Normothermic Wound Normothermic Wound TherapyTherapy

• 37 +/- 1C

• Cellular function & enzymatic and biochemical reactions are optimized at normal body temperatures


• Hippocrates 460-370“Wounds love warm…”

• Mid 1900’s - radiant heat from infrared lamps too dry

Wound BedWound Bed

• Wounds are hypothermic (25-32C)

• Vasoconstrictive

• Depressed neutrophil activity

• Increased risk of infection

Warm-Up Warm-Up Active Wound TherapyActive Wound Therapy

Augustine Medical, Inc

Normothermia effectsNormothermia 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 VitroIn 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 VivoIn 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

IndicationsIndications

• 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


• 3rd degree burns

Normothermic Wound Normothermic Wound TherapyTherapy

• Prepare periwound tissue

• Apply heat

• Treat 1 hour, 3x per day

• Change dressings PRN

Negative Pressure Negative Pressure Wound TherapyWound Therapy

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


• Negative pressure increases tension among adjacent cells

• Alters cell shapes, thereby stimulating growth & division

• V.A.C., 1995

The V.A.C. (Vacuum-The V.A.C. (Vacuum-Assisted Closure)Assisted Closure)

Kinetic Concepts, Inc (KCI)

The Mini-V.A.C.The Mini-V.A.C.

Negative Pressure Negative Pressure Wound Therapy EffectsWound 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

In VivoIn 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


• Stage III, IV pressure ulcers

• Venous, arterial, neuropathic

• Subacute, acute — burns, dehisced incisions, mesh skin flaps, grafts, muscle flaps


• Necrotic tissue

• Untreated osteomyelitis

• Malignancy in wound

• Fistulas to organs or body cavities

• Precaution - bleeding, anticoagulant use


• 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 oxygenHyperbaric oxygen

• 100% O2 at greater than ATA pressure

Oxygen in WoundsOxygen in Wounds

• Perfusion

• Collagen deposition

• Granulation

• Leukocyte function

• Bacteriocidal effects

Hypoxia vs HyperoxiaHypoxia vs Hyperoxia

Hyperoxia

• increases rate of collagen synthesis

• accelerates healing & epithelialization

Hypoxia

• increases angiogenesis

Systemic vs. TopicalSystemic 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

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

Advanced Hyperbaric Technologies, Inc.

ChamberChamber

• 50 mm Hg above atmospheric pressure

• Pulsating (0 to 50 mm Hg)

• Latex sleeve

• Humidified oxygen

Advanced Hyperbaric Technologies, Inc.

Sacral UnitSacral Unit

• 22 mm Hg

• 2-3 liters of humidified O2/minute

• Constant pressure

• Seal holds unit to wound

In Vivo Studies 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


• 2 x 60 or 90-minute treatments/day

• 5 days/week

Electrical StimulationElectrical Stimulation

• Use of capacitive coupledelectrical current to transferenergy to a wound

• Current is transferred throughwet pad in contact


• Gillbert, 1600’s - 1st publication

• Galvani, 1791 - Direct current

• Matteucci - Current of injury

• 1960’s - Use of electrical current to heal wounds

Electrical TermsElectrical Terms

• Anode = positive pole

• Cathode = negative pole

• DC = direct current or galvanic

Skin Battery PotentialSkin Battery Potential

• Outside of skin: electronegative

• Inside of skin: electropositive

• Current of Injury– Shift in polarity– Outside: electropositive– Inside: electronegative

Galvanotaxic EffectsGalvanotaxic Effects

• Cells move along the pathof current flow

• Neutrophils, fibroblasts, epithelial cells to cathode

• Macrophages to anode

• Mast cells repelled by anode

Summary Effects (polar) Summary Effects (polar) Negative - CathodeNegative - 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) Summary Effects (polar) Positive - AnodePositive - Anode

• Attracts macrophages

• Promotes epithelial growth and organization

• Decreases mast cells in healing wounds

• Acts as a vasoconstrictor

• Decreases blood flow

• Anti-microbial

Stimulatory EffectsStimulatory Effectson Cellson 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 FlowEffects 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 EffectsAntibacterial Effects

Inhibition of

• Pseudomonas aeruginosa

• Staph aureus

• E. Coli

• Staph epidermis

Indications for UseIndications for Use

• Pressure ulcers

• Vascular ulcers

• Surgical wounds

• Neuropathic ulcers


• Basil or squamous cell carcinoma

• Untreated osteomyelitis

Electrical Stimulation Electrical Stimulation TherapyTherapy

• DC, 1 mAmp/inch2 electrode– 30-60 minutes/day– 5 days/week

• HVPC, 150 V – 120 pulse/sec, 255 s pp– 30 minutes/day– 5 days/week

Clinical Modalities Clinical Modalities ResearchResearch

• Evaluate effectiveness of modality

• Why does it work?

• Interactions with other modalities

• What population does it work with?

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Modalities

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