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PHTH 550 - Orthopedics > Lecture 24 - Wound healing and biophysical agents > Flashcards

Lecture 24 - Wound healing and biophysical agents Flashcards

1
Q

What is the definition for chronic wound?

A

A wound that deviates from the expected sequence of repaire in terms of time, appearance and response to aggresive and appropriate treatment

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2
Q

Factors that impede healing (9)

A
  1. Low blood oxygen content (due to poor circulation)
  2. Excessive physical strain (immobilation-> movement)
  3. Infection
  4. Foreign body not removed from the wound
  5. Sustained pressure – affecting the blood flow
  6. Age, level of mobility (immobility)
  7. Patient nutrition
  8. Systemic disease (diabetes, spinal cord injury)
  9. Medications
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3
Q

What medications impede healing and why?

A

Corticosteroids
anti-inflammatory effect stabilizes cellular membranes;
inhibits the production of prostaglandins
Non-steroidal anti-inflammatories (NSAIDS) aspirin, ibuprofene – inhibit prostaglandin

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4
Q

Lack of what vitamines impede healing?

A

Vitamin C – hydroxylation during the synthesis of collagen

Vitamin A – increases the availability of macrophages

Zinc – increases epithelialization

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5
Q

Types of chronic wound (6)

A

Pressure ulcers

Lower extremity
- Diabetic foot ulcers neuropathic
Leg ulcers:
- Venous insufficiancy
- Arterial insufficiancy

Inflammatory

Malignant

Post-surgical

Post-traumatic

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6
Q

Pressure ulcers etiology?

A

Localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period

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7
Q

Neuropathic ulcers definition, prevalence and etiology

A

Definition: secondary to peripheral neuropathy

Prevalence: most common in diabetics

Etiology:
- Sensory: no feedback about tissue trauma
- Motor: abnormal foot mechanics
- Autonomic
Decreased blood flow
Decreased hydration
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8
Q

To what are due venous ulcers ?

A

Blood flow:
Compromised
Back flows due to incompetent valves

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9
Q

What is primary cause (1) and predisposing factors to arterial ulcers (5)?

A

Primary cause is arteriosclerosis of medium or large arteries

Predisposing factors

  • Smoking
  • Diabetes
  • Hyperlipidemia
  • Hypertension
  • Genetics
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10
Q

Explain stage 1 of wound development

A

STAGE I
Redness or blue-gray discoloration over the pressure area

In dark-skinned people, the area may appear drier

Usually reversible at this stage if the pressure ’d

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11
Q

Explain stage 2 of wound development

A

STAGE II
Skin is reddened and may or may not be broken
Abrasions, blisters (cloques) , or a shallow crater at the site
Epidermis alone or both the epidermis and the dermis
If neglected, further and deeper damage occurs

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12
Q

Explain stage III of wound development

A

All the layers of the skin are destroyed and a deep crater forms

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13
Q

Explain stage IV

A

The ulcer extends through the skin and subcutaneous tissues, and may involve bone, muscle, and other structures
The patient will experience fluid loss and pain
Great risk for infection

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14
Q

Theurapeutic effects of HVPC (6)

A

increase microcirculation

decrease and prevent edema

increase re-oxygenation

Antibacterial effects

Bioelectrical effects
Galvanotaxis

Cellular effects

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15
Q

Explain bioelectrical potential

A

Skin surface is electronegative
Average surface charge = -23.4mV
Maintains tissue health
Deeper epidermal cells and dermis are + ve
Thus wound cavity is positive
After injury, the injured site sets up a ‘current of injury’ (- ve surface & +ve wound) = Skin Battery
Estim applied over the dermal wound enhances the healing process

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16
Q

What is the process of galvanotaxis

A

HVGS enhances wound healing by causing inflammatory, phagocytic and repair cells to migrate to wound

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17
Q

Different stages of repair respond to currents of different polarity, positive bioelectric charge is used for __a__ and negative bioelectrical charge is used for __b__.
& what cells are implicated

A

a. early stages of healing, Neutrophils, macrophages, epidermal cells
b. later stages of healing, neutrophils, fibroblasts

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18
Q

Cellular effects of HVPC (5)

A

Stimulate tissue formation
collagen synthesis
ATP output

increase capillary density

increase collagen organization

increase wound strength

Releases growth factors (e.g., increase fibroblasts)

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19
Q

Indications for HVPC (4)

A

Chronic wounds: most types

Pressure ulcers Diabetic
PVD

Failure to heal using conventional care

No clinical signs of healing after 14 days
PMHx of impaired healing

Issues of healability

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20
Q

Factors affecting healability (4)

A

Medical status
Anemia, malnutrition, hyperglycemia

Blood flow

Patient compliance to treatment

Chronicity of ulcer
Likelihood of healing decreases significantly with time

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21
Q

Application of HVPC (3 steps)

A
  1. Remove petroleum and metal residue
  2. Remove foreign/necrotic materials: Debridement + Irrigate wound
3. Apply conducting agent/electrode
Aluminium foil in saline soaked gauze
metallic gauze
single use electrode
Hydrogel
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22
Q

Does HVGS has good evidence?

A 
YAS QUEEN.
Pressure ulcers: high voltage = ‘A’
Diabetic ulcers also respond well unless
Blood sugar poorly managed
Too chronic
23
Q

Contraindications for HVGS?

A

Same as any electrical modality with the addition of:
Osteomyelitis
Heavy metal residue (be aware of ingredients in wound care products, some may have some metal residue)

24
Q

Therapeutic effects of US (2)

A

increase fibroblast activity (collagen formation)

Shortens inflammatory phase
increase inflammatory response so it is more efficient
increase phagocytes & degranulation
Results in increase debridement

25
Application methods for US (3)
Peri-ulcer (skin) Water bath Over ulcer Fill with saline solution or Hydrogel (Intrasite) and cover with dressing (Hydrogel sheet)
26
What are the US parameters for wound Rx
Intensity: 0.2 W/cm2 Frequency: 3 MHz Pulsed: 20% duty cycle Duration: 5min/5cm2
27
Why use UVC for chornic wound healing?
Inhibit bacterial growth | Indicated for treatment of infected wounds, particularly if antibiotic resistant
28
Contraindications of UVC (7)
``` Dermatological conditions eczema Photosensitivity Fever Erythema TB Skin cancer (Hx or active) HIV (activated by UVC) ```
29
Safety precautions for UVC (3)
Eyes (wear protection) PT and patient Cancer Minimize exposure Avoid UVA/UVB wavelengths Burn : keep the duration very short
30
Physiological effects of low level laser therapy? (11)
Biostimulation improved metabolism, increase of cell metabolism Increases speed, quality & tensile strength of tissue repair Modulates blood circulation Increase ATP production Anti-inflammatory & anti-edematous effects Stimulates healing (increase macrophage activity) Stimulation circulatory system (healing, clot formation) Cell migration Cell proliferation (new healthy cells & tissue) increase collagen production Alters nerve conduction velocity (stimulates nerve activity) Degranulation or removal of the necrotic tissue
31
What controversy with Low level laser therapy (1)
Controversy Kills bacteria vs. stimulation of bacterial growth? Therefore, NOT used if infection is present
32
Therapeutic effects of whirlpool (3)
Removal of debris and exudate increase perfusion to local tissues Neuronal effects to produce analgesia
33
Is whirlpool used to control infection ?
NOOOO. The use of whirlpool to control infection is poorly documented Has been found to cause nosocomial infection in patients with burns
34
Indications for whirlpool (4)
``` Wounds with Necrosis Adherent dressings Debris/dirt from trauma With residual topical agent ```
35
Procedure for Whirlpool (3)
Water temperature should be monitored and set at 37° C (peripheral immersion) Frequency and duration: No clear guideline Monitor vital signs (HR, BP, RR) Hx of CVA, cardiac or cardiovascular disease hypertension
36
Contraindications for whirlpool (9)
``` Moderate-severe oedema Lethargy/unresponsiveness Maceration Febrile conditions Compromised cardiovascular or pulmonary system Acute phlebitis Renal failure Dry gangrene Incontinence ```
37
Precautions for whirlpool (5)
``` Clean granulating wounds Epithelialising wounds New skin grafts New tissue flaps Non-necrotic ulcers 2° diabetic neuropathy ```
38
What are the signs and symptoms (3) and goals of treatment during inflammatory phase (5) ?
SIGNS AND SYMPTOMS 1. Cardinal signs: redness, heat, pain, edema 2. Pain at rest 3. Pain and limitation of movement ``` GOALS OF TREATMENT vasoconstriction decrease vasoactive agents decrease pain decrease edema decrease muscle spasm ```
39
Signs and sx (3) and goals of treatment for reparative phase (4)
SIGNS & SYMPTOMS Inflammation Pain at the end of movement Joint stiffness ``` GOALS OF TREATMENT vasodilatation decrease edema decrease pain decrease muscle spasm ```
40
What are signs and sx (2) and goals of treatment (4) for remodeling phase
SIGNS & SYMPTOMS Pain Joint stiffness ``` GOALS OF TREATMENT vasodilatation increase flexibility increase force proprioceptive reeducation ```
41
Causes of chronic inflammation (4)
Prolonged auto-inflammatory response or repeated trauma Predominant cell types: Lymphocytes, monocytes, macrophages, (not neutrophils which are responsible for healing) Excessive proliferation Excessive collagen formation → scarring, adhesions (capsular, tendinous, muscular)
42
Factors influencing inflammation and repair process in order to reduce chronicity (6)
Nutrition: Vitamin C, Vitamin A, Zinc Systemic disease: Immunological, circulatory Medication: corticosteroids, non-steroidal anti-inflammatories (NSAIDS) Immobilisation Biophysical modalities Physical treatment
43
Non electrical physical modalities (3)
HEAT COLD ULTRASOUND
44
Electrical physical modalities (5)
TENS, DD, IFC, HVPG, DIRECT CURRENT | Iontophoresis, wound healing
45
Monochromatic irradiation (light) physical modalities (2)
Laser, UV
46
Modalities having a therapeutic effects on circulation ? (4)
heat, cold, exercise, USc
47
Modalities having a therapeutic effects on healing? 2 types (10)
Direct: LASER, USp, HVPG, DD, IFC, DC, Transverse frictions Indirect: Heat, Exercise, Stretching
48
Modalities having a therapeutic effect on flexibility? (6)
``` Heat Exercise Stretching Massage CPM - continuous passive mouvement Contract-Relax ```
49
Modalities having a therapeutic effect on muscle stimulation (6)
E stem DD, IFC TENS acupuncture Vibration (tonic vibration reflex) HVPG
50
Modalities having a therapeutic effect on sensory stimulation (5)
TENS DD, IFC, HVPG Vibration
51
Factors to consider when chosing one modality (11)
Type of client Age of client Capacity of client to understand intervention Stage of healing Contra-indications Short-term treatment goals Long-term treatment goals Time allotted for treatment Combination of modalities Integration of modalities in overall treatment Client response
52
Priorities continuum when chosing a modality? (4)
1. primary underlying problem 2. problem most likely to respond to treatment 3. tx that can address more than one problem simultaneously 4. symptomatic relief only
53
Principles governing the selection of biophysical agents(9)
1. Determine the stage of inflammation (if required) Determine the chronicity of the problem (acute, sub- acute, chronic) Determine the irritabilty of the symptom Determine if there are any contra-indications for any biophysical agents Determine short-term and long-term treatment goals Determine treatment frequency Consider the time available for treatment Select the appropriate biophysical modality(ies) site and size of the lesion the penetration of the modality the capacity of the patient to tolerate the modality the capacity of the patient to cooperate during the application of the modality. Determine the order of application of the modalities chosen
54
Principles impeding the selection of biophysical agents (3)
Never combine two modalities that have the same effect using similar mechanisms ex: IFC and DD Never combine two deep heating modalities (risk of burns) ex: short-wave diathermy (SWD) and continuous US In general, do not combine two modalities that have the opposite effects ex : Ice followed immediately by heat or vice versa Exception: when treating edema and doing contrast bath

PHTH 550 - Orthopedics (10 decks)

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