Lecture 24 - Wound healing and biophysical agents Flashcards
What is the definition for chronic wound?
A wound that deviates from the expected sequence of repaire in terms of time, appearance and response to aggresive and appropriate treatment
Factors that impede healing (9)
- Low blood oxygen content (due to poor circulation)
- Excessive physical strain (immobilation-> movement)
- Infection
- Foreign body not removed from the wound
- Sustained pressure – affecting the blood flow
- Age, level of mobility (immobility)
- Patient nutrition
- Systemic disease (diabetes, spinal cord injury)
- Medications
What medications impede healing and why?
Corticosteroids
anti-inflammatory effect stabilizes cellular membranes;
inhibits the production of prostaglandins
Non-steroidal anti-inflammatories (NSAIDS) aspirin, ibuprofene – inhibit prostaglandin
Lack of what vitamines impede healing?
Vitamin C – hydroxylation during the synthesis of collagen
Vitamin A – increases the availability of macrophages
Zinc – increases epithelialization
Types of chronic wound (6)
Pressure ulcers
Lower extremity - Diabetic foot ulcers neuropathic Leg ulcers: - Venous insufficiancy - Arterial insufficiancy
Inflammatory
Malignant
Post-surgical
Post-traumatic
Pressure ulcers etiology?
Localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period
Neuropathic ulcers definition, prevalence and etiology
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
To what are due venous ulcers ?
Blood flow:
Compromised
Back flows due to incompetent valves
What is primary cause (1) and predisposing factors to arterial ulcers (5)?
Primary cause is arteriosclerosis of medium or large arteries
Predisposing factors
- Smoking
- Diabetes
- Hyperlipidemia
- Hypertension
- Genetics
Explain stage 1 of wound development
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
Explain stage 2 of wound development
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
Explain stage III of wound development
All the layers of the skin are destroyed and a deep crater forms
Explain stage IV
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
Theurapeutic effects of HVPC (6)
increase microcirculation
decrease and prevent edema
increase re-oxygenation
Antibacterial effects
Bioelectrical effects
Galvanotaxis
Cellular effects
Explain bioelectrical potential
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
What is the process of galvanotaxis
HVGS enhances wound healing by causing inflammatory, phagocytic and repair cells to migrate to wound
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. early stages of healing, Neutrophils, macrophages, epidermal cells
b. later stages of healing, neutrophils, fibroblasts
Cellular effects of HVPC (5)
Stimulate tissue formation
collagen synthesis
ATP output
increase capillary density
increase collagen organization
increase wound strength
Releases growth factors (e.g., increase fibroblasts)
Indications for HVPC (4)
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
Factors affecting healability (4)
Medical status
Anemia, malnutrition, hyperglycemia
Blood flow
Patient compliance to treatment
Chronicity of ulcer
Likelihood of healing decreases significantly with time
Application of HVPC (3 steps)
- Remove petroleum and metal residue
- Remove foreign/necrotic materials: Debridement + Irrigate wound
3. Apply conducting agent/electrode Aluminium foil in saline soaked gauze metallic gauze single use electrode Hydrogel
Does HVGS has good evidence?
YAS QUEEN. Pressure ulcers: high voltage = ‘A’ Diabetic ulcers also respond well unless Blood sugar poorly managed Too chronic
Contraindications for HVGS?
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)
Therapeutic effects of US (2)
increase fibroblast activity (collagen formation)
Shortens inflammatory phase
increase inflammatory response so it is more efficient
increase phagocytes & degranulation
Results in increase debridement
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)
What are the US parameters for wound Rx
Intensity: 0.2 W/cm2
Frequency: 3 MHz
Pulsed: 20% duty cycle
Duration: 5min/5cm2
Why use UVC for chornic wound healing?
Inhibit bacterial growth
Indicated for treatment of infected wounds, particularly if antibiotic resistant
Contraindications of UVC (7)
Dermatological conditions eczema Photosensitivity Fever Erythema TB Skin cancer (Hx or active) HIV (activated by UVC)
Safety precautions for UVC (3)
Eyes (wear protection) PT and patient
Cancer
Minimize exposure
Avoid UVA/UVB wavelengths
Burn : keep the duration very short
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
What controversy with Low level laser therapy (1)
Controversy
Kills bacteria vs. stimulation of bacterial growth?
Therefore,
NOT used if infection is present
Therapeutic effects of whirlpool (3)
Removal of debris and exudate
increase perfusion to local tissues
Neuronal effects to produce analgesia
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
Indications for whirlpool (4)
Wounds with Necrosis Adherent dressings Debris/dirt from trauma With residual topical agent
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
Contraindications for whirlpool (9)
Moderate-severe oedema Lethargy/unresponsiveness Maceration Febrile conditions Compromised cardiovascular or pulmonary system Acute phlebitis Renal failure Dry gangrene Incontinence
Precautions for whirlpool (5)
Clean granulating wounds Epithelialising wounds New skin grafts New tissue flaps Non-necrotic ulcers 2° diabetic neuropathy
What are the signs and symptoms (3) and goals of treatment during inflammatory phase (5) ?
SIGNS AND SYMPTOMS
- Cardinal signs: redness, heat, pain, edema
- Pain at rest
- Pain and limitation of movement
GOALS OF TREATMENT vasoconstriction decrease vasoactive agents decrease pain decrease edema decrease muscle spasm
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
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
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)
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
Non electrical physical modalities (3)
HEAT
COLD
ULTRASOUND
Electrical physical modalities (5)
TENS, DD, IFC, HVPG, DIRECT CURRENT
Iontophoresis, wound healing
Monochromatic irradiation (light) physical modalities (2)
Laser, UV
Modalities having a therapeutic effects on circulation ? (4)
heat, cold, exercise, USc
Modalities having a therapeutic effects on healing? 2 types (10)
Direct: LASER, USp, HVPG, DD, IFC, DC,
Transverse frictions
Indirect: Heat, Exercise, Stretching
Modalities having a therapeutic effect on flexibility? (6)
Heat Exercise Stretching Massage CPM - continuous passive mouvement Contract-Relax
Modalities having a therapeutic effect on muscle stimulation (6)
E stem
DD, IFC
TENS acupuncture Vibration (tonic vibration reflex)
HVPG
Modalities having a therapeutic effect on sensory stimulation (5)
TENS
DD, IFC, HVPG
Vibration
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
Priorities continuum when chosing a modality? (4)
- primary underlying problem
- problem most likely to respond to treatment
- tx that can address more than one problem simultaneously
- symptomatic relief only
Principles governing the selection of biophysical agents(9)
- 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
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
