Physiotherapy in Wound Healing; Role of Electrotherapy

Role of various Electrotherapy modalities in Wound Healing. For physiotherapy students

1. ELECTROTHERAPY in Wound Healing 1 Dr Sreeraj S R, Ph.D

2. Normal Phases of wound Repair Pathological / physical insult Inflammatory Phase Proliferation Phase Maturation Phase Hemostasis Phase Vasodilatation Clot Formation Phagocytosis Epithelialization Fibroplasia / Collagen Formation Wound Contraction Neovascularization Collagen synthesis/ Lysis Collagen fiber orientation Healed Injury 3 2 4 1 2

3. Hemostasis Phase Immediate response to injury to prevent blood loss. There is; Reflex vasoconstriction Platelets derived from bone marrow gets activated by injury which mediate the release of adenosine diphosphate, fibrinogen, fibronectin resulting in clumping of platelets and thrombosis. Activated platelets also secretes several growth factors like platelet-derived growth factor (PDGF) which stimulate fibroblasts to produce collagen, proteoglycans, and glycosaminoglycans which contribute to provisional matrix of the fibrin clot. 3

4. Inflammatory Phase Begins with haemostasis and chemotaxis. Both the thrombocytes (platelets) and WBCs speed up the inflammatory process by releasing more mediators and Cytokines. Serotonin and histamine are released from platelets and increase cellular permeability. The PDGF attracts fibroblasts and, along with transforming growth factor, enhance division and multiplication of fibroblasts to synthesize collagen. Inflammatory cells, such as neutrophils, monocytes, and endothelial cells, adhere to a fibrin scaffold that is formed by platelet activation. The neutrophils enable phagocytosis of cellular debris and bacteria, allowing for decontamination of the wound.  4

5. The Proliferative Phase The fibroblasts have started to lay down new collagen, proteoglycans and glycosaminoglycans to form the core of the wound and help stabilize the wound. Re-epithelialisation starts to occur via coordinated proliferation and migration of basal keratinocytes located at the wound margin, starting with a thin superficial layer to more durable layer of cells to bridge the wound. Neovascularization occurs through both angiogenesis and vasculogenesis , which is the formation of new blood vessels from endothelial progenitor cells (EPCs). Once collagen fibers have been laid down on the fibrin framework, the wound starts to mature and is facilitated by continued deposition of fibroblasts and myofibroblasts. 5

6. The Maturation Phase The maturation or remodelling phase starts around week 3 and can last up to 12 months. The excess collagen degrades, and wound contraction also begins to peak around week 3. Wound contraction occurs to a much greater extent in secondary healing than in primary healing. The maximal tensile strength of the incision wound occurs after about 11 to 14 weeks. 6

7. Graphical Representation Three Phases With Approximate Timeline 0 day 2 days 2 weeks 3 months Inflammatory Phase prepares the wound for healing Proliferative Phase rebuilds damaged structures and strengthens the wound Remodelling Phase modifies scar tissue into its mature form 7

8. Wound Contraction Healing by primary intention in which restoration of  continuity occurs directly by fibrous adhesion, without  formation of granulation tissue; it results in a thin scar. Healing by secondary intention when the edges of the  wound are far apart and cannot be brought together. Granulations form from the base and sides of the wound  toward the surface. 8

9. Factors Affecting Healing Process Infection Poor hygiene Local blood supply Oedema Inhibited wound oxygenation Smoking Delayed inflammatory response Insufficient diet or malnutrition Psychological Stress Age effects Diabetes mellitus 9

10. Wound measurements The purpose of any wound measurement is to monitor the progress of healing through changes in the length, width, area or volume of a wound. Part of initial assessment Aids re-evaluation for accurate communication between professionals Objective form of assessment Enhances quality of patient care Monitor treatment efficacy Enhances overall wound management 10

11. Wound measurements Simple measurements:  measuring its linear dimensions with a tape measure or ruler like length x width. Wound tracing: a pen is used to trace the outline of the wound directly onto sterile transparent film. Moulds :  A three-dimensional mould of the wound can be created by taking a cast of the wound cavity using a saline or alginate filling. Scaled photographs:  This uses a photograph to calculate length and width, which are expressed in simple measurements. Planimetrics :  A transparent sheet of graph paper is laid over the photograph or wound tracing, and the number of complete graph squares within the boundaries of the wound are added up to produce a scale area calculation by using either manually or using a computer. 11

12. Wound measurements 12

13. High Frequency Modalities in Wound Healing

14. High Frequency modalities used to promote wound healing are… Ultrasound PSW 14

15. Ultrasound Ultrasound benefit wound healing in.. Inflammatory Phase : Causes a degranulation of mast cells resulting in the release of histamine, neutrophils, proteoglycans.  These mediators play an important role in absorbing neutrophils and monocytes to the injured site. Proliferative Phase   : Effect fibroblasts and stimulate them to secrete collagen. Accelerate the process of wound contraction Increase tensile strength of the healing tissue 15

16. Application Remove dressings and clean wound In cases of cavity type of wound a sterile aqueous hydro gel filler OR saline cotton swabs should be used to fill the wound to prevent presence of air. A hydro gel sheet   should be placed on top of this. Apply an ultrasonic coupling gel on top of the sheet. 16

17. Dosimetry For wound Frequency of 3 MHz 20 % duty cycle Intensity usually 0.3 to 0.5 watts/cm 2 . Duration 5 to 10 minutes For peri wound tissue 1 MHz, continuous ultrasound. Intensity 1 and 1.5 watts/cm 2 Duration 2-3 minutes per zone. Can be increased by 30 second increments to a maximum of 5 minutes per zone and delivered 3 times per week. 17

18. Phonophoresis 20% Zink Oxide ointment Frequency of 3 MHz 20 % duty cycle Intensity usually 0.3 to 0.5 watts/cm 2 Duration 5 to 10 minutes Should not be given to patients sensitive to metal 18

19. PSW Goldin et al (1981) list the following as the primary effects of pulsed SW: Reduction (resolution) of the inflammatory process. Increased number of white cells, histocytes & fibroblasts in a wound. Improved rate of oedema dispersion. Encourages absorption of heamatoma . Prompts a more rapid rate of fibrin fibre orientation & deposition of collagen. Encourages collagen layering at an early stage. 19

20. Dosage 25 – 30 W 20 min. Longer pulse duration 20

21. Actinotherapy LASER Ultraviolet 21

22. Physiological & Therapeutic Effects Bio stimulation: improved cell metabolism > Increases speed, quality & tensile strength of tissue repair Pain Relief:  Laser decreases nerve sensitivity by decreasing bradykinin; a pain eliciting chemical, releases endorphins and enkephalins that produce an analgesic effect Anti-inflammatory/Healing: Laser increases ATP which accelerates the repair processes of the cell. Increases blood supply: Laser causes widening of the arteries and veins around the injury which increase nutrients and oxygen and helps to remove damaged cellular debris . Increase macrophage activity: WBC activity is enhanced leading to a more rapid repair process. Improved Vascular Activity:  Laser light increases the formation of new capillaries in damaged tissue, which speeds up the healing process, and closes wounds quickly. Reduced Fibrous Tissue Formation: Due to i ncrease in Fibroblast Proliferation, collagen synthesis and remodeling. https://www.spineuniverse.com/treatments/physical-therapy/pain-relief-healing-laser-therapy

23. Application & Dosimetry Wound margins Direct contact 1 – 2 cm from edges 4 – 10 j/cm 2 Wound bed Noncontact 1 – 5 j/cm 2 23

24. Ultraviolet Antibiotic effects of UVR - C ( 100 – 280 nm) used for Sterilization of wound U VC is the frequency band most used because it: Destroys bacteria Enhances epithelialisation And is absorbed almost equally by all skin colours UVR – A and UVR – B known to Promote granulation tissue Remove slough Stimulate epidermal growth 24

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26. Electrical Stimulation in Wound Healing

27. Bioelectric System The body has its own bioelectric system A current termed the "current of injury" is generated between the skin and inner tissues when there is a break in the skin. Healing of the injured tissue is arrested or will be incomplete if these currents no longer flow while the wound is open. A rational for applying electrical stimulation is that it mimics the natural current of injury and will jump start or accelerate the wound healing process 27

28. Effects of ES Up regulates insulin receptors on fibroblasts. Up regulation of TGF-β ( Transforming growth factor beta)  which is a protein that controls proliferation, cellular differentiation in most cells Increases angiogenesis Decreases bacterial burden Increases blood flow Increases wound tensile strength 28

29. Indications Pressure Ulcers Diabetic ulcers Venous Ulcers Traumatic Wounds Surgical Wounds Ischemic Ulcers Donor Sites Wound Flaps Burn wounds 29

30. TYPES OF ELECTRICAL CURRENT There are three types of electrical current that assist in wound closure and healing: Direct current (DC) Alternating current, and Pulsed current (PC) High Voltage Pulsed current, monophasic Low Voltage Pulsed Current, monophasic/biphasic 30

31. High Voltage Pulsed Stimulation Application of high voltage, low amperage and direct current to a specific region of the body Characteristics of HVPS include: a very short pulse duration between 20-200µs, voltage greater than 100 volts stimulation range between 0-150Hz, unique twin peak monophasic waveform 31

32. Treatment Protocol Pulse frequency: 100 pps Pulse duration: 20 to 100 µ sec. Polarity: + ve for anti microbial effects and – ve to enhance granulation tissue formation and re epithelialization Intensity: 100-150 volts Treatment duration: 45 to 60 min. 5 to 7 days per week. 32

33. Electrotaxis in Electrical Fields 33

34. Application Have supplies ready before undressing the wound. Position patient for ease of access by staff and comfort of both. Remove the dressing and place in an infectious waste bag. Cleanse wound thoroughly to remove slough, exudates and any petrolatum products Open gauze pads and soak in normal saline solution, squeeze out excess liquid. Fill the wound cavity with gauze including any undermined/tunneled spaces. Pack gently. An alternative is to use an amorphous hydro gel impregnated gauze/ Hydro gel sheets 34

35. Application Stimulating Electrode Placement: Place over the gauze packing and hold in place with bandage tape. Connect to stimulator lead Dispersive electrode placement: Usually placed proximal to the wound Place over soft tissues, avoid bony prominences Place a wet lint pad under the dispersive electrode Dispersive pad should be larger than the sum of the areas of the active electrodes and wound packing. The greater the separation between the active and dispersive electrode the deeper the current path. Use for deep and undermined wounds 35

36. References Georgina G. The importance of continuous wound measuring. Wounds UK, 2006,Vol 2, No 2. 60-68 http://www.worldwidewounds.com/2006/january/Fette/Clinimetric-Analysis-Wound-Measurement-Tools.html#ref10 http://medicaledu.com/ultrasnd.htm http://www.campbellteaching.co.uk/sample.pdf Electrotherapy explained, 4th edition, Low & Reed, Elsevier Clayton’s electrotherapy, 10th edition, Sheila Kitchen Handbook of practical electrotherapy, Mitra PK, Jaypee publications Physical Agents in Rehabilitation, From Research to Practice, 2nd edition, Michelle H. Cameron, Saunders Elsevier David Cukjati , Rajmond Savrin . Electric Current Wound Healing. Katheriene Lampe, Electrotherapy in Tissue Repair, Journal of Hand Therapy, 1998, 131 – 138 Julia Shaw , Patrick M. Bell. Wound Measurement in Diabetic Foot Ulceration. Global Perspective on Diabetic Foot Ulcerations. InTech 2011. 72 - 82 36