p.t management of wound

Electrical stimulation affects the biological phases of wound healing in the following ways:
Inflammation phase

Initiates the wound repair process by its effect on the current of injury
Increases blood flow
Promotes phagocytosis
Enhances tissue oxygenation
Reduces edema perhaps from reduced microvascular leakage
Attracts and stimulates fibroblasts and epithelial cells
Stimulates DNA synthesis
Controls infection ( Note: HVPC proven bacteriocidal at higher intensities than use in clinic and may not be tolerated by patient)
Solubilizes blood products including necrotic tissue

Proliferation phase

Stimulates fibroblasts and epithelial cells
Stimulates DNA and protein synthesis
Increases ATP generation
Improves membrane transport
Produces better collagen matrix organization,
Stimulates wound contraction

Epithelialization phase

Stimulates epidermal cell reproduction and migration
Produces a smoother, thinner scar

INDICATIONS FOR THE THERAPY

Use and application of the modality is not pathology dependent.
Types of wounds for which there is indication to use HVPC include:

Pressure Ulcers Stage I through IV
Diabetic ulcers due to pressure, insensitivity and dysvascularity
Venous Ulcers
Traumatic Wounds
Surgical Wounds
Ischemic Ulcers
Vasculitic Ulcers
Donor Sites
Wound Flaps
Burn wounds

PROCEDURE

The protocols change as the wound healing phase changes. Assessment and diagnosis of the wound healing phase determines the treatment protocol. The set up and protocols used by Sussman are the same regardless of wound pathogenesis.

Research Wisdom:
<BLOCKQUOTE>
Research compared direct application of HVPC to the wound, using the whirlpool to conduct the current and whirlpool alone. Application of HVPC directly to the wound had best outcomes. Safety is also a concern because electrical leads can become tangled in the turbine of the whirlpool and HVPC stimulators have been known to fall into the water. </BLOCKQUOTE>

Research Wisdom - Best method for effective and safe HVPC treatment

Protocol for treatment:

Wound Healing Phase Diagnosis: Inflammation phase
Expected outcomes:

Wound progresses to the Proliferation phase

Change in Wound Healing Phase Diagnosis: Proliferation phase
Stimulator settings:

Polarity - negative
Pulse rate - 100 - 128 pps
Intensity - 100-150 volts
Duration - 60 minutes
Frequency 5-7 x per week, once daily

Wound Healing Phase Diagnosis: Proliferation phase
Expected Outcomes:

Wound progresses to Contraction and Epithelization phase.

Change in Wound Healing Phase Diagnosis: Epithelialization phase

Stimulator settings:

Polarity - alternate every three days ie 3 days negative followed by 3 days positive
Pulse rate - 64 PPS
Intensity - 100-150 volts
Duration - 60 minutes
Frequency 5-7 x per week, once daily

Setting Up the Patient

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, exudate and any petrolatum products
Sharp debride necrotic tissue, if required, before HVPC treatment
Open gauze pads and fluff, then soak in normal saline solution, squeeze out excess liquid. An alternative is to use an amorphous hydrogel impregnated gauze. Hydrogel sheets can also be used to conduct current under the electrodes
Fill the wound cavity with gauze including any undermined/tunneled spaces. Pack gently.
Place an electrode over the gauze packing cover with dry gauze pad and hold in place with bandage tape.
Connect an alligator clip to the foil.
Connect to stimulator lead
Dispersive electrode placement:

Usually placed proximal to the wound
Place over soft tissues, avoid bony prominences
Place a washcloth, wetted with water and wrung out, under the dispersive electrode
Place against skin and hold in good contact at all edges with a nylon elasticized strap.
If placed on the back, the weight of the body plus the strap can be used to achieve good contact at the edges
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
Dispersive and active electrodes can be close together but should not touch. Current flow will be shallow> Use for shallow, partial thickness wounds

Clinical wisdom:
<BLOCKQUOTE>
All petrolatum products including enzymatic debriding agents such as collagenase, Santyl , and fibrinolysin, Elase , which are petrolatum-based products, must be removed before treatment or current will not be conducted into the wound tissues.

PRECAUTIONS

Signs of adverse effects were evaluated in the various clinical trials and none were found except some skin irritation or tingling under the electrodes in a few cases. Patients with severe peripheral vascular occlusive disease (PVD), may experience some increased pain, usually described as throbbing, in the leg after electrical stimulation.
Research Wisdom:
<BLOCKQUOTE>
An alternative protocol with reported healing, by Kaada, calls for placing the active electrode on the web space of the hand between thumb and first finger instead of over the ulcer. This may be more comfortable for the patient with PVD. </BLOCKQUOTE></BLOCKQUOTE>
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CONTRAINDICATIONS

Contraindications for treatment with electrical stimulation include:

Placement of electrodes tangential to the heart
Presence of a cardiac pacemaker
Placement of electrodes along regions of the phrenic nerve
Presence of malignancy
Placement of electrodes over the carotid sinus
Placement of electrodes over the laryngeal musculature
Placement of electrodes over topical substances containing metal ions
E.I. povidone iodine and mercurochrome, unless thoroughly cleaned.
Placement of electrodes over osteomyelitis

Note: This paper on electrical stimulation for wound healing has been excerpted from: Chapter 16, Sussman, C and Byl, N, Electrical Stimulation for Wound Healing, Wound Care Collaborative Practice Manual for Physical Therapists and Nurses, Sussman, C. And Bates-Jensen, BM, Aspen Publishers 1998.
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