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Wound Healing

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Pathological / physical insult

Inflammatory Phase Proliferation Phase Maturation Phase

Vasoconstriction

Vasodilatation

Clot Formation

Phagocytosis

Epithelialization

Fibroplasia / Collagen Formation

Wound Contraction

Neovascularization

Collagen synthesis/ Lysis

Collagen fiber orientation

Healed Injury

Normal Phases of Repair

21 3

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1. Healing by primary intention

2. Healing by secondary intention

3. Delayed primary closure

� Infection

� Poor hygiene

� Local blood supply

� Oedema

� Inhibited wound

oxygenation

� Smoking

� Cooling of the wound

� Delayed inflammatory

response

� Insufficient diet or

malnutrition

� Proteins

� Carbohydrates

� Fats

� Vitamins

� Minerals

� Psychological Stress

� Age effects

� Diabetes mellitus

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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

� Monitors treatment efficacy

� May help predict healing

� Enhances overall wound management

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� 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 processed by a special

used 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.

� Computerized stereophotogrammetry: This uses two pictures of the

same area taken from different known positions to produce a three-

dimensional image for measurement.

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Wound Healing

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High Frequency modalities used to promote

wound healing are…

1. Ultrasound

2. LASER

3. Ultraviolet

4. PSW

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Ultrasound benefit wound healing in..

1. Inflammatory Phase :

causes a degranulation of mast cells

resulting in the release of histamine.

2. Proliferative Phase :

effect fibroblasts and stimulate them to

secrete collagen. This can accelerate the

process of wound contraction and increase

tensile strength of the healing tissue

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1. Treat at the lowest intensity.

2. Assure that the applicator is kept in constant

motion throughout treatment

3. Proper acoustic coupling medium is used.

4. Reduce the intensity or terminate treatment

if the patient complains of any increase in

pain.

1. remove dressings and clean wound

2. A hydro gel sheet should be placed in direct contact with the wound bed and wound margins

3. In cases of cavity type of wound a sterile aqueous hydro gel filler should be used. The cavity is filled with the aqueous gel and then covered wit the hydro gel sheet

4. Apply an ultrasonic coupling gel on top of the sheet.

5. Remove all underlying air bubbles

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� frequency of 3 MHz

�20 % duty cycle

� intensity usually 0.3 to 0.5 watts/cm 2.

�Duration 5 to 10 minutes

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� 1 MHz, continuous ultrasound

� intensity is typically set to between 1 and 1.5

watts/cm 2.

� Initial treatment is about 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.

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�20% Zink Oxide ointment

� frequency of 3 MHz

�20 % duty cycle

� intensity usually 0.3 to 0.5 watts/cm2

�Duration 5 to 10 minutes

�Should not be given to patients sensitive to

metal

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�Stimulate ATP production

� Increase immune system

� Increase collagen synthesis

Wound margins

� Direct contact

� 1 – 2 cm from edges

� 4 – 10 j/cm2

Wound bed

� Non contact

� 1 – 5 j/cm2

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� U VC is the frequency band most commonly used

because it:

� enhances epithelialisation

� destroys bacteria

� Causes minimal erythema

� and is absorbed almost equally by all skin colours

� Antibiotic effects of UVR - C ( 100 – 280 nm) used for

Sterilization of wound

� UVR – A and UVR – B known to

1. Promote granulation tissue

2. Remove slough

3. Stimulate epidermal growth

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� Goldin et al (1981) list the following as the primary

effects of pulsed SWD:

1. Reduction (resolution) of the inflammatory

process.

2. Increased number of white cells, histocytes &

fibroblasts in a wound.

3. Improved rate of oedema dispersion.

4. Encourages absorption of heamatoma.

5. Prompts a more rapid rate of fibrin fibre

orientation & deposition of collagen.

6. Encourages collagen layering at an early stage.

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�25 – 30 W

�20 min.

�Longer pulse duration

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Wound Healing

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� 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

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�Up regulates insulin receptors on fibroblasts.

�Up regulation of TGF-β.

(Transforming growth factor beta) is

a protein that controls proliferation, cellular

differentiation in most cells

� Increases angiogenesis

�Decreases bacterial burden

� Increases blood flow

� Increases wound tensile strength

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�Pressure Ulcers

�Diabetic ulcers

�Venous Ulcers

�Traumatic Wounds

�Surgical Wounds

� Ischemic Ulcers

�Donor Sites

�Wound Flaps

�Burn wounds

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There are three types of electrical current that

assist in wound closure and healing:

� Direct current (DC)

� Alternating current, and

� Pulsed current (PC)

1. High Voltage Pulsed current, monophasic

2. Low Voltage Pulsed Current, monophasic/biphasic

� 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

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�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.

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� 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

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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

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1. Georgina G. The importance of continuous wound measuring. Wounds UK, 2006,Vol

2, No 2. 60-68

2. http://www.worldwidewounds.com/2006/january/Fette/Clinimetric-Analysis-

Wound-Measurement-Tools.html#ref10

3. http://medicaledu.com/ultrasnd.htm

4. http://www.campbellteaching.co.uk/sample.pdf

5. Electrotherapy explained, 4th edition, Low & Reed, Elsevier

6. Clayton’s electrotherapy, 10th edition, Sheila Kitchen

7. Handbook of practical electrotherapy, Mitra PK, Jaypee publications

8. Physical Agents in Rehabilitation, From Research to Practice, 2nd edition, Michelle

H. Cameron, Saunders Elsevier

9. David Cukjati, Rajmond Savrin. Electric Current Wound Healing.

10. Katheriene Lampe, Electrotherapy in Tissue Repair, Journal of Hand Therapy, 1998,

131 – 138

11. Julia Shaw , Patrick M. Bell. Wound Measurement in Diabetic Foot Ulceration.

Global Perspective on Diabetic Foot Ulcerations. InTech 2011. 72 - 82