How can physiotherapy help chronic wounds?

Physiotherapy treatments available for wounds

1. HVPC – High Voltage pulsed current
   – Uses pulsed electrical current to stimulate cellular growth
   – Research shows HVPC is helpful for pressure sores (see 7,9 below)
   – Treatment timeline depends:
   • on wound characteristics (type, size, depth)
   • minimum of 3 sessions– Start your rehab journey today – Book here
2. LLLT – Low Level Laser Therapy Check our blog post here
   – Uses infrared light to stimulate cellular growth and regeneration (1,5)
   – Research shows GOOD results found with wavelength: 635 – 658 nm (1,3,6)
   – Laser can be used for all types of wounds
   – Not used in infected wounds
   – BEST for: pressure sores, venous wounds
   – Treatment timeline:
   • depends on the wound characteristics (type, size, depth)
   • minimum of 3 sessions
   – Start your rehab journey today – Book here

Combination of therapies for Wound Management

Absolute MUST:
– Posture change – every 2 hours to avoid pressure sores (11)
– Pressure relief – every 15 minutes for at least 2 minutes

Wheelchair Pressure offloading technique:

1. Pushing up holding the armrests
2. Side sitting
3. Leaning forward
4. Lying down on belly if possible

Other Treatments:
– Dressing change: see wound care nurse, nurse practitioner for management
– Compression stockings (some cases)
= reduce fluid retention
= promote venous return

Proper hygiene – clean, dry, hydrated, and supple skin heals faster 😊
Proper water and food intake
= nourished body heals faster
= see Dietitian/Nutritionist/Physician for guidance

FUTURE possibilities:

• Tissue bioengineering (ongoing research)
  • development of cells and human tissues through bioengineering (8).

Physiotherapy plays a big role in prevention and treatment of wounds, along with a multi-disciplinary team involving physicians, nurse practitioners, wound care nurses, caregivers, dietitian/nutritionist among others.

What is a chronic wound?

Chronic wound = acute wound that has not healed in the expected time frame

Types of wounds

1. Venous wound
   – most common type of chronic wounds
   – appears along ankle / shin area
   – caused by:

   pooling + retention of fluid

   inefficient pumping mechanism (lack of muscle help & poor recoil / elasticity of vessels)

   

   leads to venous stasis
   =
   Skin vulnerability

   Risk factors include:
   – presence of varicose veins
   – history of blood clots
   – history/diagnosis of chronic venous insufficiency
   – lack of movement and mobility

2. Diabetic wound
   – wound created by ‘usual’ mechanism (cut, pressure, abrasion, blister, friction, etc)
   BUT heals poorly or delayed healing due to HIGH blood sugar levels
   – delayed skin regeneration
3. Pressure wound aka pressure sore, pressure ulcer or bedsores
   – most common in neurological conditions (bed ridden or wheelchair)
   – Common areas: (pressure sensitive areas / high pressure area
   • back of head
   • elbows
   • sacral/coccyx
   • sides of hip
   • ankle
   • heel
4. Arterial wound
   – Due to poor arterial circulation (arterial blood flow) to tissue in the extremities
   – Vulnerability in skin integrity = easy to ‘break skin’
   – Poor healing due to poor blood flow
   – Common areas:
   • legs
   • feet
   • toesRisk factors include:
   – lack of movement / mobility
   – history of arterial diseases
   • hardening of arteries (Atherosclerosis)
   • thickening of arteries – fat build up (Arteriosclerosis)
   – trauma
   – blood vessel restriction
   – uncontrolled diabetes and high blood pressure
   – inflammatory disease of blood vessels (Vasculitis)

Picture of a pressure wound – staging depends on the amount of tissue taken

Image reference: 4-Stages-of-Wounds-from-National-Pressure-Ulcer-Advisory-Panel.jpg (793×282) (researchgate.net)

Classification of pressure wounds – by its type, size, depth, and any other characteristics such:

– Tunneling: channel or pathway that extends in any direction from the wound
– Undermining: tissue destruction underlying intact skin along wound borders.

Image reference: undermining vs tunneling – Bing images

Infection identification

Recognize signs and symptoms and seek medical treatment right away.
Some signs are:
– Bad smell from wound
– Yellowish, greenish discharge from wound
– Inflammation: redness, swelling, warmth, pain, fever
– Pus drainage

Untreated wounds might lead to:
– generalized infection
– pain
– poor/delayed healing
– more severe outcomes – GET IT CHECKED

Treatment prognosis

VERY GOOD! 😊
– depends on the specificities of the wound

• type
• size
• depth

– Timeline:

• Small wounds = 2 weeks to 2 months
• Large wounds = 3 to 6 months

Wound healing stages:

1. healing from inside out – Hemostasis
2. Soft tissues grow back again – Inflammatory
3. formation of a scab – Proliferative
4. closing of the open area – Remodelling

Case study

1. Client
   • 70y client bedridden, dementia state
   • history of R thumb stage 4 chronic wound – over a year
   • Physiotherapy treatment: Low level laser application and pressure relief technique
   • 3 months treatment – 30 sessions

   SENSITIVE INFORMATION!! CLICK TO REVEAL

   

   

   

   
2. Client
   • 79y client, poor mobility due to Post polio syndrome
   • Spine kyphosis
   • history of thoracic spine wound stage 4 for 3 years
   • Ongoing treatment – 7 sessions
   

   

   

   

REFERENCE

1. Glass GE. Photobiomodulation: The Clinical Applications of Low-Level Light Therapy. Aesthet Surg J. 2021 May 18;41(6):723-738. doi: 10.1093/asj/sjab025. PMID: 33471046.
2. Photobiomodulation of wound healing via visible and infrared laser irradiation – DOI: 10.1007/s10103-017-2191-0 . Photobiomodulation of wound healing via visible and infrared laser irradiation – PubMed (nih.gov)
3. Mosca RC, Ong AA, Albasha O, Bass K, Arany P. Photobiomodulation Therapy for Wound Care: A Potent, Noninvasive, Photoceutical Approach. Adv Skin Wound Care. 2019 Apr;32(4):157-167. doi: 10.1097/01.ASW.0000553600.97572.d2. PMID: 30889017.
4. Posten W, Wrone DA, Dover JS, Arndt KA, Silapunt S, Alam M. Low-level laser therapy for wound healing: mechanism and efficacy. Dermatol Surg. 2005 Mar;31(3):334-40. doi: 10.1111/j.1524-4725.2005.31086. PMID: 15841638.
5. Kuffler DP. Photobiomodulation in promoting wound healing: a review. Regen Med. 2016 Jan;11(1):107-22. doi: 10.2217/rme.15.82. Epub 2015 Dec 18. PMID: 26681143.
6. Machado RS, Viana S, Sbruzzi G. Low-level laser therapy in the treatment of pressure ulcers: systematic review. Lasers Med Sci. 2017 May;32(4):937-944. doi: 10.1007/s10103-017-2150-9. Epub 2017 Jan 23. PMID: 28116536.
7. Khouri C, Kotzki S, Roustit M, Blaise S, Gueyffier F, Cracowski JL. Hierarchical evaluation of electrical stimulation protocols for chronic wound healing: An effect size meta-analysis. Wound Repair Regen. 2017 Sep;25(5):883-891. doi: 10.1111/wrr.12594. Epub 2017 Dec 8. PMID: 29052946.
8. Yu R, Zhang H, Guo B. Conductive Biomaterials as Bioactive Wound Dressing for Wound Healing and Skin Tissue Engineering. Nanomicro Lett. 2021 Dec 2;14(1):1. doi: 10.1007/s40820-021-00751-y. PMID: 34859323; PMCID: PMC8639891.
9. Gardner SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on chronic wound healing: a meta-analysis. Wound Repair Regen. 1999 Nov-Dec;7(6):495-503. doi: 10.1046/j.1524-475x.1999.00495.x. PMID: 10633009.
10. Summary of the best evidence for postural change in the prevention of pressure injury in critically ill adult patients. Crossref DOI link: https://doi.org/10.21037/APM-21-2521. Published: 2021-11. Summary of the best evidence for postural change in the prevention of pressure injury in critically ill adult patients – Xue – Annals of Palliative Medicine (amegroups.com)

Useful resources

1. Physiopedia: lllt and wound healing – Search Results – PubMed (nih.gov)
2. National Library of Medicine: Pubmed – lllt and wound healing – Search Results – PubMed (nih.gov)
3. WALT – World Association for Photobiomodualtion Therapy – DOSAGE OF LASER TREATMENT RECOMENDATIONS – WALT | World Association For Photobiomodulation Therapy (waltpbm.org)
4. Swedish Laser Medical Society – www.laser.nu