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

1. ELECTROTHERAPY IN
WOUND HEALING
Dr Sreeraj S R, Ph.D

2. Sreeraj S R
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

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Hemostasis Phase
• Immediate response to injury to prevent blood loss.
• There is;
1. Reflex vasoconstriction
2. 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.
3. 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.

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Inflammatory Phase
• Begins with haemostasis and chemotaxis.
• Both the thrombocytes (platelets) andWBCs 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.

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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.

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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.

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Graphical Representation Three Phases With ApproximateTimeline
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

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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.

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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

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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

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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.

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Wound measurements

13. High Frequency Modalities in
Wound Healing

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

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

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Application
1. Remove dressings and clean
wound
2. 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.
3. A hydro gel sheet should be
placed on top of this.
4. Apply an ultrasonic coupling gel
on top of the sheet.

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Dosimetry
For wound
 Frequency of 3 MHz
 20 % duty cycle
 Intensity usually 0.3 to 0.5
watts/cm2.
 Duration 5 to 10 minutes
For peri wound tissue
 1 MHz, continuous ultrasound.
 Intensity 1 and 1.5 watts/cm2
 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.

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Phonophoresis
 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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PSW
• Goldin et al (1981) list the following as the primary effects of pulsed SW:
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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Dosage
• 25 – 30W
• 20 min.
• Longer pulse duration

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Actinotherapy
1. LASER
2. Ultraviolet

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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 increase in Fibroblast Proliferation, collagen
synthesis and remodeling.
https://www.spineuniverse.com/treatments/physical-therapy/pain-relief-healing-laser-therapy

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Application & Dosimetry
Wound margins
• Direct contact
• 1 – 2 cm from edges
• 4 – 10 j/cm2
Wound bed
• Noncontact
• 1 – 5 j/cm2

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

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26. Electrical Stimulation in
Wound Healing

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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

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Effects of ES
 Up regulates insulin receptors on fibroblasts.
 Up regulation ofTGF-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

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Indications
1. Pressure Ulcers
2. Diabetic ulcers
3. Venous Ulcers
4. TraumaticWounds
5. SurgicalWounds
6. Ischemic Ulcers
7. Donor Sites
8. Wound Flaps
9. Burn wounds

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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)
1. HighVoltage Pulsed current, monophasic
2. LowVoltage Pulsed Current, monophasic/biphasic

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HighVoltage 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

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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.

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Electrotaxis in Electrical Fields

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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

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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

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References
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. PhysicalAgents in Rehabilitation, From Research to Practice, 2nd edition, Michelle H. Cameron, Saunders
Elsevier
9. David Cukjati, Rajmond Savrin. ElectricCurrent Wound Healing.
10. Katheriene Lampe, Electrotherapy inTissue Repair, Journal of HandTherapy, 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