Effects of 35 kHz, low-frequency ultrasound application in vitro on human fibroblast morphology and migration patterns.

Low-frequency ultrasound (LFU) in the frequency range 30-40 kHz administered using different delivery methods (waterbath and noncontact spray) has shown positive effects on chronic wound healing rates in humans, but the underlying mechanisms are only beginning to be explored. To examine the effects of LFU delivered at 35 kHz on the morphology and migration of human fibroblasts, real-time videography was used to record the rate and character of cultured human fibroblast migration at 8-hour increments for 48 hours in a wound assay model. Cells were treated with 35 kHz LFU or saline only (control). Cellular morphology (cell shape, packing, and apparent length) and migration patterns including orientation were analyzed using time-lapse videography. LFU delivered at a frequency of 35 kHz produced a different pattern of fibroblast migration in vitro (varied orientation versus vertical orientation for untreated cells) and altered cell morphology compared to controls. The observed pattern of migration was more varied and widely distributed across multiple angles versus the predominant parallel orientation of the migrating untreated cells. The potential implications of these findings on collagen placement in the extracellular matrix, which may affect degree of soft tissue scarring, should be further investigated.

Chronic wound repair and healing in older adults: current status and future research.

Older adults are more likely to have chronic wounds than younger people, and the effect of chronic wounds on quality of life is particularly profound in this population. Wound healing slows with age, but the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood. Most studies have used in vitro approaches and various animal models, but observed changes translate poorly to human healing conditions. The effect of age and accompanying multimorbidity on the effectiveness of existing and emerging treatment approaches for chronic wounds is also unknown, and older adults tend to be excluded from randomized clinical trials. Poorly defined outcomes and variables; lack of standardization in data collection; and variations in the definition, measurement, and treatment of wounds also hamper clinical studies. The Association of Specialty Professors, in conjunction with the National Institute on Aging and the Wound Healing Society, held a workshop, summarized in this article, to explore the current state of knowledge and research challenges, engage investigators across disciplines, and identify research questions to guide future study of age-associated changes in chronic wound healing.

Use of silicone materials to simulate tissue biomechanics as related to deep tissue injury.

OBJECTIVE: Deep tissue injury (DTI) is caused by prolonged mechanical loading that disrupts blood flow and metabolic clearance. A patient simulator that mimics the biomechanical aspects of DTI initiation, stress and strain in deep muscle tissue, would be potentially useful as a training tool for pressure-relief techniques and testing platform for pressure-mitigating products. As a step toward this goal, this study evaluates the ability of silicone materials to mimic the distribution of stress in muscle tissue under concentrated loading. METHODS: To quantify the mechanical properties of candidate silicone materials, unconfined compression experiments were conducted on 3 silicone formulations (Ecoflex 0030, Ecoflex 0010, and Dragon Skin; Smooth-On, Inc, Easton, Pennsylvania). Results were fit to an Ogden hyperelastic material model, and the resulting shear moduli (G) were compared with published values for biological tissues. Indentation tests were then conducted on Ecoflex 0030 and porcine muscle to investigate silicone's ability to mimic the nonuniform stress distribution muscle demonstrates under concentrated loading. Finite element models were created to quantify stresses throughout tissue depth. Finally, a preliminary patient simulator prototype was constructed, and both deep and superficial "tissue" pressures were recorded to examine stress distribution. RESULTS: Indentation tests showed similar stress distribution trends in muscle and Ecoflex 0030, but stress magnitudes were higher in Ecoflex 0030 than in porcine muscle. All 3 silicone formulations demonstrated shear moduli within the range of published values for biological tissue. For the experimental conditions reported in this work, Ecoflex 0030 exhibited greater stiffness than porcine muscle. CONCLUSION: Indentation tests and the prototype patient simulator trial demonstrated similar trends with high pressures closest to the bony prominence with decreasing magnitude toward the interfacial surface. Qualitatively, silicone mimicked the phenomenon observed in muscle of nonuniform stress under concentrated loading. Although shear moduli were within biological ranges, stress and stiffness values exceeded those of porcine muscle. This research represents a first step toward development of a preclinical model simulating the biomechanical conditions of stress and strain in deep muscle, since local biomechanical factors are acknowledged to play a role in DTI initiation. Future research is needed to refine the capacity of preclinical models to simulate biomechanical parameters in successive tissue layers of muscle, fat, dermis, and epidermis typically intervening between bone and support surfaces, for body regions at risk for DTI.

Chronic wound repair and healing in older adults: current status and future research.

The incidence of chronic wounds is increased among older adults, and the impact of chronic wounds on quality of life is particularly profound in this population. It is well established that wound healing slows with age. However, the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood. Most studies have used in vitro approaches and various animal models, but observed changes translate poorly to human healing conditions. The impact of age and accompanying multi-morbidity on the effectiveness of existing and emerging treatment approaches for chronic wounds is also unknown, and older adults tend to be excluded from randomized clinical trials. Poorly defined outcomes and variables, lack of standardization in data collection, and variations in the definition, measurement, and treatment of wounds also hamper clinical studies. The Association of Specialty Professors, in conjunction with the National Institute on Aging and the Wound Healing Society, held a workshop, summarized in this paper, to explore the current state of knowledge and research challenges, engage investigators across disciplines, and identify key research questions to guide future study of age-associated changes in chronic wound healing.

Priorities, strategies, and accountability measures in interprofessional education.

PURPOSE: The purpose of this pilot study was to identify the priorities, strategies, and accountability measures for interprofessional education (IPE) being used by health professions programs, allied health colleges, and/or universities. METHOD: An electronic survey was sent to 114 deans, associate deans, and directors (program, clinical education, graduate studies) at six institutions with allied health programs, including three academic medical centers and three comprehensive public institutions. The survey consisted of basic demographic questions and questions assessing knowledge of the Interprofessional Education Collaborative (IPEC) concepts of IPE, program-specific accreditation requirements for IPE, and institutional priorities, strategies, and accountability measures for IPE activities. RESULTS: An overall response rate of 50% (57/114) was achieved with representation from a total of 34 different allied health programs. Chi-squared statistics showed statistically significant differences (p<0.05) between the frequencies of survey responses and institutional types in the inclusion of IPE in the college/school's vision, the physical space available to accommodate IPE needs, and the commitment to set aside time for IPE. CONCLUSION: This study found that there is not a clear mandate or direction from most allied health disciplinary accrediting bodies for IPE. While there appears to be distinct movement by institutions to hold programs accountable for IPE and to integrate IPE into the curricula, barriers remain that have slowed the desired degree of implementation of an interprofessional curricula. While institutions, college, and/or programs may be slow to formally include IPE in its vision, this study found that, in general, support is being provided for IPE activities.

The Topical Evolution: Free Ions, Orthomolecular Agents, Phytochemicals, and Insect-Produced Substances.

Significance: A variety of topical antiseptic substances have been used historically to treat open wounds with suspected tissue infection or that are slow to heal. However, the effectiveness of these substances in treating infected or recalcitrant wounds remains controversial. Recent Advances: Newly formulated topical antiseptics delivered through differing dressing technologies, such as ionic substances, hold the potential to limit the development of and treat antibiotic-resistant microbes in open wounds. Other topically delivered substances, such as insect-derived substances, orthomolecular agents, and phytochemicals, also present opportunities to optimize wound healing by decreasing tissue bioburden and facilitating the wound healing process. Critical Issues: Limited systemic perfusion of open wounds in individuals with certain diagnoses, such as peripheral arterial disease or necrotizing infection and the increasing number of antibiotic-resistant wound pathogens, suggests a continued role for topically applied antiseptic agents. Likewise, the failure of wounds to heal when treated with standard of care therapy opens the door to innovative treatment approaches that include the natural substances described in this article. Future Directions: Evidence for the use of select topical antiseptic agents from each of the aforementioned categories will be discussed in this article. Additional well-controlled clinical studies are needed to provide definitive recommendations for many of these topical agents.

Overview of guidelines for the prevention and treatment of venous leg ulcers: a US perspective.

Comprehensive care of chronic venous insufficiency and associated ulcers requires a multipronged and interprofessional approach to care. A comprehensive treatment approach includes exercise, nutritional assessment, compression therapy, vascular reconstruction, and advanced treatment modalities. National guidelines, meta-analyses, and original research studies provide evidence for the inclusion of these approaches in the patient plan of care. The purpose of this paper is to review present guidelines for prevention and treatment of venous leg ulcers as followed in the US. The paper further explores evidence-based yet pragmatic tools for the interprofessional team to use in the management of this complex disorder.

mobilityRERC state of the science conference: Individualizing pressure ulcer risk and prevention strategies.

UNLABELLED: Pressure ulcers (PUs) remain a costly and, often avoidable, complication of full time wheelchair use. Clinicians routinely evaluate PU risk to assist in selecting devices and interventions that may prevent PUs from occurring. Clinical assessment of risk can be evaluated in many different manners, both formally and informally and, typically, is based on combinations of demographic, disability and client-reported behavioral factors. Many of these factors add to PU risk because they impact the physiology and/or biomechanics of the skin and tissue. This article results from a presentation during the Wheeled Mobility Rehabilitation Engineering Research Center's (RERC's) State of the Science Conference in 2012. The presentation's purpose was to present issues and concepts related to pressure ulcer prevention and set the stage for group discussion which followed the presentation. This article progresses through the current state of the science related to PU risk, starting with the tissue and cellular changes resulting from pressure, through the impact that external loading has on blood flow and tissue deformation, and ending with clinical assessment of risk based upon demographic and behavioral factors. IMPLICATIONS FOR REHABILITATION: Factors leading to the development of PUs are numerous and varied, but the defining factor is excessive external loading or pressure on the skin. The amount of pressure needed to cause tissue damage varies widely within and across individuals--based on anatomy and the presence or absence of bony structures under the area of interest, tissue stiffness and other individual characteristics, and most importantly--the amount of tissue deformation that occurs. Clinicians routinely evaluate wheelchair users with respect to pressure ulcer risk, however, objective risk measurements that inform prescription are not readily available. A need exists to provide clinicians with objective measurements of pressure ulcer risk that can inform individualized interventions.

Using simulation and patient role play to teach electrocardiographic rhythms to physical therapy students.

PURPOSE: THE AIMS OF THE STUDY WERE TO DIFFERENTIATE: (1) physical therapy (PT) students' preferred method for learning electrocardiographic (ECG) recognition utilizing standardized patient (SP) and human patient simulation (HPS) approaches, (2) the impact of HPS or SP on confidence in interpreting ECG, and 3) the effect of HPS or SP on students' ability to make clinical decisions based upon ECG interpretation. METHODS: "Three educational methods were employed to teach ECG recognition to two different years of novice PT students enrolled in a cardiopulmonary physical therapy class. First, all students had a traditional lecture on ECG. Following the lecture, two problem-based learning (PBL) approaches were utilized. One approach used a SP and paper ECG strips, and the second approach utilized HPS with simulated ECG monitoring."(1) Following the two PBL approaches, a post instructional survey regarding the learning experiences was conducted. Following instruction, each cohort (n = 24, n = 29) of PT students was given a mixed methods survey about their experience. RESULTS: Survey return rate amongst both cohorts was 77%. Independent sample of individual cohort and paired t-tests of combined data comparing HPS to SP revealed a strong preference for HPS (p = 0.003 (2008 cohort) and p = 0.0001 (2010 cohort)) and combined cohort (p = 0.0001). There were no significant differences in responses between cohorts or preference between the HPS method and the use of SP and HPS combined. Additionally, 75% of respondents either strongly agreed or agreed that they felt confident with their skill in ECG interpretation as presented with HPS or SP. 90% either strongly agreed or agreed that they understood how the ECG relates to patient treatment. Summative assessment utilizing HPS revealed that students were competent in their performance in ECG recognition and clinical decision making related to patient treatment.(1) CONCLUSION: Data support that HPS was the preferred method to improve student confidence in ECG recognition and interpretation.

Retrospective analysis of pulsed radiofrequency energy therapy use in the treatment of chronic pressure ulcers.

OBJECTIVE: : The purpose of the study was to evaluate the benefit of using pulsed radiofrequency energy (PRFE) therapy in the treatment of chronic pressure ulcers. DESIGN: : A retrospective analysis was performed using case series data from the Provant Wound Registry, which consists of demographic characteristics and wound healing outcomes for patients treated with the Provant Therapy System. SETTING: : The analysis subset consisted of data from 39 distinct centers, including both residential and ambulatory care facilities. PARTICIPANTS: : The analysis included data from 89 patients. The majority of patients (89%) were cared for in residential facilities, whereas 11% of patients were cared for in ambulatory care facilities. MAIN OUTCOME MEASURES: : Specific outcomes that assessed wound healing between the initial time point and at the 4-week follow-up were as follows: percent wound surface area reduction (PWAR), proportion of wounds achieving 50% reduction or greater in wound surface area (50% PWAR), and the rate of wound healing (wound healing trajectory in centimeters squared per day). MAIN RESULTS: : Overall, there was a 51% median reduction in wound surface area (PWAR) after 4 weeks of PRFE therapy for wounds in the study, with 51% of wounds (56/110) achieving 50% reduction or greater in wound surface area (50% PWAR). Rate of healing measurements for the overall study group showed a median wound healing trajectory of 0.13 cm/d at 4 weeks. CONCLUSION: : Compared with historical controls and other studies using similar surrogate wound healing markers, these results suggest PRFE therapy is a beneficial adjuvant treatment option for healing chronic pressure ulcers.

The effects of low-frequency ultrasound (35 kHz) on methicillin-resistant Staphylococcus aureus (MRSA) in vitro.

Scanning electron microscopy study results support an in vitro bactericidal effect of low-frequency ultrasound (LFU) delivered at 40 kHz on bacteria, including methicillin-resistant Staphylococcus aureus (MRSA). The purpose of this in vitro study was to determine the effects of LFU delivered at 35 kHz on bacterial viability, cell wall structure, and colony characteristics, including antibiotic resistance on vegetative forms of MRSA. A known MRSA isolate from a patient lower extremity wound was subcultured, plated, and grown on sheep blood agar (SBA). Serial dilutions of the organisms were made and treated with LFU for 30, 60, and 180 seconds. One hundred microliters (microL) of control (untreated organisms) and treated samples were inoculated to SBA in triplicate and three separate experiments were conducted. Using standard microbiological techniques, a reduction in MRSA from 1 million colony forming units (CFU) at baseline to 6 CFU after 30 seconds of treatment with 35 kHz was observed. MRSA plated at 108 CFU and treated with 35 kHz showed a 44.1% viability with flow cytometry, compared to 92.5% viability of untreated control MRSA. Changes in pigmentation, odor, colony size, and hemolysis pattern also were observed in the LFU-treated bacteria. The effect of LFU on methicillin resistance was dose-dependent; the zone of inhibition increased from 6 mL at baseline to 14.3 mL after 30, 16.7 after 60, and 20.3 after 180 seconds of treatment. The results suggest that, in this in vitro model, 35-kHz LFU reduces CFU of bacteria, punctures and fractures cell walls, and alters colonial characteristics of MRSA, including resistance to the oral form of methicillin. Studies to elucidate the observed effects of LFU on MRSA and evaluate its effect in vivo are warranted.

An overview of tissue types in pressure ulcers: a consensus panel recommendation.

Pressure ulcer assessment is usually performed at the bedside by a clinician with minimal training in wound assessment. A multidisciplinary panel of United States' wound experts was assembled to provide anatomically accurate and practical terms associated with pressure ulcer assessment, healing, and nonhealing in order to help clinicians identify and describe tissue types and pressure ulcer stages. Specifically, anatomical markers and/or structures within the wound are described to facilitate tissue type identification and pressure ulcer staging. The panel agreed that the provision of a common language facilitates quality care across settings. Although some research has been conducted, additional studies to determine the validity and reliability of wound assessment and healing terms and definitions, as well as pressure ulcer staging systems, are needed.

Ultrasound therapy for recalcitrant diabetic foot ulcers: results of a randomized, double-blind, controlled, multicenter study.

An estimated 15% of patients with diabetes will develop a foot ulcer sometime in their life, making them 30 to 40 times more likely to undergo amputation due to a non-healing foot ulcer than the non-diabetic population. To determine the safety and efficacy of a new, non-contact, kilohertz ultrasound therapy for the healing of recalcitrant diabetic foot ulcers - as well as to evaluate the impact on total closure and quantitative bacterial cultures and the effect on healing of various levels of sharp/surgical debridement - a randomized, double-blinded, sham-controlled, multicenter study was conducted in hospital-based and private wound care clinics. Patients (55 met criteria for efficacy analysis) received standard of care, which included products that provide a moist environment, offloading diabetic shoes and socks, debridement, wound evaluation, and measurement. The "therapy" was either active 40 KHz ultrasound delivered by a saline mist or a "sham device" which delivered a saline mist without the use of ultrasound. After 12 weeks of care, the proportion of wounds healed (defined as complete epithelialization without drainage) in the active ultrasound therapy device group was significantly higher than that in the sham control group (40.7% versus 14.3%, P = 0.0366, Fisher's exact test). The ultrasound treatment was easy to use and no difference in the number and type of adverse events between the two treatment groups was noted. Of interest, wounds were debrided at baseline followed by a quantitative culture biopsy. The results of these cultures demonstrated a significant bioburden (greater than 10(5)) in the majority of cases, despite a lack of clinical signs of infection. Compared to control, this therapeutic modality was found to increase the healing rate of recalcitrant, diabetic foot ulcers.

Chronic fall risk among aged individuals with type 2 diabetes.

Falls in the elderly are common and a frequent source of injury. Chronic fall risk factors were evaluated in aging individuals with type 2 diabetes from two different settings--an urban day care center (age range: 57 to 83 years) and a rural community center (age range: 62 to 97 years). Six fall-related risk factors were studied: client history/subjective assessment of fall history, daily medication intake, number of medical diagnoses, balance (Tinetti Balance and Gait Tool), lower extremity protective sensation (Semmes-Weinstein monofilament testing), and relaxed gait velocity (timed functional walk test). Both groups demonstrated a high risk for chronic falling with a mean of 4.8 and 4.0 risk factors present in individuals from the urban day care center and the rural community center, respectively. No differences between clients in the two centers with respect to number of medications and comorbidities were found. In both groups, > 50% of individuals reported a history of falling. Loss of protective sensation was detected in 100% of the individuals from the urban day care center compared to 67% in the rural community center. Similarly, 40% of the individuals from the urban day care center demonstrated impaired balance as compared to 29% from the rural community center. A similar ratio of impaired balance to loss of lower extremity protective sensation was demonstrated across the two groups. These data indicate a potential relationship between loss of protective sensation and impaired balance. These findings also indicate that individuals in urban and rural community settings share similar risk factors for chronic falling.