The relationship between pressure offloading and ischial tissue health in individuals with spinal cord injury: An exploratory study.

Objectives: To compare thickness and texture measures of tissue overlying the ischial region in able-bodied (AB) individuals vs. individuals with spinal cord injury (SCI) and to determine if there is a relationship between pressure offloading of the ischial tuberosities (IT) and tissue health in individuals with SCI. Design: Exploratory cross-sectional study. Setting: University setting and rehabilitation hospital. Outcome Measures: Thickness and texture measurements from ultrasound images of tissues overlying the IT were obtained from AB individuals (n = 10) and individuals with complete or incomplete traumatic and non-traumatic SCI American Spinal Injury Association Impairment Scale (AIS) classification A-D (n = 15). Pressure offloading was measured in individuals with SCI and correlated with tissue health measurements. Results: The area overlying the IT occupied by the muscle was significantly greater in the SCI when compared with AB cohort. The area occupied by the muscle in individuals with SCI appeared to lose the striated appearance and was more echogenic than nearby skin and subcutaneous tissue (ST). There was no correlation between offloading times and thickness, echogenicity and contrast measurements of skin, ST and muscle in individuals with SCI. Conclusion: Changes in soft tissues overlying the ischial tuberosity occur following SCI corresponding to the loss of striated appearance of muscle and increased thickness of the area occupied by the muscle. Further studies using a larger sample size are recommended to establish if thickness and tissue texture differ between individuals with SCI who sustain pressure injuries vs. those who do not.

Skin color and tissue thickness effects on transmittance, reflectance, and skin temperature when using 635 and 808 nm lasers in low intensity therapeutics.

OBJECTIVE: To examine the role of skin color and tissue thickness on transmittance, reflectance, and skin heating using red and infrared laser light. METHODS: Forty volunteers were measured for skin color and skin-fold thickness at a standardized site near the elbow. Transmittance, reflectance and skin temperature were recorded for energy doses of 2, 6, 9, and 12 Joules using 635 nm (36 mW) and 808 nm (40 mW) wavelength laser diodes with irradiances within American National Standards Institute safety guidelines (4.88 mm diameter, 0.192 W/cm2 and 4.88 mm diameter, 0.214 W/cm2 , respectively). RESULTS: The key factors affecting reflectance to an important degree were skin color and wavelength. However, the skin color effects were different for the two wavelengths: reflectance decreased for darker skin with a greater decrease for red light than near infrared light. Transmittance was greater using 808 nm compared with 635 nm. However, the effect was partly lost when the skin was dark rather than light, and was increasingly lost as tissue thickness increased. Dose had an increasing effect on temperature (0.7-1.6°C across the 6, 9, and 12 J doses); any effects of wavelength, skin color, and tissue thickness were insignificant compared to dose effects. Subjects themselves were not aware of the increased skin temperature. Transmittance and reflectance changes as a function of energy were very small and likely of no clinical significance. Absorption did not change with higher energy doses and increasing temperature. CONCLUSION: Skin color and skin thickness affect transmittance and reflectance of laser light and must be accounted for when selecting energy dose to ensure therapeutic effectiveness at the target tissue. Skin heating appears not to be a concern when using 635 and 808 nm lasers at energy doses of up to 12 J and irradiance within American National Standards Institute standards. Photobiomodulation therapy should never exceed the American National Standards Institute recommendation for the maximum permissible exposure to the skin. Lasers Surg. Med. 50:291-301, 2018. © 2017 Wiley Periodicals, Inc.

Neuromuscular Electrical Stimulation for Treatment of Muscle Impairment: Critical Review and Recommendations for Clinical Practice.

Purpose: In response to requests from physiotherapists for guidance on optimal stimulation of muscle using neuromuscular electrical stimulation (NMES), a review, synthesis, and extraction of key data from the literature was undertaken by six Canadian physical therapy (PT) educators, clinicians, and researchers in the field of electrophysical agents. The objective was to identify commonly treated conditions for which there was a substantial body of literature from which to draw conclusions regarding the effectiveness of NMES. Included studies had to apply NMES with visible and tetanic muscle contractions. Method: Four electronic databases (CINAHL, Embase, PUBMED, and SCOPUS) were searched for relevant literature published between database inceptions until May 2015. Additional articles were identified from bibliographies of the systematic reviews and from personal collections. Results: The extracted data were synthesized using a consensus process among the authors to provide recommendations for optimal stimulation parameters and application techniques to address muscle impairments associated with the following conditions: stroke (upper or lower extremity; both acute and chronic), anterior cruciate ligament reconstruction, patellofemoral pain syndrome, knee osteoarthritis, and total knee arthroplasty as well as critical illness and advanced disease states. Summaries of key details from each study incorporated into the review were also developed. The final sections of the article outline the recommended terminology for describing practice using electrical currents and provide tips for safe and effective clinical practice using NMES. Conclusion: This article provides physiotherapists with a resource to enable evidence-informed, effective use of NMES for PT practice.

Objectif : en réponse à des demandes de conseils de physiothérapeutes pour optimiser la stimulation musculaire à l'aide de la stimulation électrique neuromusculaire (SENM), une revue, une synthèse et une extraction de données de la littérature ont été entreprises par six formateurs, cliniciens et chercheurs en physiothérapie dans le domaine des agents électrophysiques. L'objectif était de cibler des affections couramment traitées ayant fait l'objet d'une quantité suffisante d'études pour tirer des conclusions concernant l'efficacité de la SENM. Les études devaient porter sur la SENM produisant des contractions musculaires visibles et toniques. Méthodes : quatre bases de données électroniques (CINAHL, Embase, PubMed et Scopus) ont été parcourues à la recherche d'études pertinentes publiées entre la création des bases de données et mai 2015. D'autres articles ont été tirés de bibliographies de revues systématiques et de collections personnelles. Résultats : les données extraites ont été synthétisées par consensus des auteurs en vue de dresser des recommandations sur l'optimisation des paramètres et des techniques d'application de la stimulation dans le traitement de déficits musculaires associés aux affections suivantes: accident vasculaire cérébral (extrémité inférieure ou supérieure; aigu ou chronique), reconstruction du ligament croisé antérieur, syndrome fémoro-rotulien douloureux, arthrose du genou et arthroplastie totale du genou, ainsi que des maladies graves et en stade avancé. Les auteurs fournissent également un résumé des éléments clés de chaque étude incluse dans la revue. Enfin, ils recommandent une nomenclature de l'électrothérapie et présentent des conseils pour l'utilisation sécuritaire et efficace de la SENM. Conclusion : ce document constitue pour les physiothérapeutes une ressource permettant d'appuyer leur utilisation de la SENM sur des données probantes.

Trunk Function and Ischial Pressure Offloading in Individuals with Spinal Cord Injury.

OBJECTIVE: To determine if there is a relationship between trunk function and offloading of the ischial tuberosities in individuals with Spinal Cord Injury (SCI). DESIGN: Prospective cross-sectional evaluation. SETTING: Sub-acute rehabilitation hospital. PARTICIPANTS: Fifteen non-ambulatory participants with complete or incomplete traumatic and non-traumatic SCI, American Spinal Injury Association Impairment Scale (AIS), Classification A-D. OUTCOME MEASURES: Isometric trunk strength using a hand held dynamometer, the ability to reach using the multidirectional reach test and offloading times of the ischial tuberosities using a customized pressure mat. RESULTS: Participants who were able to engage in the multidirectional reach test were defined as "Reachers", whereas individuals who were unable to engage in the multidirectional reach test were defined as "Non-Reachers". Trunk strength was significantly higher in Reachers compared with Non-Reachers (P < 0.05). Offloading times over the left and right ischial tuberosities were lower in Non-Reachers when compared with Reachers, however the results were statistically significant only for offloading over the right ischial tuberosity (P < 0.05). There was no correlation between trunk strength and pressure offloading times for both groups. CONCLUSIONS: Regardless of an individual's ability to engage in a reaching task, participants with spinal cord injury spent more time offloading the left ischial tuberosity compared with the right ischial tuberosity. The study highlights the need to identify factors that may contribute to offloading behavior in individuals with spinal cord injury who lack sufficient trunk strength.

Effects of low intensity laser irradiation during healing of infected skin wounds in the rat.

BACKGROUND AND OBJECTIVE: Low intensity laser irradiation remains a controversial treatment for non-healing wounds. This study examines the effect of low intensity light on healing of infected skin wounds in the rat. MATERIALS AND METHODS: Wounds on the rat dorsum were inoculated with Pseudomonas aeruginosa. Wounds were irradiated or sham-irradiated three times weekly from day 1 to 19 using 635-nm or 808-nm diode lasers delivering continuous wave (CW) or intensity modulated (3800 Hz) laser radiation, all at radiant exposures of 1 and 20 J/cm2. Wound area and bacterial growth on the wound surface were evaluated three times a week. Histological and immunohistochemical analyses were performed at day 8 and 19. RESULTS: Wounds that were irradiated using a wavelength of 635 nm (1 and 20 J/cm2) or intensity modulated 808-nm laser light at 20 J/cm2 were smaller in area at day 19 than the sham-irradiated controls (achieved significance level=0.0105-0.0208) and were similar to controls in respect of bacterial growth. The remaining light protocols had no effect on wound area at day 19 although they increased Staphylococcus aureus growth across the time line compared with controls (p<0.0001 to p<0.004). CW 808-nm light at 20 J/cm2 significantly delayed half-heal time. Histological and immunohistochemical analyses supported wound closure findings: improved healing was associated with faster resolution of inflammation during the acute phase and increased signs of late repair at day 19. Significant inflammation was seen at day 19 in all irradiated groups regardless of radiant exposure, except when using 635 nm at 1 J/cm2. CONCLUSIONS: Red light improved healing of wounds. Only one 808-nm light protocol enhanced healing; lack of benefit using the remaining 808-nm light protocols may have been due to stimulatory effects of the light on S. aureus growth.

Ultraviolet-C irradiation in the management of pressure ulcers in people with spinal cord injury: a randomized, placebo-controlled trial.

OBJECTIVE: To compare the effects of ultraviolet-C (UVC) with placebo-UVC on pressure ulcer healing in individuals with spinal cord injury (SCI). DESIGN: Double-blind randomized trial with stratification for ulcer location to buttock or lower extremity. Subjects were followed up for 1 year postintervention. SETTING: Rehabilitation institution. PARTICIPANTS: Adult inpatients and outpatients (N=43) with SCI and stage 2 to 4 pressure ulcers (n=58). INTERVENTIONS: Ulcers and periwound skin were irradiated 3 times per week using UVC or placebo-UVC. The endpoint was wound closure or hospital discharge without closure. MAIN OUTCOME MEASURES: Primary outcome was weekly percent area relative to baseline. Secondary outcomes were mean percent area change between consecutive weeks, surface appearance, weeks to closure, and impact on quality of life and wound status postintervention. RESULTS: Groups were similar at baseline for all demographic characteristics except ulcer duration (P=.02). Groups were similar when healing was compared overall. Subgroup analysis showed that the percent area relative to baseline for stage 2 buttock ulcers was significantly smaller in the group receiving UVC compared with placebo at weeks 3, 5, and 7. During weeks 1 through 8, these ulcers were 26% to 76% of baseline area using UVC versus 111% to 180% for placebo (achieved significant level [ASL], .03-.08; effect size, 0.5-0.8). Groups were similar in the percent area relative to baseline for stage 2 lower extremity ulcers. Group mean percent area change between consecutive weeks for all stage 2 ulcers was 36.6% with the use of UVC and 5.8% for placebo (ASL=.09). There were no group differences in the percent area relative to baseline and the mean percent area change between consecutive weeks for stage 3 to 4 ulcers. Groups were similar for all other secondary outcomes. CONCLUSIONS: UVC is beneficial for stage 2 buttock ulcers. Further studies are warranted using a larger sample size, carefully considered exclusion criteria, and strategies to ensure homogeneity of the groups that are being compared.

Effects of low intensity laser irradiation during healing of skin lesions in the rat.

OBJECTIVE: To determine whether laser light can improve healing of skin wounds by killing wound bacteria while simultaneously accelerating host tissue activity. MATERIALS AND METHODS: Wounds on the rat dorsum were irradiated or sham-irradiated three times weekly from days 1 to 19 using 635 or 808 nm diode lasers at 1 or 20 J/cm(2). Wound area and bacterial growth were evaluated three times weekly. Histological analysis was performed on days 8 and 19. Immunohistochemical analysis was performed on day 19. RESULTS: Wounds that were irradiated using 635 nm light at 1 J/cm(2) healed similarly to controls. Wounds that were irradiated using 808 nm (1 and 20 J/cm(2), P

Heat shock protein expression in rat skeletal muscle after repeated applications of pulsed and continuous ultrasound.

OBJECTIVE: To determine whether repeated ultrasound treatments are capable of increasing the expression of heat shock protein (HSP) 72 and HSP 25 in rat skeletal muscles. DESIGN: In vivo, experimental, controlled study. SETTING: Animal laboratory. ANIMALS: Male Sprague-Dawley rats (n=9). INTERVENTIONS: Ultrasound (1MHz, 15 min, 2.0 cm2 transducer) continuous at 1.0 W/cm2 spatial average temporal average intensity (CONTUS) or pulsed at 2.0 W/cm2 spatial average temporal peak intensity 50% duty cycle (PULS50) was applied on 4 consecutive days to the lower leg muscles of 1 hindlimb in each rat (n=9). MAIN OUTCOME MEASURES: Twenty-four hours after the final ultrasound application, hindlimb muscles were removed, weighed, and assessed for HSP 72 and HSP 25 content by Western blotting. Bands from blots were quantified and data were assessed using t tests (alpha=.05). RESULTS: Ultrasound did not affect core or contralateral hindlimb muscle temperature. Average muscle temperatures during the final day ultrasound treatments were 38.71 degrees +/-0.30 degrees C when using PULS50 and 38.16 degrees +/-0.57 degrees C when using CONTUS. PULS50 significantly increased HSP 25 content in the plantaris and soleus muscles and HSP 72 content in the plantaris muscles. CONTUS significantly increased HSP 72 content in the white gastrocnemius muscle. CONCLUSIONS: HSPs can be induced in skeletal muscle when ultrasound is used on a repeated basis to treat soft tissue.

Effects of low-level laser therapy (LLLT) of 810 nm upon in vitro growth of bacteria: relevance of irradiance and radiant exposure.

OBJECTIVE: The aim of this study was to investigate the irradiance-dependency of low-level laser therapy (LLLT) effects on bacterial growth. BACKGROUND: LLLT is applied to open wounds to improve healing; however, its effect on wound bacteria is not well understood. MATERIALS AND METHODS: Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus were irradiated using a wavelength of 810 nm at irradiances of 0.015 W/cm2 (0-50 J/cm2) and 0.03 W/cm2 (0-80 J/cm2). Bacteria were counted after 20 h of incubation. RESULTS: LLLT effects varied significantly with species. P.aeruginosa growth decreased overall dependent on an interaction of irradiance and radiant exposure; greatest inhibition was produced using high irradiance delivering radiant exposures in the range of 1-20 J/cm2 (p = 0.001-0.04). In contrast, E. coli growth increased overall (p = 0.01), regardless of irradiance; greatest effects were produced using low radiant exposures (1-20 J/cm2). There was a main effect for irradiance (p = 0.03) on S. aureus growth; however, growth was not different compared with controls. Additional analysis showed that there were differences in growth of P.aeruginosa when comparing samples that were matched by exposure times (66, 329, 658, 1316, 1974, and 2632 sec) rather than radiant exposure; this suggests that irradiance rather than exposure time was the significant factor in P. aeruginosa inhibition. CONCLUSION: These findings have immediate relevancy in the use of LLLT for infected wounds. Exposure to 810-nm irradiation (0.03 W/cm2) could potentially benefit wounds infected with P. aeruginosa. However, increased E. coli growth could further delay recovery.

Effects of 810 nm laser irradiation on in vitro growth of bacteria: comparison of continuous wave and frequency modulated light.

BACKGROUND AND OBJECTIVES: Low intensity laser therapy may modify growth of wound bacteria, which could affect wound healing. This study compares the effects on bacteria of 810 nm laser using various delivery modes (continuous wave or frequency modulated light at 26, 292, 1000, or 3800 Hz). STUDY DESIGN/MATERIALS AND METHODS: Staphylococcus (S.) aureus, Escherichia (E.) coli, and Pseudomonas (P.) aeruginosa were plated on agar and then irradiated (0.015 W/cm(2); 1-50 J/cm(2)) or used as controls (sham irradiated); growth was examined after 20 hours of incubation post exposure. RESULTS: There were interactions of species and modulation frequency in the overall effects of irradiation (P = 0.0001), and in the radiant exposure mediated effects (P = 0.0001); thus individual frequencies and each bacterium were analysed separately. Bacteria increased following 3800 Hz (P = 0.0001) and 1000 Hz (P = 0.0001) pulsed irradiation; at particular radiant exposures P. aeruginosa proliferated significantly more than other bacteria. Pulsed laser at 292 and 26 Hz also produced species-dependent effects (P = 0.0001; P = 0.0005); however, the effects for different radiant exposures were not significant. Bacterial growth increased overall, independent of species, using continuous mode laser, significantly so at 1 J/cm(2) (P = 0.02). Analysis of individual species demonstrated that laser-mediated growth of S. aureus and E. coli was dependent on pulse frequency; for S. aureus, however, there was no effect for different radiant exposures. Further tests to examine the radiant exposure effects on E. coli showed that growth increased at a frequency of 1000 Hz (2 J/cm(2); P = 0.03). P. aeruginosa growth increased up to 192% using pulsed irradiation at 1000-3800 Hz; whereas 26-292 Hz laser produced only a growth trend. CONCLUSIONS: The findings of this study point to the need for wound cultures prior to laser irradiation of infected wounds. Similar investigations using other common therapeutic wavelengths are recommended.

Effects of 630-, 660-, 810-, and 905-nm laser irradiation delivering radiant exposure of 1-50 J/cm2 on three species of bacteria in vitro.

OBJECTIVE: To examine the effects of low-intensity laser therapy (LILT) on bacterial growth in vitro. BACKGROUND DATA: LILT is undergoing investigation as a treatment for accelerating healing of open wounds. The potential of coincident effects on wound bacteria has received little attention. Increased bacterial proliferation could further delay recovery; conversely inhibition could be beneficial. MATERIALS AND METHODS: Pseudomonas aeruginosa, Escherichia coli, and Staphylococcus aureus were plated on agar and then irradiated with wavelengths of 630, 660, 810, and 905 nm (0.015 W/cm(2)) and radiant exposures of 1-50 J/cm(2). In addition, E. coli was irradiated with 810 nm at an irradiance of 0.03 W/cm(2) (1-50 J/cm(2)). Cells were counted after 20 h of incubation post LILT. Repeated measures ANOVA and Tukey adjusted post hoc tests were used for analysis. RESULTS: There were interactions between wavelength and species (p = 0.0001) and between wavelength and radiant exposure (p = 0.007) in the overall effects on bacterial growth; therefore, individual wavelengths were analyzed. Over all types of bacteria, there were overall growth effects using 810- and 630-nm lasers, with species differences at 630 nm. Effects occurred at low radiant exposures (1-20 J/cm(2)). Overall effects were marginal using 660 nm and negative at 905 nm. Inhibition of P. aeruginosa followed irradiation using 810 nm at 5 J/cm(2) (-23%; p = 0.02). Irradiation using 630 nm at 1 J/cm(2) inhibited P. aeruginosa and E. coli (-27%). Irradiation using 810 nm (0.015 W/cm(2)) increased E. coli growth, but with increased irradiance (0.03 W/cm(2)) the growth was significant (p = 0.04), reaching 30% at 20 J/cm(2) (p = 0.01). S. aureus growth increased 27% following 905-nm irradiation at 50 J/cm(2). CONCLUSION: LILT applied to wounds, delivering commonly used wavelengths and radiant exposures in the range of 1-20 J/cm(2), could produce changes in bacterial growth of considerable importance for wound healing. A wavelength of 630 nm appeared to be most commonly associated with bacterial inhibition. The findings of this study might be useful as a basis for selecting LILT for infected wounds.