The wound healing trajectory and predictors with combined electric stimulation and conventional care: one outpatient wound care clinic's experience.

BACKGROUND: Electric stimulation (E-stim) has been found to be an effective treatment in improving wound healing rates. However, the wound healing trajectory and its related predictors for complete wound closure (CWC) have not been reported with E-stim treatment. MATERIALS AND METHODS: This was a retrospective study. Data on 159 patients treated at an outpatient wound clinic utilizing combined intervention of E-stim and conventional care were included. The Kaplan-Meier healing curve together with linear regression models depicted the percentage of patients with CWC against time. RESULTS: With 100, 112 and 140 days of treatment, the percentages of patients with CWC were 59·12%, 61·01% and 65·41%, respectively. Linear regression models predicted that all patients would achieve CWC by 21·55, 22·26 and 24·80 weeks, respectively. The speed for the increase in the number and percentage of patients with CWC peaked between 50-75 days of treatment. To optimize timely healing, referral to other treatment facilities or change of treatment protocol is warranted around the peak time. With the combined intervention of E-stim and conventional care, positive predictors for CWC included a shorter wound duration at initial evaluation (P = 0·005, OR = 3·10), better compliance with appointments (P = 0·007, OR = 3·38) and the diagnosis of venous leg ulcer (P = 0·001, OR = 3·88). CONCLUSIONS: This study provided preliminary data on wound healing trajectory and predictors with combined E-stim and conventional care. E-stim seemed to expedite wound healing; however, further research studies are needed.

Physical Therapy in Wound Care: A Cost-Effectiveness Analysis.

Management of chronic wounds remains unsatisfactory in terms of treatment cost and time required for complete wound closure (CWC).This study aimed to calculate the healing rates, estimated cost, and time required for CWC in wounds; compare estimated wound care costs between healing and nonhealing wounds; and compare cost effectiveness between venous leg ulcer (VLU) and non-VLU.This was a retrospective cohort study performed at a physical therapy (PT) wound care clinic. Deidentified patient data in the electronic medical database from September 10, 2012 to January 23, 2015 were extracted.Among 159 included patients with wounds, 119 (74.84%) patients were healed with CWC. The included patients were treated for 109.70 ±â€Š95.70 days, 29.71 ±â€Š25.66 visits, and at the costs per treatment episode of $1629.65 ±â€Š1378.82 per reimbursement rate and $2711.42 ±â€Š2356.81 per breakeven rate. For patients with CWC (healing group), the treatment duration was 98.01 ±â€Š76.12 days with the time for CWC as 72.45 ±â€Š64.21 days; the cost per treatment episode was $1327.24 ±â€Š1143.53 for reimbursement rate and $2492.58 ±â€Š2106.88 for breakeven cost. For patients with nonhealing wounds, treatment duration was found to be longer with costs significantly higher (P < 0.01 for all). In the healing group, no differences were found between VLU and non-VLU in treatment duration (95.46 days vs. 100.88 days, P = 0.698), time for CWC (68.06 days vs. 77.38 days, P = 0.431), and cost ($2756.78 vs. 2397.84 for breakeven rate, P = 0.640) with the exception of wound dressing costs ($329.19 vs. 146.47, P = 0.001).Healing rates may be affected with patient exclusions. Costs at physicians' offices were not included.Incorporation of PT in wound care appeared to be cost effective. PT may thus be a good referral option for patients with wounds. However, the results should be interpreted cautiously and further studies are warranted.

Dry needling versus acupuncture: the ongoing debate.

Although Western medical acupuncture (WMA) is commonly practised in the UK, a particular approach called dry needling (DN) is becoming increasingly popular in other countries. The legitimacy of the use of DN by conventional non-physician healthcare professionals is questioned by acupuncturists. This article describes the ongoing debate over the practice of DN between physical therapists and acupuncturists, with a particular emphasis on the USA. DN and acupuncture share many similarities but may differ in certain aspects. Currently, little information is available from the literature regarding the relationship between the two needling techniques. Through reviewing their origins, theory, and practice, we found that DN and acupuncture overlap in terms of needling technique with solid filiform needles as well as some fundamental theories. Both WMA and DN are based on modern biomedical understandings of the human body, although DN arguably represents only one subcategory of WMA. The increasing volume of research into needling therapy explains its growing popularity in the musculoskeletal field including sports medicine. To resolve the debate over DN practice, we call for the establishment of a regulatory body to accredit DN courses and a formal, comprehensive educational component and training for healthcare professionals who are not physicians or acupuncturists. Because of the close relationship between DN and acupuncture, collaboration rather than dispute between acupuncturists and other healthcare professionals should be encouraged with respect to education, research, and practice for the benefit of patients with musculoskeletal conditions who require needling therapy.

Chronic and non-healing wounds: The story of vascular endothelial growth factor.

The pathophysiology of the chronicity and non-healing status of wounds remains unknown. This paper presents the following hypothesis: abnormal patterns of vascular endothelial growth factor receptors (VEGFRs) are the culprits of wound chronicity and non-healing. More specifically, for patients with poor circulation, the decreased VEGFR-2 level is the cause of poor wound healing; for patients with non-compromised circulation, for example, patients with concurrent chronic wounds and active autoimmune diseases, the increased VEGFR-1 level is related to the non-healing status of wounds. The hypothesis is supported by the following facts. VEGFR-1 is the main contributor for inflammation and VEGFR-2 facilitates angiogenesis; soluble VEGFR-1 (sVEGFR-1) inactivates both VEGFR-1 and VEGFR-2. Patients with auto-immune disease have abnormally increased VEGFR-1 and decreased sVEGFR. Wounds in patients with active autoimmune diseases have poor response to electric stimulation which facilitates chronic wound healing in patients without active autoimmune diseases via increasing vascular endothelial growth factor (VEGF) secretion. Patients with chronic wounds (including diabetic foot ulcers and venous leg ulcers) but no active autoimmune diseases have decreased VEGFR-2 levels. We thus believe that abnormal patterns of VEGFRs are the culprits of wound chronicity and non-healing. For wounds with compromised circulation, VEGFR-2 decrease contributes to its chronicity; whereas for wounds with non-compromised circulation, VEGFR-1 increase is the leading cause of the non-healing status of chronic wounds. Treatments and research in wound care should be tailored to target these changes based on circulation status of wounds. Complete elucidation of changes of VEGFRs in chronic and non-healing wounds will enhance our understandings in tissue healing and thus better our selection of appropriate treatments for chronic and non-healing wounds.

Management of a Dehisced Hand Wound Using Hydrogen Peroxide, Electrical Stimulation, Silver-containing Dressings, and Compression: A Case Study.

Wound dehiscence is the separation of a wound along surgical sutures. A 57-year-old, otherwise healthy mechanic presented with a large open wound of >1 month duration on his left hand. His wound had dehisced after treatment that involved cleansing, surgical sutures, and oral antibiotics. He presented with a 5.0 cmx0.7 cmx0.3 cm lesion through the palmar creases of the hand with edema around the fourth and fifth digits and a callous formation around the distal portion of the wound. The wound had scant serosanguinous drainage and some induration at the periwound area, as well as a moderate foul odor. Tendons were not affected, but function was limited, the hand was painful, and the patient had been unable to work. Treatment was initiated with twice-a-week immersion of the hand in hydrogen peroxide diluted with water subjected to high-voltage pulsed current electric stimulation (HVPC). The wound was dressed with silver-containing dressings secured with stretch gauze and a compression garment. The wound was completely closed after 9 visits (35 days). No functional limitations of the hand or fingers, no cosmetic defect, and no wound recurrence were noted 9 months after healing. Although uncommon, dehisced wounds, especially in certain anatomical locations such as the hand, can be difficult to heal and may cause long-term problems with functioning. The treatment combination facilitated expedient healing of this dehisced hand wound. Research is needed to help elucidate the observations from this case study.

Oriental medicine and chronic wound care: theory, practice, and research .

In East Asian countries, oriental medicine (OM) has been used for thousands of years to manage a wide variety of chronic wounds, but in western countries the role of OM in wound care remains to be established. To summarize current practices and available evidence of OM in the management of chronic wounds, a search of Chinese and English databases was conducted and summarized with an emphasis on randomized controlled trials, clinical trials, and meta-analyses of topical and systemic OM treatments. Hundreds of reports were identified, mostly in the Chinese literature, but few randomized controlled clinical studies have been conducted. Available preclinical and clinical evidence suggests there may be a role for OM modalities, especially herbal medicine, in the management of chronic wounds. Before conducting the needed rigorous clinical studies, wound care experts should agree on and help standardize herbal formulations - a unique challenge for the usually individualized OM approach to care. However, the literature suggests uncovering pathways for future research may help patients all over the world benefit from the thousands of years of documented experience managing chronic wounds with OM.

Analysis of the proteomic profile of chronic pressure ulcers.

Analysis of the proteomic profile of pressure ulcers over time is a critical step in the identification of biomarkers of healing or nonhealing in pressure ulcers. The wound fluid from 32 subjects with 42 pressure ulcers was evaluated over 6 weeks at 15 time points. Samples specific to both the interior and the periphery of the wound bed were collected. Antibody screening arrays, isobaric tags for relative and absolute quantitation with mass spectrometry and multiplexed microarrays were used to characterize wound fluid and results were correlated with clinical outcome. Twenty-one proteins were found to distinguish between healed and chronic wounds and 19 proteins were differentially expressed between the interior and periphery of wounds. Four proteins, pyruvate kinase isozymes M1/M2, profilin-1, Ig lambda-1 chain C regions, and Ig gamma-1 chain C region, were present in lower levels for periphery samples when compared to interior samples and six proteins, keratin, type II cytoskeletal 6A (KRT6A), keratin, type I cytoskeletal 14, S100 calcium binding proteins A7, alpha-1-antitrypsin precursor, hemoglobin subunit alpha, and hemoglobin subunit beta, were present in higher levels in periphery samples when compared with interior samples. S100 calcium binding protein A6, S100 calcium binding protein A7, and soluble receptor for advanced glycation end-products had higher levels in the periphery of chronic wounds vs. the interior in planar arrays. A significant temporal trend was noted for monokine induced by gamma interferon (MIG), synonomous with chemokine (C-X-C motif) ligand 9 (CXCL9), which increased as wounds healed and remained nearly constant for ulcers that were not approaching closure.

Analysis of pressure ulcer wound fluid using two-dimensional electrophoresis.

The incidence rate of pressure ulcers in the USA ranges from 0.4% to 38% in acute care settings and from 2.2% to 23.9% in long-term care settings, and their treatment costs are in the billions of dollars yearly. The proteome of wound fluid may contain early indicators or biomarkers associated with healing in pressure ulcers that would enable treatment regimes to be optimised for each individual. Wound fluid was collected from the interior and periphery of 19 chronic pressure ulcers at 15 time points during 42 days for an analysis of protein expression. Proteins were fractionated using two-dimensional polyacrylamide gel electrophoresis. A comparison of the spot distributions indicates a biochemical difference between the interior and the periphery of wounds. Pressure ulcers that healed show a greater number of spots for interior and peripheral locations combined over time when compared with wounds that did not heal. Using this technique, protein S100A9 was identified as a potential biomarker of wound healing. The identification of differences within the proteome of healing versus non healing pressure ulcers could have great significance in the use of current treatments, as well as the development of new therapeutic interventions.

Low-voltage direct current as a fungicidal agent for treating onychomycosis.

Onychomycosis, most commonly caused by two species of dermatophyte fungi--Trichophyton rubrum and Trichophyton mentagrophytes--is primarily treated with regimens of topical and systemic antifungal medications. This study was undertaken to evaluate in vitro the efficacy of low-voltage direct current as an antifungal agent for treating onychomycosis. Agar plate cultures of T rubrum and T mentagrophytes were subjected to low-voltage direct current electrostimulation, and antifungal effects were observed as zones in the agar around the electrodes lacking fungal growth. Zones devoid of fungal growth were observed for T rubrum and T mentagrophytes around anodes and cathodes in a dose-dependent manner in the current range of 500 microA to 3 mA. Low-voltage direct current electrostimulation has great clinical potential for the treatment of onychomycosis and perhaps other superficial maladies of fungal etiology.

Topical hyperbaric oxygen and electrical stimulation: exploring potential synergy.

Treatment of chronic wounds involves interventions ranging from dressings to surgery. Modalities gaining popularity in clinical settings include topical hyperbaric oxygen and electrical stimulation. A prospective, uncontrolled study was conducted to obtain preliminary observations and data about the effects of topical hyperbaric oxygen therapy and topical hyperbaric oxygen used with electrical stimulation on the healing of chronic wounds. All subjects were geriatric residents of long-term care facilities with Stage III or Stage IV pressure ulcers. Topical hyperbaric oxygen was applied daily to the wounds of eight subjects; three also received electrical stimulation. Initial wound size ranged from 87.75 cm2 to 7.04 cm2 with an average size of 30.1 +/- 28.5 (mean +/- sd) cm2. Healing times ranged from 8 to 49 weeks. After 4 weeks of treatment with topical hyperbaric oxygen, wound size decreased an average of 34.4% +/- 22.9%. Incidentally, the wounds of five of the eight subjects decreased more than 20%, for an average of 51.8% +/- 17.9%. No significant differences in healing were observed between patients receiving topical hyperbaric oxygen alone and those receiving topical hyperbaric oxygen/electrical stimulation. Preliminary data indicate that topical hyperbaric oxygen facilitates wound healing and full closure for pressure ulcers in patients with and without diabetes mellitus. A multicenter, prospective, randomized, double-blind controlled study is currently under way.