ELECTROTHERAPY

IN WOUND HEALING
-Hitesh Rohit(4th year B.P.T.)
BASICS
• Stages of wound healing :-
• 1) Initial haemorrhage:-
• As a result of injury, the woundspace is filled with blood and
fibrin clot which dries.

• 2) Inflammatory phase:-
• There is an initial acute inflammatory response followed by
appearance of macrophages which clear off the debris.
• 3) Epithelial changes:-
• The epidermal cells from both the margins of wound
proliferate and migrate into the wound in the form of
epithelial spurs till they meet in the middle and re-
epithelialise the gap completely.
• 4) Granulation tissue:-
• Granulation tissue is formed by proliferation of fibroblasts
and neovascularisation from the adjoining viabe elements.
• 5) Wound contraction:-
• Due to the action of myofibroblasts present in granulation
tissue, the wound contracts to one-third to one-fourth of its
original size.
• Wound contraction occurs at a time when active granulation
tissue is being formed.
• Factors affecting wound healing:-
• Local factors:-
• Tissue hypoxia
• Pressure
• Tissue edema
• Necrotic material
• Infection
• Contamination from incontinence
• Desiccation
• Maceration
• Systemic factors:-
• Smoking
• Stress
• Comorbidity
• Diabetes
• Obesity
• Anemia
• Malnourishment
• Immune compromise
• Senescence
Electrotherapy in
wound healing
• Various low frequency and high frequency currents using
modalities are effective in promoting acute and chronic
wound healing.Some of the instruments which are used,are
given in detail here:-
• 1)Laser
• 2)UV radiation
• 3)Shock wave therapy
• 4)Ultrasound
• 5)Electrical stimulation
Low-level laser and

wound healing
• It has been shown that the laser therapy had the potential to
improve wound healing and reduce pain and inflammation.
• The main indications of low-reactive-level laser therapy
(LLLT) are reduction of pain and inflammation.
• It amplifies tissue repair, enhances regeneration of different
nerves and tissues, and prevents tissue injury in situations
where it is likely to occur.
•Low-reactive-level laser therapy (LLLT) enhances the
activation of intracellular or extracellular chromophores and
the initiation of cellular signaling by exposing cells or tissue to
low levels of red and near infrared (NIR) light.
•The biological effects of LLLT are decreased inflammatory
cells, increased fibroblast reproduction and angiogenesis, and
stimulation of granulation tissue and augmented collagen
synthesis.
• Low-level laser therapy (LLLT) is also a novel approach for
treating wounds.
• Greatest benefits have been achieved through wavelengths of
632–1000 nm.
• The mechanism of action of LLLT is defined through wound
contraction which accelerates the wound healing process.
• The mechanism of LLLT on wound healing is not yet fully
understood nevertheless it appears that LLLT has a wide area
of effects at all the levels of molecular, cellular, and tissue
ingredients.
• The main biological mechanism behind the effects of LLLT is
proposed to be absorption of red and NIR light by mitochondrial
components, in particular cytochrome c oxidase (CCO) which is
concluded in the respiratory chain located within the
mitochondria , and also in the plasma membrane of cells.
• Accordingly, a chain of events and various process carries out in
the mitochondria leading to wound healing.
• Although LLLT is now used as a portable minimally invasive,
easy-to-use, and cost-effective modality to promote wound
healing, it is also employed for treatment of diabetic lower
extremity ulcer.
• Inappropriate choice of light source and dosage can be the
cause of negative results of many of the published studies on LLLT.
• In addition, eventual mismatch of the patient’s skin to the
application of LLLT were described, such as: improper
preparation and oily debris that can interfere with the influence of
the light source, and cause failure to account for skin
pigmentation.
• Unsuitable maintenance of the LLLT devices can reduce its
efficiency and interfere with clinical results as well.
• It is important to notice that there is an optimal dose of light for
any particular issues.
• Nevertheless,many systematic reviews point that LLLT is an
effective therapeutic modality on wound healing and diabetic
foot ulcer recovery.
• Relative contraindications
• 1)Cancer
• Do not use LLLT over any known malignant lesions unless: for
pain relief during the terminal stages of the illness, and for
cancer therapy side effects (e.g., oral mucositis, radiation
dermatitis, etc.).
•2)Pregnancy:-
There is no evidence of harm to an unborn baby; however, there are
no safety tests either, so for medico legal reasons it is recommended
to not treat directly over the developing fetus.

•3)Thyroid:-
Although relatively low intensity is far less likely to trigger any
adverse events when treating that region of the neck,but for
precautions we should not apply lasers directly over the thyroid.
Phototherapy(UV irradiation) and
wOuNd healing
• New contemporary research shows that controlled UV exposure
might have some eventual benefit in wound healing and cutaneous
homeostasis.
• The effectiveness of UV energy in enhancing biological changes
depends on the chosen irradiation parameters, with maximal
effective wavelength and lowest irradiation level.
• The main mechanism of phototherapy is related to the depth of
penetration.
• UVA, for example, has the longest wavelength and penetrates
to the upper part of dermis in human skin, and UVB only
penetrates down to the basal layer; however, UVC only reaches
the upper part of the epidermis.
• UV has bactericidal effect and its radiation to the skin can
increase blood flow, producing erythema and epidermal
hyperplasia.
• The induced erythema via vasodilatation and inflammatory
response represents the first phase of healing.
• In addition, UV light irradiation increases cellular proliferation
in the stratum corneum, which can be a protective mechanism
against further sunlight damage.
Although UV protection and antisolars are commonly advised
during and after wound healing, it is possible that UV also
affects the melanocyte redistribution and prevents the normal
cutaneous response to injury.
• It has been shown that UVC light per se could stimulate
wound healing. UVC light enhances fibronectin and growth
factors release leading to increase healing cascade and wound
contraction.
• UV can promote endothelial cell proliferation [36] and
augment epidermal thickness and reepithelialization or
desquamation of the leading edge of periulcer epidermal
cells.
• UVC (200–280 nm) has a significant antimicrobial effect and
can be used as efficient bactericide agent for treatment of
acute wound infections and killing pathogens without
undesirable injury to host tissue.
• UVB (280–315 nm) irradiation to the wound has wound
healing stimulating effect and extracorporeal UVB irradiation
of blood adds immune system stimulating effects too.
• Although UVA (315–400 nm) has specific effects on cell
biologic events, it has not yet been extensively applied to
wound treatment.
Contraindication of phototherapy:-
Childhood
Pregnancy and breastfeeding (PUVA)
Immobility or inability to stand unassisted for 10 min or longer
Very fair skin (skin type 1 and 2, especially PUVA)
• Past excessive exposure to natural sun light or phototherapy
• Immunosuppressive medication
• Photosensitizing creams or medications
• Past skin cancer, especially melanoma
 Shock wave and
wound healing
• Although hearing extracorporal shock wave brings the treatment
of urinary stones in the mind but it also has some benefits in the
treatment of acute and chronic wounds.
• Shock waves are biphasic high-energy acoustic waves that can
be produced by electrohydraulics.
• Although the exact mechanisms of shock wave therapy are not
entirely elucidated, it may harbor eventual immunomedulatory
effects, acting by transient micromechanical forces in altering
various biologic activities.
•Shock wave therapy increased expression of macromolecules
in wound healing such as VEGF, proliferating cell nuclear
antigen, and endothelial nitric oxide synthesis.
•Beacause of the considerable experience in using shock wave
in the treatment of urolithiasis and other conditions in humans,
it appears to be a safe technology.
•The clinical effect of this technology in various wound types
and the particular mechanisms of action are now beginning to
be understood. Shock waves may also stimulate sensory nerve
fibers and decrease pain.
• Clinical studies of shock wave therapy in wound healing
suggest that many factors such as wound cause, size, and
duration may impact response to shock wave therapy.
• However, the actual administration of shock wave therapy in
current clinical studies varies in type (unfocused versus
focused).
• Primary studies suggest that unfocused shock wave therapy is
more effective than focused one in the treatment of
superficial soft tissue defects yet, without direct comparison
between unfocused and focused shock wave therapy in
clinical trials to date.
Contraindications:-
Absolute
• Lungs: Treatments must not be performed across or directed to
the lungs and heart.
• Eyes: Tissue of the eye could be adversely affected by shock
wave.
• Brain: The destructive forces seen at transitions could damage
and destroy brain matter.
• Major blood vessels: Both the major blood vessels in the neck
and thigh should be avoided to prevent damage and potential
catastrophic bleeding.
Open wounds/postsurgical wounds with or without stabilization
(glue, stitches, steristrips): Shock wave damages tissues and local
circulation. This could lead to degradation of the wound, further
bleeding, and delayed healing.
Implanted devices or hormones.
• Epiphysis: Open growth plates could potentially be damaged by
shock wave either by using settings that create more growth and
close them too quickly or by using settings that delay growth.
• Major nerves: Superficial major nerves like the brachial plexus,
ulna/radial nerve should not be treated directly (treatment around
these areas is acceptable just not directly to the nerve).
Relative
Genitals; pregnancy; clotting disorders/anticoagulants; joint
replacements, certain settings have been used to loosen
previously implanted joints ready for a new implant;
infection; and cancer.
• Corticosteroid injection: Generally people recommend
waiting 1 month before application.
 Ultrasound in
wound healing
• Therapeutic ultrasound is utilized by physical therapists to
deliver a high frequency mechanical vibration to facilitate
healing at a cellular level.
• Therapeutic ultrasound is often used by physiotherapists to
reduce pain, increase circulation and increase mobility of soft
tissues. Additionally, the application of ultrasound can be
helpful in the reduction of inflammation, reducing pain and the
healing of injuries and wounds.
Ultrasound therapy causes mechanical vibrations, from high
frequency sound waves, on skin and soft tissue via an aqueous
medium. The transducer head converts power from the
generator into acoustic power that can cause thermal or non-
thermal effects.
• The parameters (frequency, duration and intensity) are set on
the programme controller by the user.
• Effects on the Phases of Wound Healing
• 1) Inflammatory phase
When ultrasound is applied in this phase, it enhances the
degranulation of mast cells resulting in the release of histamine
and other mediators that attract fibroblasts and endothelial cells
to the injured area.
This will later result in the formation of collagen-containing
vascular granulation tissue.
• Early intervention with ultrasound should result in an
accelerated acute inflammatory phase, moving to a more
quick entry into the proliferative phase and improving
comfort of the patient in this phase.
• 2)Proliferative Phase:-
• In this phase, Ultrasound stimulates fibroblast migration and
proliferation to secrete collagen, improving tensile strength of
the healing connective tissues.
• The production of vascular endothelial growth factor and
angiogenesis are also promoted by the application of ultrasound
in this phase.
• In the end, there is an accelerated process of wound contraction
as ultrasound may cause the early development of
Myofibroblasts. Low-intensity, non-thermal ultrasound within
72 hours following an injury can promote wound contraction
which should result in a smaller scar.
•3)Epithelialization Phase:-
Application of Ultrasound to the peri-wound area stimulate
the release of growth factors needed to regenerate
epithelial cells, further protecting the body from infection and
reinstate skin integrit
4)Maturation or Remodeling Phase:-
• The response to ultrasound in this stage is dependent on if
therapy was initiated in the inflammatory phase. Application
of thermal ultrasound during this phase affects the collagen
extensibility and enzyme activity and therefore also improves
tensile strength of the healing tissue.
Suggested Frequencies:-
Dermal Wounds – 3MHz
• Deep lacerations or Periwound Skin – 1Mhz
Application to Periwound Tissue:-
Parameters
1MHz, continuous mode with intensity at 1 – 1.5 W/ cm squared.
The aim is to produce a thermal effect for vasodilation and
increased tissue oxygen levels.
• The ultrasound head should be 1.5 or 2 times the size of the area
to be treated. Aqueous medium is applied to the transducer and is
moved in a slow circular motion around the treated area. 2-3
minutes completes per zone, 3 times per week.
Application to Wound:-
Parameters
20% duty cycle, 3MHz with intensity at 0.3-0.5 W/cm
squared.
The aim is to stimulate protein synthesis and increase cell
proliferation.
• The dressings should be removed and wound should be
debrided of dressing residue and foreign debris. Apply a
hydrogel sheet over the wound, removing any air bubbles.
The ultrasound head should be 1.5 or 2 times the size of the
treated area. If the area is large, treatment can be completed in
sections with 1-2 minutes per zone. Ultrasound medium is
applied to the transducer and in contact with the hydrogel
sheet.
• Acute wounds can be treated 1-2 times per day and then
continued 2-3 times per week.
Precautions and Contraindications:-
Contraindicated over eyes, genital areas, abdominal area and
exposed neural tissue
Should be avoided in cases of thromboembolic diseases
Avoided in patients with pacemakers
Precautions should be taken with sensory impairments
• Ultrasound should be terminated if there is increased pain
Electrical stimulation in
wound healing
• Electrical stimulation is a method of physical therapy used for
accelerating wound healing.
• It has effectiveness in Facilitating healing in both acute and
chronic wounds.
• It is used to eliminate bacterial load, promote granulation,reduce
inflammation & edema, reduce wound related pain.
• Electrotherapy works by stimulating cell migration, cell
proliferation rate, and growth factor secretion via creating an
electrical current.
• The anode attracts macrophages, neutrophils, and
keratinocytes. The cathode attracts activated neutrophils,
fibroblasts, myofibroblasts, and endothelial cells.
• Method of application:-
• Direct method of application includes and electrical
stimulation unit treatment and non treatment electrode and a
saline soaked gauze or hydrogel dressing over wound bed to
enhance electrical conductivity.
• Indirect method application:-Here electrodes are placed
around the periwound skin using gel.
• References:-

• Physical Modalities in the Management of Wound(s)-By