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Scope of the Problem

Pressure ulcers, or PRUs, have affected humans for ages, and addressing

the overall management of pressure ulcers is now a prominent national

healthcare issue. Despite current interest and advances in medicine,surgery, nursing care, and self-care education, pressure ulcers remain a

major cause of morbidity and mortality. This is particularly true for

persons with impaired sensation, prolonged immobility, or advanced age.

See the image below.

Advanced sacral pressure ulcer shows the effects of pressure,

shearing, and moisture.

Research in the area of pressure ulcers, specifically in characterization,

prevention, and treatment of pressure ulcers, is important in preventing

secondary complications in persons with disabilities. As the standards of

acute, posttraumatic, and rehabilitation care improve, the population ofpersons with lifelong functional impairments continues to grow.

Consequently, the prevention of secondary complications has become an

increasingly prominent concern.

Definitions

"an inflammatory, often suppurating lesion on the skin or an internal

mucosal surface of the body, as in the duodenum, resulting in necrosis of

the tissue."

"a local defect or excavation on the surface of an organ or tissue which is

produced by sloughing of inflammatory necrotic tissue."

"an area of unrelieved pressure over a defined area, usually over a bony

prominence, resulting in ischemia, cell death, and tissue necrosis."

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Pressure ulcers commonly develop on the occiput of geriatric and

pediatric patients who spend extended amounts of time lying supine.

Patients with the secondary manifestations of osteoporosis and associated

thoracic kyphosis can develop pressure ulcers over the spinous processes.Elderly patients and patients with diabetes often have pressure ulcers on

the heel.

Summary of Contributing Factors

Factors contributing to pressure ulcers are summarized below.

Pathomechanical factors (extrinsic or primary) include the following:

Compression

Maceration

Immobility

Pressure

Friction

Shear

Pathophysiologic factors (intrinsic or secondary) include the following:

Fever

Anemia

Infection

Ischemia

Hypoxemia

Malnutrition

Spinal cord injury

Neurologic disease

Decreased lean body mass

Increased metabolic demands Risk assessment includes the following:

Complete medical history taking

Determination of Norton (or Braden) score (see Table 1,

below).

Skin examination

Identification of previous pressure ulcer sites

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Prime candidates for pressure ulcers includes the following:

Elderly persons

Persons who are chronically ill (eg, those with cancer,

stroke, or diabetes)

Persons who are immobile (eg, due to fracture, arthritis, or

pain)

Persons who are weak or debilitated

Patients with altered mental status (ie, under the effects of

narcotics, anesthesia, or coma)

Persons with decreased sensation and/or paralysis

Secondary factors include the following:

Illness or debilitation increases pressure ulcer formation

Fever increases metabolic demands

Predisposing ischemia

Diaphoresis promotes skin maceration

Incontinence causes skin irritation and contamination

Other factors, such as edema, jaundice, pruritus, and xerosis

(dry skin)

Rationale for strategies to prevent pressure ulcers

Skin care is paramount and must be carried out in conjunction with the

following principles:

Pressure relief is important. Patients should be shifted or turned in

position every 2 hours. Support surfaces and specialty beds require

criteria for use.

Patients can benefit from lying prone.

Minimize shearing forces by keeping the head of the bed lower than 45.

Use an air-fluidized bed.

Persons who use a wheelchair should be taught to perform pushup

exercises and to lean side to side for pressure relief.

Use of pressure-relieving cushions of air, foam, gel, or a combination canhelp relieve pressure.

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Frictional relief is also important.

Nutritional support involves several steps, as follows:

Obtain the patient's nutritional history.

Perform physical examination.

Obtain anthropometric measurements.

Order laboratory studies (eg, albumin, total lymphocyte

count, transferrin level).

Provide enteral or parenteral support.

Provide vitamin therapy.

Muscle spasms should be controlled. Involuntary muscle contractions can

lead to abrasions. The use of oral antispasticity agents is the simplest

method of controlling spasticity. Pressure ulcers occur more frequently inpatients with flaccid paralysis than in those with spasticity.

Prevention of contractures is another strategy. Uncontrolled spasticity or

lack of movement causes shortening of the muscles, usually the hip, knee,

elbow, and ankle plantar flexors. Contractures can limit the patient to

only a few positions. Contractures can be prevented in patients who have

some mobility by encouraging ambulation and range-of-motion exercises

twice daily.

Debridement and debriding agents

The purpose of wound debridement is to remove all materials that

promote infection, delay granulation, and impede healing, including

necrotic tissue, eschar, and slough (ie, the stringy yellow, green, or gray

nonviable debris in an ulcer). Accurate ulcer staging cannot be made until

necrotic tissue is removed. Three debridement procedures are commonly

used: enzymatic debridement, mechanical nonselective debridement, and

sharp debridement.

Enzymatic debridement uses various chemical agents (proteolytic

enzymes) that act by attacking collagen and liquefying necrotic wound

debris without damaging granulation tissue.Proteolytic enzymes are used

to chemically debride wounds. The action of these enzymes is aimed

specifically at necrotic tissue.

Mechanical nonselective debridement, in which necrotic tissue is

loosened and removed, is generally accomplished by whirlpool

treatments, forceful irrigation, or use of wet-to-dry dressings. Wet-to-dry

dressings involve placing wet gauze into the lesion and allowing it to dry.

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A few hours later, when the dressing is removed, the necrotic debris that

has adhered to the dressing is also removed. Solutions commonly used

for wet-to-dry dressings include normal saline and 0.25% acetic acid

solution.

Povidone-iodine solution can be used to debride infected ulcers.

Although the effervescent action of hydrogen peroxide results in wound

debridement, it is not recommended for frequent use in pressure ulcers,

because it indiscriminately removes necrotic material and fragile

granulation tissue.

The widespread practice of using hydrogen peroxide continues, but it is

not recommended for long-term use because it and other cleansing agents

have been found to be toxic to fibroblasts.

Once debridement has been completed and clean granulation tissue has

been established, the use of debridement agents should be discontinued

and the site should be kept clean and moist.

Sharp debridement is surgical removal of the eschar and any devitalized

tissue within it. Although sharp debridement is the most effective method

of removing necrotic tissue, it is contraindicated in certain patients,

particularly those who cannot withstand the loss of blood that may occur

during the procedure. Moist devitalized tissue supports the proliferation

and growth of pathogens. The removal of this devitalized tissue is a

prerequisite to new tissue growth.

Sharp debridement is indiscriminate in the removal of vital and

devitalized tissue. A great deal of clinical skill and judgment are needed

in surgically debriding a wound.

Elderly patients and those with diabetes often have pressure ulcers of the

heel that look black and have eschar. Conventional wisdom encourages

physicians to debride the eschar, but it is usually protective and should beleft to autodebride unless an active infection dictates more aggressive

measures.

Surgical debridement is well established as an approach to pressure ulcer

care, but more research is needed.

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Dressings for pressure ulcers

Transparent adhesive dressings are semipermeable and occlusive. They

allow gaseous exchange and transfer of water vapor from the skin, and

they prevent maceration of the healthy skin around the wound. In

addition, these dressings are not absorptive, they reduce the incidence of

secondary infection, and they eliminate the risk of traumatic removal.

However, transparent adhesive dressings do not function well on patients

who are diaphoretic or on patients with wounds that have significantexudate.

Hydrocolloid wafer dressings contain hydroactive particles that interact

with wound exudate to form a gel. These dressings provide absorption of

minimal to moderate amounts of exudate and keep the wound surface

moist. This gel can have fibrillolytic properties that enhance wound

healing, protect against secondary infection, and insulate the wound from

contaminants.

Gel dressings are available in sheet form, in granules, and as liquid gel.

All forms of gel dressings keep the wound surface moist as long as they

are not allowed to dehydrate. Some gel dressings provide limited to

moderate absorption, some provide insulation, and some provide

protection against bacterial invasion. All gel dressings provide atraumatic

removal(see Table 2, below).

Calcium alginate dressings (eg, Sorbsan) are semiocclusive, highly

absorbent, and easy to use.They are natural, sterile, nonwoven dressings

derived from brown seaweed. Calcium alginate dressings are extremely

effective in treating wet (exudative) wounds and can be used on wounds

that are contaminated or infected.

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Phototherapy

Definition

Phototherapy, or light therapy, is the administration of doses of bright

light in order to normalize the body's internal clock and/or relieve

depression.

Precautions

Patients with eye problems should see an ophthalmologist regularly, both

before and during phototherapy. Because some ultraviolet rays are

emitted by the light boxes used in phototherapy, patients taking

photosensitizing medications (medications making the skin more

sensitive to light) and those who have sun-sensitive skin should consult

with their physician before beginning treatment. Patients with medical

conditions that make them sensitive to ultraviolet rays should also be seen

by a physician before starting phototherapy.

Pressure Ulcer (Decubitus) Treatment

The Episcan dermal ultrasound scanner is used for early detection ofpressure sores before they are visible and to guide treatment including the

detection of wound undermining.

For treatment of pressure ulcers low power laser therapy has been

available for some time but the take up has been slow, since it requires a

trained therapist, special eye protection and closed treatment rooms. The

coverage is quite small, so laser phototherapy treatments are too slow,

expensive and impractical in many long term care environments, which is

where pressure ulcers most often occur.

Phototherapy for decubitus

The Q.Light PROnon-laser phototherapy device from Switzerlandnow treats larger areas more quickly and it has a built in timer, aperture

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control and display for accurate treatments. It gives up to 40cm diameter

coverage and does not require special training or eye protection, making

it eminently practical and convenient to use in open ward situations,

including over a patient's bed.

Just a few minutes per day when the wound is clean and exposed is allthat is required and the results can be remarkable in terms of accelerated

healing, including stimulating even very stubborn wounds to heal. The

treatment is painless, drug-free and non-invasive so it can be used in

conjunction with existing therapies.

Some non-laser phototherapy devices offer a fixed frequency range

including infra-red, but infra-red can be uncomfortable for infected

wounds or burns.

Q.Light PRO overcomes this objection as it is a flexible, modularsystem. It uses a range of optional filter modules to provide specific lightfrequencies from the visible and near-infra red range for different medical

conditions and there is no ultra-violet component. Filter modules are

simply slotted in and out according to need and are clearly labelled,

making

Q.Light PROsimple to use in practical, daily situations in hospitals,care homes and clinics.

Light Therapy

Light Therapy already has a long history going back thousands of years.

The first source of light used for medical treatment was the sunlight

which is known as heliotherapy and dates from about 1400 BC In 1903

The Danish Physician Niels Ryberg Finsen was awarded one of the

earliest noble prizes for his 'Finsen light Therapy' for infectious diseases.

Dr Finsen hence is considered to be the founder of modern light therapy.

The important therapeutic effects prompted many researchers and

scientists to develop and use filtered solar and artificial light source and

the phototherapy techniques became an alternative to heliotherapy.

Further studies by other researchers and scientists resulted in the creation

of the Bioptron polarized light that works with almost the whole range

of the visible and part of the infrared light, and the Bioptron devices

were launched.

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This was a huge development, and the Bioptron Light Therapy became

an effective and viable additional treatment for various conditions and

illnesses, affecting both adults and children.

Studies and researches into the effect of phototherapy using Polarized,

Incoherent, low energy light therapy show that polarized light help speed

up the healing process in cases such as venous leg ulcers, pressure sores

and burns. "In conclusion, the results of this clinical study demonstrate

that polarized-light therapy reduces the need for surgery in the treatment

of deep dermal burns. In this group of patients, the use of polarized light

accelerated wound healing and allowed very early pressure therapy, thus

reducing hypertrophic scarring and contracture. No extension of thehospital stay was required. Because of the better aesthetic and functional

results (especially in burns of hands), polarized-light therapy has become

the therapy of choice for deep dermal burns in University Hospital"

The term 'light' refers to the visible part of the electromagnetic radiation

spectrum. The light used in the submitted clinical trials consists of the

visible and part of the infrared light measuring between 480 nanometresand up to 3000 nanometres. This Bioptron range ensures the exclusion

of any UV light thus avoiding any UV radiation and posing no risk to the

patient.

Today it is known that the human organism transforms light into

electrochemical energy, which activates a chain of biochemical reactions

within cells, stimulating metabolism and reinforcing the immune

response of the entire human body.

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Bioptron Light Therapy can be used as mono-therapy and/or as

complementary therapy for pain treatment in the following indications:

Rheumatology (osteoarthritis, rheumatoid , chronic arthritis),

Physiotherapy (low back pain, shoulder and neck pain, carpal tunnelsyndrome, scar tissue, musculoskeletal injuries) and Soft Tissue Injuries

(soft tissue injuries of muscles, tendons and ligaments, muscle spasm,

sprains, strains, tendonitis, tennis elbow.(

General Benefits

Bioptron Light Therapy can be used both as a complementary treatment

to support conventional medical methods and as monotherapy for certain

indications.

Bioptron Light Therapy can:

Improve microcirculation;

Harmonize metabolic processes;

Reinforce the human defence system;

Stimulate regenerative and reparative processes of the entire

organism; Promote wound healing;

Relieve pain or decrease its intensity.

The outstanding characteristics of Bioptron Light enable the light to

penetrate not only the skin but also the underlying tissues. Thus the

positive effect of Bioptron Light is not limited to the treated skin area

but also has a beneficial effect on the entire organism.

Bioptron Light has biostimulative effects: when applied to

the skin; it stimulates light-sensitive intracellular structures and

molecules. This initiates cellular chain reactions and triggers so-

called secondary responses, which are not only limited to the

treated skin area, but can involve the whole body;

Bioptron Light Therapy stimulates and modulates

reparative and regenerative processes as well as the processes of

the human defence-system;

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Bioptron Light Therapy acts in a natural way by

supporting the regenerative capacity of the body and therefore

helps the body to release its own healing potential.

Wound Healing

Bioptron Light Therapy can be used as monotherapy and/or as

complementary therapy for wound healing in the following indications:

Wounds after a trauma (injuries)

Burns

Wounds after operations

Leg ulcers

Decubitus (pressure sores)

We recommend consulting a physician before using Bioptron Light

Therapy in order to receive professional advice as to whether this

treatment is recommendable or whether other medical treatment is

necessary.

Pain Treatment

Bioptron Light Therapy can be used as monotherapy and/or as

complementary therapy for pain treatment in the following indications:

Rheumatology

Osteoarthritis

Rheumatoid arthritis (chronic)

Arthroses

Physiotherapy

Low back pain Shoulder and neck pain

Carpal tunnel syndrome

Scar tissue

Musculoskeletal injuries

Sports Medicine

Soft tissue injuries of muscles, tendons and ligaments including:

Muscle spasm

Sprains

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Strains

Tendonitis

Ligament and muscle tears

Dislocations

Contusions Tennis elbow

We recommend consulting a physician before using Bioptron Light

Therapy in order to receive professional advice as to whether this

treatment is recommendable or whether other medical treatment is

necessary.

Colour Therapy

Health is contingent upon balancing not only our physical needs, butour emotional, mental and spiritual needs as well. The colour

chakra therapy principle is based on the assumption that

colours are associated with seven main chakras, which are

spiritual centres in our bodies located along the spine. These

chakras are like spirals of energy, each one relating to the

specific area.

Chakra is the Sanskrit word for 'wheel'. It is assumed that

chakras store and distribute energy. There are seven of thesechakras and each is associated with a particular organ or

system in the body. Each chakra has a dominant colour, which

may become imbalanced. If this happens, it can cause a

disorder and physical ramifications. By introducing the

appropriate colour, the disorder is considered to be improved.

Light and Colour are essential for our body and soul, however,

colour therapy works purely as an alternative, non medical,

holistic level, unlike the polarized, low energy Incoherent lighttherapy described above.

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What is LLLT?

LLLT (Low Level Laser Therapy) is the application of red and near infra-red light over

njuries or lesions to improve wound / soft tissue healing and give relief for both acute and

chronic pain.

LLLT is used to: increase the speed, quality and tensile strength of tissue repair; give pain

relief; resolve inflammation; improve function of damaged neurological tissue and often used

as an alternative to needles for acupuncture.

The red and near infrared light (600nm-1000nm) commonly used in LLLT can be produced by

aser or high intensity LED. The intensity ofLLLT lasers and LED's is not high like a surgical

aser. There is no heating effect.

The effects of LLLT are photochemical (like photosynthesis in plants). Red and near infrared

ight can affect cell membrane permeability and aid the production of ATP thereby providing

he cell with more energy which in turn means the cell is in optimum condition to play its part

n a natural healing process.

LLLT devices are typically delivering 10mW - 500mW (0.2 -> 0.01 Watts). The power density

ypically ranges from 0.05W/Cm2 -> 5 W/Cm2.

LLLT is popularly used for soft tissue injuries, joint conditions, chronic pain, non-healing

wounds and ulcers, post-op pain and acupuncture.

http://www.thorlaser.com/LLLT/http://www.thorlaser.com/LLLT/benefits-of-LLLT.htmhttp://www.thorlaser.com/LLLT/LLLT-light.htmhttp://www.thorlaser.com/LLLT/http://www.thorlaser.com/LLLT/how-does-LLLT-work.htmhttp://www.thorlaser.com/products/index.htmhttp://www.thorlaser.com/LLLT/http://www.thorlaser.com/LLLT/http://www.thorlaser.com/LLLT/benefits-of-LLLT.htmhttp://www.thorlaser.com/LLLT/LLLT-light.htmhttp://www.thorlaser.com/LLLT/http://www.thorlaser.com/LLLT/how-does-LLLT-work.htmhttp://www.thorlaser.com/products/index.htmhttp://www.thorlaser.com/LLLT/

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How

does

LLLT

work?

Like photosynthesis - the correct wavelengths and power of light at certain intensities for an

appropriate period of time can increase ATP production and cell membrane perturbation

could lead to permeability changes and second messenger activity resulting in functional

changes such as increased syntheses, increased secretion and motility changes. Red and near

infrared light seem to be the most ideal wavelengths.Red light acts on the mitochondria and

near infrared light on the mitochondria and at the cell membrane. In in-vitro and animal

LLLT wound healing studies comparing wavelengths, red consistently is more effective.

Shorter wavelengths are not so good, expensive to produce and with poor penetration they

are a poor choice.

Clinical Effects ofLLLT

An appropriate dose of light can improve speed and quality of acute and chronic woundhealing, soft tissue healing, pain relief, improve the immune system and nerve regeneration.

Applications with good RCT evidence include Venous Ulcers, Diabetic Ulcers,

Osteoarthritis, tendonitis, Post Herpetic Neuralgia (PHN, shingles) & postoperative pain.

To paraphrase NASA research:

Low-energy photon irradiation by light in the far-red to near-IR spectral range with low-

energy (LLLT) lasers or LED arrays has been found to modulate various biological

processes in cell culture and animal models. This phenomenon of photobiomodulation hasbeen applied clinically in the treatment of soft tissue injuries and the acceleration of wound

healing. The mechanism of photobiomodulation by red to near-IR light at the cellular level

has been ascribed to the activation of mitochondrial respiratory chain components, resulting

in initiation of a signaling cascade that promotes cellular proliferation and cytoprotection.

A growing body of evidence suggests that cytochrome oxidase is a key photoacceptor of

light in the far-red to near-IR spectral range. Cytochrome oxidase is an integral membrane

protein that contains four redox active metal centers and has a strong absorbance in the far-

red to near-IR spectral range detectable in vivo by near-IR spectroscopy.

Moreover, 660680 nm of irradiation has been shown to increase electron transfer in

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Physiotherapy for Wound Healing

Services Include:

assessment of wound status and consultation regarding factors impairing wound

healing

selection and design of a safe and comfortable wound treatment using a

therapeutic modality

creation of a program of exercises/ positioning to help circulation and aid in

wound closure

wherever possible, provision of training to the patient or the patients delegate

on how to continue treatments at home

facilitation of any necessary equipment rental or purchase through a local

supplier ongoing evaluation of the wound healing and progression of the programme of

treatment as appropriate

Exercises/Positioning

Many chronic leg wounds are in part due to poor blood circulation and swelling of the leg.

Leg exercises help improve circulation and reduce swelling.

Prolonged or inappropriate positioning/seating surfaces for immobile individuals can lead to

pressure ulcers. Treatment of these ulcers requires offloading or more appropriate seating

surfaces. These factors will be evaluated and addressed.

Therapeutic Modalities

Physiotherapy involves the use of many different modalities that

are shown through research to aid in the healing of soft tissues.

Treatments such as electrotherapy, ultrasound, laser therapy and

ultraviolet light are all safe, comfortable, non-invasive means of

delivering electrical, sonic, light or thermal energy to a wound.

Electrical stimulation in particular has very strong evidence

supporting its use in healing of chronic wounds including those

that are infected. Electrical stimulation for this purpose is

recommended in several respected guidelines on the management

of ulcers including the RNAO Pressure Ulcer Guideline and the Canadian Association of

Wound Care Ulcer Guidelines.

http://www.blasersphysiotherapy.com/category/section/subpage/modalities.htmlhttp://www.blasersphysiotherapy.com/category/section/subpage/laser.htmlhttp://www.blasersphysiotherapy.com/category/section/subpage/modalities.htmlhttp://www.blasersphysiotherapy.com/category/section/subpage/laser.html

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Laser Treatment for Pressure Ulcer Healing Post SCI

Lasers have been used in the treatment of wounds since the 1970s.

Lasers are believed to exert their effects on the proliferative phase of

wound healing, prompting fibroblast activity and granulation tissue

formation in non-healing, chronic wounds. Currently the use of laser

to promote wound closure in chronic wounds is not supported by

evidence, The two studies presented in this document support this

conclusion.

EFFECT OF VISIBLE LIGHT ON SOME CELLULAR AND

IMMUNE PARAMETERS

. visible light provokes the release of some biological mediators

(cytokines) from the immune competent cells and in this way stimulates

the natural resistance of an organism. Similar to UV radiation and

without the negative effect of suppressed natural killer cell activity, the

application of visible light, preferably linearly polarised light (LPL), forthe extracorporeal exposure of human blood is suggested.

Mortality and pressure ulcers

Pressure ulcers contribute to increased mortality ,One study

identified that older patients with a pressure ulcer were threetimes more likely to die sooner than those without .In the

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community, older people with pressure ulcers were more likely

to die sooner than those without

Conclusion

Bioptron Light Therapy can be used both as a complementary treatment

to support conventional medical methods and as monotherapy for certain

indications.

Pressure ulcers, or PRUs, have affected humans for ages, and addressing

the overall management of pressure ulcers is now a prominent national

healthcare issue.

Standardized measuring techniques are necessary to provide quantitative

information on wound healing and to validate research.

The purpose of wound debridement is to remove all materials that

promote infection, delay granulation, and impede healing, including

necrotic tissue, eschar, and slough (ie, the stringy yellow, green, or gray

nonviable debris in an ulcer).

Phototherapy, or light therapy, is the administration of doses of bright

light in order to normalize the body's internal clock and/or relieve

depression.

The Episcan dermal ultrasound scanner is used for early detection ofpressure sores before they are visible and to guide treatment including the

detection of wound undermining.

LLLT is used to: increase the speed, quality and tensile strength of tissue

repair; give pain relief; resolve inflammation; improve function of

damaged neurological tissue and often used as an alternative to needles

for acupuncture.

http://www.thorlaser.com/LLLT/benefits-of-LLLT.htmhttp://www.thorlaser.com/LLLT/benefits-of-LLLT.htm

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US/UVC should be considered as an added treatment when pressure

ulcers are not healing with standard wound care post SCI.

Pulsed electromagnetic energy improves wound healing in Stage II

and Stage III pressure ulcers post SCI.

REFERENCE

my.clevelandclinic.org

profreg.medscape.com

peainthepodfitness.com

publicinfo.com

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CONTENTS

INTRODUCTION

SCOPE OF THE PROBLEM

Summary of Contributing Factors

Debridement and debriding agents

Dressings for pressure ulcers

Phototherapy

Pressure Ulcer (Decubitus) Treatment

General Benefits

What is LLLT?

How does LLLT work?

Physiotherapy for Wound Healing

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