Vascular Assessment

Vascular Assessment 

Vascular assessment as performed in lab includes palpating and grading pulses, calculating ankle brachial index, performing and evaluating capillary refill, and performing and evaluating venous refill.  Vascular assessment is particularly important for patients with peripheral arterial disease and for patients receiving wound care.  The initial evaluation of the wound care patient should always contain a thorough vascular assessment.  

Supporting Articles: 

The first article supports the use of ABI for evaluating peripheral vascular disease (PVD).  The second article supports the use of photolpethysmography (PPG) for assessing venous insufficiency.  The third article supports the use of strain gauge plethysmography (SGP) for assessing venous incompetence.   

Ikem et. al evaluated the occurrence of peripheral vascular disease (PVD) using ankle-brachial index (ABI) in diabetic patients with and without foot ulcers and the risk factors associated with diabetic foot ulcers (DFU).  Seventy-four patients were recruited with 42 males and 32 females.  Forty-six had foot ulcers while twenty-eight were without.  Thirty-one patients with DFU were diagnosed with PVD (based on ABI <.9) while ten patients without DFU were diagnosed with PVD.  The researchers also looked at the occurrence of PVD determined by the absence of more than 2 pulses and found that assessment by palpation is subjective while the use of ABI is quantitative and more reliable.  The study also showed that patients with DFU and PVD showed a significant correlation with tobacco use, duration of diabetes and systolic blood pressure.  The results of this study showed that the use of ABI with a hand held Doppler will help with early diagnosis of PVD and help prevent and reduce the high rate of limb loss in these types of patients. 

  

Kelechi et. al proposed a screening procedure to assess venous insufficiency with a hand-held photoplethysmography (PPG) instrument in a clinical setting (Kelechi & Bonham, 2008).  PPG is a noninvasive technology that is used for venous assessment in the lower extremities.  Although duplex ultrasound is the gold standard for assessment, there are many instances where access or expertise is not available.  PPG is underused in clinical settings, but it has great potential since it can be used outside of laboratory settings.  In laboratory settings, PPG has demonstrated high validity and reliability in identifying the presence of chronic venous disorders (CVD).  If PPG is used in a variety of clinical settings, the ultimate goal of early diagnosis and prompt therapeutic interventions for patients with CVD can be achieved that might otherwise go unrecognized.  

Skeik et. al used strain gauge plethysmography (SGP) with and without tourniquet application to distinguish between the superficial and deep components of venous incompetence (Skeik, Kalsi, Wysokinski, Heaser, & Wennberg, 2012).  SGP with tourniquet application was found to be a simple and fast technique that could identify patients with superficial venous incompetence. This can be easier than ultrasound technique which uses time consuming methods that are operator dependent and unable to provide overall haemodynamic assessment of the venous system.  In addition, the ultrasound technique does not globally assess the component of superficial and deep venous insufficiency.  

Refuting Articles:  

The first article discusses the limitation of using ABI to diagnose peripheral vascular disease (PVD).  The second and third articles discuss the limitations of using the capillary refill test.  

Premalatha et. al compared colour duplex ultrasound (CDU) and ankle-brachial pressure index (ABI) measurements in patients with peripheral vascular disease (PVD).  The aim of their study was to compare the specificity and sensitivity of ABI and CDU for the diagnosis of PVD.  Their study involved 100 type 2 diabetic patients who were admitted to a diabetic center with foot lesions.  These patients underwent both CDU and ABI measurements.  A diagnosis of PVD was given if the individual had a haemodynamically significant obstruction on the CDU or if the ABI was <.9.  CDU was the gold standard they used to find the sensitivity and specificity of ABI.  Twenty subjects that were diagnosed with PVD by the CDU were not diagnosed with PVD by the ABI.  Three subjects classified with PVD by the ABI had normal arteries on the CDU scanning.  These results indicated that ABI has a low sensitivity but a high specificity.  Based on this, the researchers believe that ABI is a good initial screening tool but patients with PVD will be missed if ABI is used alone in the diagnosis of PVD.  

In the article by Gorelick et. al., they tested the affects of ambient room temperature on the results of capillary refill test in healthy children. In this study, they tested 32 well hydrated children who presented in an urban emergency room for minor illnesses or injuries. The children were otherwise healthy with normal circulation. The subjects were randomly assigned to a cold waiting room and a warm waiting room where they stayed for 15 minutes prior to seeing the physician at which time capillary refill test was performed. The results of this study found that the average capillary refill time in the warm waiting room was 0.85 +/- 0.45 seconds and in the cold waiting room was 2.39 +/- 0.76 seconds. It is important to remember that a capillary refill time of >2 seconds is considered a positive finding for vascular impairment. Ultimately this study showed that a decrease in ambient room temperature can significantly lengthen capillary refill time thus suggesting that it is not a reliable test for vascular impairment.

In the article by McGee et al., they sought to find which components of a physical exam truly and accurately assist in determining the presence and location of peripheral arterial disease. In this study, the authors analyzed 17 different relevant studies to determine the level of evidence for each. After the levels of evidence were found, the authors determined that the 4 aspects of the physical exam that are positive diagnostic findings for the presence of PAD are abnormal pedal pulses, a unilaterally cool extremity, extended venous filling time, and femoral bruits. Other examination findings including warm knees, the Buerger test, various lower extremity bruits, and an abnormal femoral pulse were found to assist in deciding the extent and location of the present PAD. However, the capillary refill test foot discoloration, atrophic skin, and loss of hair on the extremities were not considered useful for diagnosing PAD.   Ultimately this study showed that many of the vascular assessment tools are useful in diagnosing PAD, however, capillary refill and skin changes of the extremity are not reliable diagnostic findings.

Ann Bonsignore, Mallory Mahoney, Laura Sweeney, Brandon Walker 

 

Works Cited

Ikem, R., Ikem, I., Adebayo, O., & Soyoye, D. (2010). An assessment of peripheral vascular disease in patients with diabetic foot ulcer. Foot (Edinburgh, Scotland), 20(4), 114-7. doi:10.1016/j.foot.2010.09.002

Kelechi, T. J., & Bonham, P. A. (2008). Measuring venous insufficiency objectively in the clinical setting. Journal of Vascular Nursing , 26 (3), 67-73.

Skeik, N., Kalsi, H., Wysokinski, W. E., Heaser, T. V., & Wennberg, P. W. (2012). Predicting superficial venous incompetence with strain gauge plethysmography. Phlebology , 27 (3), 135-140.

Premalatha, G., Ravikumar, R., Sanjay, R., Deepa, R., & Mohan, V. (2002). Comparison of colour duplex ultrasound and ankle-brachial pressure index measurements in peripheral vascular disease in type 2 diabetic patients with foot infections. The Journal of the Association of Physicians of India, 50, 1240-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12568206

Gorelick, M. H., Shaw, K. N., & Baker, M. D. (1993). Effect of ambient temperature on capillary refill in healthy children. Pediatrics, 92(5), 699-702. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8414858

McGee, S. R., & Boyko, E. J. (1998). Physical examination and chronic lower-extremity ischemia: a critical review. Archives of internal medicine, 158(12), 1357-64. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9645831

Sussman, C., & Bates-Jensen, B. (2007). Wound Care: A Collaborative Practice Manual for Health Professions. Baltimore, Maryland, United States of America: Lippincott Williams & Wilkins.

Pulse Lavage

Literature Review of Pulse Lavage – Katie B, Michael D, Amanda Y, Adam M

Evidence for Pulse Lavage:

Pulsed lavage in wound cleansing

In a review done by Ludedtke-Hoffman and Schafer (2000), they discussed various studies concerning pulsed lavage and the effectiveness of various levels pressure (psi) on bacterial contamination in wounds.  Pressures of 1 psi or less are shown to be ineffective for wound cleansing, resulting in significant bacterial counts.  Pressures of 5 to 10 psi are most effective for debridement of loose necrotic tissue.  Pressures above 10 psi are most effective for bacterial infections 

In the review, they also discussed potential hazards associated with pulsed lavage in wound care.  One concern was the development of bacteremia in a wounds following pulsed lavage. In the study, a water-pik at 50 psi was used by participants with their regular tooth brushing routine.  Blood samples were taken at 15, 45, and 60 days after use and had no evidence of periodontal disease or bacteremia. 

Another study cited in the review looked at potential damage and particle penetration as a result of pulsed lavage in animals. Irrigation was applied at 8 psi with a piston syringe, 70 psi with pulsed irrigation, and then had a control group that didn’t receive irrigation.  While both irrigation groups had similar infection rates, they were still higher than that of the control group leading researchers to believe that high pressure irrigation does result in some tissue damage making infection a high likelihood.  As stated in the article: “ Wheeler et al cautioned that high-pressure irrigation should not be used indiscriminately.  Rather, its use should be reserved for heavily contaminated wounds” (Ludedtke-Hoffmann & Schafer, 2000).        

Ludedtke-Hoffmann, K. A., & Schafer, D. S. (2000). Pulsed lavage in wound cleansing. Journal of the American Physical Therapy Association, 80(3), 292-300.

Comparison of Bulb Syringe and Pulsed Lavage Irrigation with Use of a Bioluminescent Muskuloskeletal Wound Model

 Major Steven J. Svoboda, MD1; Terry G. Bice, MS1; Heather A. Gooden, BS1; Daniel E. Brooks, BS1; Darryl B. Thomas, MD1; Joseph C. Wenke, PhD1

There are many variables to wound irrigation. The purpose of this study was to compare the efficacy of pulse lavage and bulb syringe irrigation in reducing wound bacterial counts. This study used a contaminated musculoskeletal wound that was developed using  a bioluminescent strain of Pseudomonas aeruginosa that can be quantified. Goats were the patients in this study and were randomly assigned either pulse lavage or bulb syringe irrigation. Each wound was irrigated with normal saline solution in 3-L increments for a total of 9 L and was imaged after each 3-L increment. In addition, culture samples were taken from different tissues in the wound before and after irrigation. Pulsed lavage decreased the amount of luminescent units by 52%, 64%, and 70% at 3, 6, and 9 L, respectively. The bulb syringe irrigation only reduced the  luminescent units by 33%, 44%, and 51% at the same volumes. Significant differences were noted between the two groups after both 6 and 9 L. The conclusion of this study is that pulse lavage is more effective than bulb syringe irrigation.

Comparison of Wound Irrigation and Tangential Hydodissection in Bacterial Clearance of Contaminated Wounds: Results of a Randomized, Controlled Clinical Study

This randomized controlled trial compared the use of pulse lavage (PL) to a high-pressure parallel waterjet (HPPWJ), in their abilities to reduce bacterial counts on infected wounds.  The study consisted of 23 participants with 12 receiving the HPPWJ and 9 receiving PL.  Each participant was randomly assigned to which group they would be in and bacterial counts were taken pre-test and post-test (from a central location). PL was completed at a pressure of 40 psi; while the parameters for HPPWJ were set at a power setting of 4-6, or about 5,025-7,360 psi. 

After treatment, the bacterial count in the PL group was reduced by 86.9%.  And, the HPPWJ bacterial count was reduced by 90.8%.  This article was looking more towards the effectiveness of HPPWJ, but at the same time, concluded that PL is still very effective at reducing the bacterial count in contaminated wounds.

Granick, M. S., Tenenhaus, M., Knox, K. R., & Ulm, J. P. (2007). Comparison of Wound Irrigation Bacterial Clearance of Contaminated Wounds : Results of a Randomized, Controlled Clinical Study. Ostomy/Wound Management, 53(4), 64-72.

Evidence against Pulse Lavage

An Outbreak of Multidrug-Resistant Acinetobacter baumannii Associated With Pulsatile Lavage Wound Treatment

Lisa L. Maragakis, MD, Sara E. Cosgrove, MD, MS, Xiaoyan Song, MD, MS, Denny Kim, MD, MPH, Patricia Rosenbaum, RN, CIC, Nancy Ciesla, PT, BS, Arjun Srinivasan, MD, Tracy Ross, BS, Karen Carroll, MD, Trish M. Perl, MD, MSc

Pulse lavage is a high pressure irrigation method used in many health care settings for wound debridement. The objective of this study is to investigate an outbreak of the multi-drug resistant Acinetobacter baumannii and test the hypothesis that pulse lavage was the mode of transmission. The investigation  included case identification, review of medical records, environmental cultures, and pulsed-field gel electrophoresis. Patients included 11 patients infected or colonized with multidrug resistant A baumannii. 10 of these patients were health care associated cases and 8 of the 10 had received pulse lavage. These results of this investigation  confirm that pulse lavage was a risk factor for acquing multidrug-resistant A baumannii. Infection control precautions should be used during pulse lavage therapy and should be included in pulse lavage equipment labeling.

An Outbreak of Multidrug-Resistant Acinetobacter baumannii Associated With Pulsatile Lavage Wound Treatment

            In a study by Maragakis et al., researchers determined that the implementation of pulsed lavavage treatment of wounds attributed to an outbreak of a multidrug-resistant bacteria in a group of patients.  Ten patients from the same hospital acquired the bacteria, 8 of which received pulsed lavage treatment to a wound.  The researchers established that the risk of patients acquiring the bacteria who received pulsed lavage was 12% when compared to a control from the same hospital.  Acquisition of this infection was very serious, as 3 of the patients were admitted to the ICU for sepsis and 2 died.  The researchers also decided that other aquaphilic organisms could be spread through pulsed lavage.  Around the time of the outbreak, the wound care specialists changed their pulsed lavage procedure.  Instead of emptying the suction canister inserts following each treatment, they allowed the canisters to fill before replacing them.  It is hypothesized that this played a role in the epidemic.  To prevent episodes such as the latter, pulsed lavage treatment must be performed according to the manufacturers’ protocol, with the necessary infection control measures in place.

An Outbreak of Multidrug-Resistant Acinetobacter baumannii Associated With Pulsatile Lavage Wound Treatment Lisa L. Maragakis et al. JAMA.  2004; 292(24):3006-3011.doi:10.1001/jama.292.24.3006

Evidence with mixed results pertaining to Pulse Lavage

Irrigation of wounds in open fractures

“Irrigation of wounds in open fractures” is a review discussing the outcomes of using antiseptics, antibiotics, and irrigation on open fracture wounds. (Crowly, Kanakaris & Giannoudis, 2007).  The most common used antiseptics were Betadine and chlorhexidine gluconate which are used for a variety of bacteria, fungi and viruses.   Disadvantages of these were delayed wound healing from toxicity of healthy cells and destruction of fibroblasts. In animal studies it was also shown that there was a negative effect on microvascular flow and tissue integrity. Antibiotics that are commonly used are neomycin, bacitracin, and polymyxin.  Studies have shown that antibiotics have been effective in keeping bacteria levels low in wounds, however there are a few possible complications.   Reports of anaphylaxis or allergic reaction to the antibiotic of choice is a risk with using these medications  with irrigation of a wound. 

When comparing pulsed lavage with a bulb syringe, they found that pulsed lavage was more effective in bacteria clearance and wound irrigation However, there is evidence that it causes more tissue damage whereas the suction and bulb syringe do not.  The authors also discussed an animal study the showed that high pressure pulsed lavage could cause microscopic damage to bone allowing bacteria to enter into the medullary canal. Another animal study evaluated the possibility of increased fluid penetration, would resistance to infection, and transient bacteraemia caused by high pressure pulsed lavage.

Based on the current evidence, the authors recommend normal saline should be used for irrigation of fractures instead of antibiotics and antiseptics due to the possible adverse effects.  They also recommend the use of low pressure irrigation versus high pressure pulsed lavage.  If high pressure is used, the pressure limit should be 50 psi. 

Crowly, D.J., Kanakaris, N.K., & Giannoudis, P.V.(2007). Irrigation of wounds in open fractures. Journal of Bone & Joint Surgery, 89-B(5), 580-585.

HVPC in wound care

We found multiple articles that provided support for HVPC but nothing against.

The first article focuses on patients with spinal cord injuries, who have also ended up with pressure ulcers. Patients with Spinal cord injuries typically have pressure ulcers that are very slow healing and therefore increase the cost of their hospital stay. “The objective of this study was to assess the efficacy of HVPC for healing of pressure ulcers in patients with SCI.” Patients were stratified into groups according to their ulcer classification. The study group received treatment for 1 hour per day, for 20 days straight. The researchers used a twin peaked pulse, with a frequency of 100 pps and an intensity of 200 volts. A foil electrode was placed over the ulcer, after the ulcer was packed with saline soaked gauze. The results showed that the HVPC group showed a significantly greater decrease in wound surface area than the placebo group. All of the grade 2 ulcers healed in both groups, but the time was shorter for the HVPC patients. All of the grade 3 ulcers in the HVPC showed continual decrease in size, but the placebo group had some with increased size.
The limitations of this study included the placebo group had the greatest number of sacral/coccygeal
ulcers and the HVPC group had the most gluteal/ishcial tuberosity ulcers. Another limitation could have been the age of the patients in the respective groups may have affected the healing times. However, the clinical implications of this study are that HVPC, with other interventions, may help to decrease the time of wound healing in pressure ulcers on patients with spinal cord injuries. [1]

A second meta-analysis reviewed 15 articles about electrical stimulation and chronic wound healing. There were 591 ulcers treated with electrical stimulation (ES) and 212 in the control groups. The average follow up time was just over 6 weeks. The average wound size was 8.8 cm2 for the ES group and 9.2 cm2 in the control groups. The researchers found a large overlap of the confidence interval between types of electrical stimulation. The researchers analyzed 15 published articles and concluded that electrical stimulation was better for treating wound than control groups, however they did not find a significant difference between types of ES, so it is unclear which type of ES is most effective for wound therapy.[2]

A study very relevant to physical therapy pertains to people who are dependent for mobility and often develop pressure ulcers on weightbearing surfaces like the occiput, sacrum, ischial tuberosity, or calcaneus. Electrical stimulation therapy (EST) delivers a low level of electrical current directly to, or surrounding, the wound. This has been shown to induce therapeutic actions at every stage of wound healing. This single blind study compared wound size and appearance after 3 months of standard wound care (SWC) versus standard wound care plus EST. The standard wound care group received nutritional intervention, an optimal wound dressing protocol, and continence management. The SWC plus EST group received the same SWC with the addition of EST. The EST included filling the wound cavity with saline soaked silver nylon and, in 11 of the 16 subjects, a single electrode was placed over the wound and a second larger electrode was placed at least 20cm away. The other 5 subjects used a bipolar set up or an electroconductive sock. They used High Voltage Pulsed Current (HVPC) to provide 20 minutes at 100Hz, followed by 20 minutes at 10Hz, and then 20 minutes off time for 8 hours a day for 3 months. This study showed that SWC plus EST showed significant decrease in wound surface area at 3 months when compared to SWC alone. Four wounds in the SWC only group increased in size, but none with EST did. Eighty percent of the stage III-X ulcers were half as big in the EST group, compared to 36% in the SWC group. There was no difference between groups after one month, EST saw insignificantly better outcomes after 2 months, and EST was significantly better after 3 months. Fourteen of the 16 subjects in the EST group were followed until complete wound closure. This allowed the researchers to see the average time for complete healing when SWC and EST were used was 4.5 months when only 39% of the SWC group saw complete healing after 6 months. This study provides good evidence that adding HVPC electrical stimulation to standard wound care can significantly decrease healing time of pressure ulcers. [3]

A final study was retrospective and evaluated HVPC along with a multidisciplinary approach to limb salavage for diabetic patients. The wounds were in the lower extremity and the size of the wounds were compared with and without the HVPC; the wounds treated with the additional HVPC healed faster. [4]


[1] Griffin, J. W., Tooms, R. E., Mendius, R. a, Clifft, J. K., Vander Zwaag, R., & el-Zeky, F. (1991). Efficacy
of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury.
Physical therapy, 71(6), 433-42; discussion 442-4. Retrieved from http://www.ncbi.nlm.nih.gov/
pubmed/2034707
[2] Gardner, S.E., Frantz, R.A., Schmidt, F.L. (2002). Effect of electrical stimulation on chronic wound healing:a meta-analysis. Wound Repair and Regeneration, 7(6), 495-503.
[3] Houghton, P. E., Campbell, K. E., Fraser, C. H., Harris, C., Keast, D. H., Potter, P. J., Hayes,
K. C., et al. (2010). Electrical Stimulation Therapy Increases Rate of Healing of Pressure
Ulcers in Community-Dwelling People With Spinal Cord Injury. YAPMR, 91(5), 669-678.
Elsevier Inc. doi:10.1016/j.apmr.2009.12.026
[4] Burdge JJ, H. J. (2009). A study of HVPC as an adjunctive therapy in limb salvage for chronic diabetic wounds of the lower extremity. Ostomy/Wound Management, 30-38

Wound Bandaging and Dressing

Compression Treatment of Venous Leg Ulcers

The goal of wound care is to provide an appropriate environment for healing.  An important aspect of the healing environment is bandaging and dressing the respective wound.    Bandaging and dressing of a wound serves many purposes which are:  helps to debride, provides an optimal moist environment, promotes granulation and epithelialization, and protects from infection.  Because protocols for wound care dressing are highly variable and dependent upon which type of afflicting wound it is, the purpose of this blog will be to focus on compression bandaging in regards to venous leg ulcers.  Currently compression is the standard of care for treatment of venous leg ulcers.  Below are articles that discuss the effectiveness in general as well as effectiveness of different types of compression bandaging.

Supporting Articles

A systematic review and meta-analysis of randomized controlled trials calls compression treatment a “first line treatment” for venous ulcers. This “first line treatment” can be applied as a four layer bandage device or a short stretch bandage, and both are considered high compression (ankle pressure at 35-40 mm Hg). The bandage selection depends on geographic location (trends) and health care worker preference. Five trials were analyzed that compared these two methods. Both methods were shown to improve venous ulcer healing significantly, although wounds with four layer compression treatments healed on average 30% faster, regardless of prognostic profiles. There were several factors that were predictive of healing time which included: larger area, chronic ulceration, and previous episodes of ulceration. In addition, this review’s positivity for four layer bandage is of benefit for our patient because it is also more cost effective for the patient (according to costs in the UK and includes nurse and doctor visits). While both methods are successful, and if given the choice to optimize healing time and costs, one should choose four layer compressions (O'Meara et al. 2009).

Venous leg ulcers are treated with many different bandaging systems and various studies have found that the compression bandages should have sub bandage pressure values ranging from 35 to 45 mmHg to achieve the best healing results. A randomized study by Milic et al in 2009 split their subjects into three group: 42 patients were treated using an open-toed, elastic, class III compression device knitted in tubular form, 46 patients were treated with the multi-component bandaging system comprised of Tubulcus and one elastic bandage) and 43 patients were treated with the multi-component bandaging system comprised of Tubulcus and two elastic bandages. The healing rate during the 26-week treatment period was 25% in the first group, 67.4% in the second group, and 74.4% in the third group. The authors attributed the success of compression treatment in the first group was associated with the small ulcer surface (<5 cm (2)) and smaller calf circumference (CC; <38 cm), but they had better compliance than the other groups, but the healing rate was higher in these groups, especially in patients with large ulcers and a large CC (>43 cm). In conclusion, the authors found that multi- component compression systems were superior in healing rates compared to single- component compression system, but that the compression system should be individualized according to the patient's leg and calf circumference (CC). They conclude that the sub bandage pressure can be calculated with the formula CC/CC + 2

Another group of researchers wanted to explore the cost effectiveness of compression treatment following a sustained venous leg ulcer. Specifically, they hoped to discover and determine a system of compression that was more effective than the others. The systematic review by Fletcher, Cullum et al. began through a search of numerous electronic databases. They wanted to find randomized controlled trials that explored the rate of healing of venous ulcers. The group included 24 trials in the review. It was found that general compression does increase healing rates. In addition, through the exploration of the articles, they concluded high compression treatments were more effective than low compression. For example, delivering 3-4 layers of compression performs better than low compression systems or single-layer compression. Unfortunately, they were not able to determine clear differences in the effectiveness of the type of compression system used. It appears the evidence is lacking in the area, and further research is needed to conclude whether what system of bandaging is most effective. They discovered that due to a poor quality of research in the area, the method of bandaging that achieves the best outcome could not be concluded. Because of this, one could assume that rather than encouraging the use of a specific compression system, the one should focus on a high compression regime in general. One could further conclude that the least expensive compression, which offers the highest compression, should be used in the treatment of a venous ulcer.  (Fletcher, Cullum et al. 1997)

Opposing Articles

Although compression therapy is usually indicted for venous ulcers, there are some circumstances where compression is not proved to be an effective treatment. In a study by Milic et al., compression therapy was examined in 189 patients with venous ulcers.  Dressings included a layer of cotton gauze and cotton crepe bandaging with 50% overlap and no tension. Next, Tubulcus, a tubular compression sock was donned in one of five sizes, depending on calf circumference. The last layer was medium-stretch elastic bandage.  After the dressing, the subjects were advised to walk for 30 minutes to activate the calf muscle pump in hopes of clearing some edema. The participants were treated for 52 weeks and no one dropped out. The results of the study showed, among other things, that 12.7% of the ulcers did not heal. Two factors independently were predictors of poor healing: a fixed ankle joint and a calf: ankle circumference measure (CAC) <1.3.  A fixed ankle joint is indicative of decreased calf muscle pumping. A small CAC was speculated to either be found in patients with inactivity or with too much calf compression, leading to muscle atrophy. So, in these groups, constant compression therapy is not shown to be helpful (Milic et al., 2009).

Compression therapy is very commonly used to treat venous leg ulcers in the United States, but it is not the standard of care everywhere. A randomized control trial in Hong Kong by Wong et al compared three different treatments for venous leg ulcers in patients over 60 years old. They compared four layer bandaging, short stretch bandaging, and what they called usual care of moist wound dressing without compression and the impact on ulcer healing, area, and pain over the 24 week study. They found greater healing in the compression groups and that the healing time for the short stretch bandaging was shorter than the four layer bandaging group. Also, pain decrease was only significant for the compression groups. A previous meta-analysis by O'Meara in 2009 found that four layer bandaging had better results for healing time, so this study's significance demonstrates that there is still not a clear superior choice for compression between four layer and short stretch, but it does confirm that compression is still superior to non- compression in treating venous leg ulcers.

Although compression has been shown to be effective in the case of venous leg ulcerations, the standard bandaging system has not been shown to be more effective than any other compression. In a study completed in 2004, researchers hoped to compare the “generic four-layer bandage system” with a cohesive short-stretch system. Patients were selected based on the presence of leg ulceration and absence of common contraindications to compression (arterial insufficiency, etc.). The participants were randomized into two groups, one receiving the generic and the other receiving the cohesive short-stretch. The researchers found that by the end of 24 weeks, 71% of participants experienced complete ulcer closure. While the compression treatment was effective in each group, a between group difference was not seen in this study. Furthermore, the authors of the article cannot conclude that one bandaging system is superior or inferior to the other. It is clear that the newer, or more “up-to date” bandaging systems ultimately have the same effect as the traditional systems. One can further conclude that the most cost effective system should be implemented within the healthcare system, rather than the new kid on the block. A brand-name bandage system should not be regarded as superior until further evidence has shown a marked difference from current systems. (Franks, Moody et al. 2004)

References

Fletcher, A., N. Cullum, et al. (1997). "A systematic review of compression treatment for venous leg ulcers." BMJ 315(7108): 576-580.

Franks, P. J., M. Moody, et al. (2004). "Randomized trial of cohesive short-stretch versus four-layer bandaging in the management of venous ulceration." Wound Repair and Regeneration 12(2): 157-162.

Milic, D., Zivic, S, Boddanovic, D, Karanovic, N, and Golubovic, Z. (2009). Risk factors related to the failure of venous leg ulcers to heal with compression treatment. Journal of Vascular Surgery 49(5) p.1242-1247.

O’Meara, S., Tierney, J., Cullum, N., Bland, J.M., Franks, P, Mole, T and Scriven, M. (2009). Four layer bandage compared with short stretch bandage for venous leg ulcers: systemic review and meta-analysis of randomized control trials with data from individual patients. BMJ 338:b1344.

Lauren Anderson, Katherine Martin, Brandon Smith, Kayla Ubel

PUSH Scale for Wound Assessment

The Pressure Ulcer Scale for Healing (PUSH) is a commonly used tool that monitors a wound through the healing process. It is an easy, quick and effective scale that can differentiate between a healing and nonhealing wound. However, there are some limitations to the PUSH scale. Below is a review of the literature both supporting and refuting the PUSH scale.

Supporting PUSH

The study, “A Prospective Study of the PUSH Tool in Diabetic Foot Ulcers,” by Sue Gardner, Stephen Hillis, and Rita Frantz aimed to determine how scores of the PUSH tool change over time, whether the tool could predict healing time, and which categories of the tool were able to most accurately predict healing time in individuals with neuropathic foot ulcers. Patients studied had a neuropathic foot ulcer on the plantar surface of their foot and did not have peripheral arterial disease. The patients all received moist dressing and debridement of heir ulcers and were assessed using the tool 7 times over a 13 week period. The results of the study found that PUSH scores decreased over time, the PUSH was able to predict healing time, and length X width measurement may be the best predictor of healing time.

In the article by Gardner et.al., a prospective study of residents of three nursing homes in two states with pressure ulcers was completed to determine effectiveness of the PUSH scale. In order to be included in the study, the subjects had to have a stage two or greater pressure ulcer during a six month time period. The pressure ulcers were examined each week using the PUSH, the ressure Sore Status Tool (PSST), and acetate tracings. These assessments continued each week until the ulcer healed, the resident died or transferred, or the 6 months was completed. At the conclusion of the study, it was found that PUSH scores decreased among healed ulcers but did not decrease among the unhealed ulcers. “Comparison of PUSH total scores for healed and unhealed ulcers approached closure, confirming the ability of PUSH to differentiate healing from non-healing ulcers.” It was noted that the PUSH gives a valid measure of healing over time and distinguishes healing from non-healing ulcers. It is also clinically practical for tracking change. The study stated that while it was effective, mostly stage 2 ulcers were examined and more data would need to be gathered on other ulcer stages.

The study, “A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers," was conducted to evaluate the use of the Pressure Ulcer Scale for Healing (PUSH tool) in patients with one or more pressure ulcers. The main aims of the study were to determine if the total PUSH score would change significantly over time and if the PUSH total scores were significantly different for healed and unhealed pressure ulcers. The study included 72 patients with 86 pressure ulcers total (49% Stage II, 47% Stage III, 4% Stage IV). For those with multiple ulcers, the PUSH scores were added together. The results of the study showed that the PUSH total scores decreased significantly during the 8-week study. Differences were noted each week for healed ulcers, whereas scores in unhealed ulcers only showed significant differences between the first and eighth week. These findings show that the PUSH scores were consistent with healing outcomes and validate the tools ability to differentiate between healing and nonhealing pressure ulcers in multiple stages.

This study, Use of the PUSH tool to measure venous ulcer healing, demonstrates the effectiveness of the PUSH tool to measure venous wounds rather than pressure ulcers. It has a relatively small sample size in 27 patients. Ulcers were measured on each patient. If a patient had multiple ulcers, the largest one was used for measurement. These patients were seen 3 times with 1 month between each visit. Of the 23 ulcers that healed, all had a decrease in PUSH score. Additionally, the PUSH score increased in the ulcers that were not healing. The authors concluded that the PUSH is good to use to assess healing over time, but may not be best for onitoring effect of a specific intervention. The PUSH should be used as a global assessment of healing in venous ulcers.

Refuting PUSH

The article, “The PUSH Tool: A Survey to Determine Its Perceived Usefulness,” aimed to determine the positive and negative aspects of the PUSH tool through a survey completed by users of the tool. The areas of interest included: experience with the instrument, perceived ease of use, and perceived weakness. A 5 point Likert scale was used to answer statements about the PUSH tool and open ended questions were included for more detailed answers. The results of the survey found that most agreed the PUSH was quick and easy to use and that PUSH scores encourage reassessment and treatment. Many respondents agreed that improvements could be
made in the tool in the areas of the size, tissue type, and exudate amount subscales. In the open ended section suggestions were made about adding wound depth. Comments were also made suggesting that for large wounds, the tool does not portray healing appropriately.

In the article by George-Saintilus, et.al., data was gathered through retrospective chart review of patients with stage 2-4 pressure ulcers in a skilled nursing facility during a two year period. The point of this study was to determine if the PUSH correlated with nursing assessment of pressure ulcers. Analysis was then performed looking at the PUSH score, clinical nursing observation (based mainly on ulcer size), and weekly flow sheets. A kappa statistic for a 3 x 3 table was used comparing nursing observation (improved, unchanged, deteriorating) and PUSH score difference (+1, 0, -1). It was determined that although the PUSH is usually recommended, it “does not highly correlate with traditional nursing observation.” It was determined that further study would be needed to figure out what assessment tool would be most accurate and have the strongest correlation with nursing observation.
This article makes an important point that although this scale seems to work, it does not match up with the observation of health care professionals which may create confusion in prognosis as well as treatment plans.

In the article, A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers, the author describes some of the limitations for the PUSH scale. He explains that the tool incorporates three different categories (size: length x width, exudate amount and tissue type) each of which has its own weighted score. “Size is weighted about 3.33 times more heavily than exudate amount and 2.5 times more heavily than tissue type.” That means the status of the wound is mostly affected by changes in wound size over exudate amount or tissue type. This can be a problem because the dressings applied to the wound will affect the amount of exudate. Wound dressings are not all standardized when it comes to wound management, so the exudate analysis may not be as accurate. Another major limitation to the PUSH tool is that it does not assess the depth of the wound. If the tool is used to assess the healing process, the PUSH scale would not be able to determine significant improvements when depth has changed. More studies are needed to assess these limitations to determine the accuracy of the PUSH tool for wound healing assessment.

In the article, Use of the push tool to measure venous ulcer healing, the authors describe some of the limitations to the PUSH scale. One of them was that it can’t be used to measure specific
treatment effects. The scale is best used for long-term, global assessments of wound healing. They also explained that the PUSH can’t be used on every type of wound. Further studies need to be conducted to assess these limitations.

References:

Gardner, S. E., Hillis, S. L., & Frantz, R. a. (2011). A prospective study of the PUSH tool in diabetic foot ulcers. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society / WOCN, 38(4), 385-93. doi:10.1097/WON.0b013e31821e4dbd

Gardner, Sue, Rita Frantz, Sandra Bergquist, and Chingwei Shin. "A Prospective Study of the Pressure Ulcer Scale for Healing (PUSH)." Journal of Gerontology. 60A.1 (2005): 93-97. Web. 10 Apr. 2012.

Günes UY. “A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers.” Ostomy Wound Management. 2009 May
1;55(5):48-52. Web 18 Apr. 2012.

Ratliff, C. R., & Rodeheaver, G. T. (2008). Use of the push tool to measure venous ulcer healing. Ostomy Wound Management, 51(5), 58. Retrieved from http://www.o-wm.com/article/4082?

Berlowitz, D. R., Ratliff, C., Cuddigan, J., & Rodeheaver, G. T. (2005). The PUSH tool: a survey to determine its perceived usefulness. Advances in skin & wound care, 18(9), 480-3. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16365545

George-Saintilus, Erica, Barbara Tommasulo, et al. "Pressure Ulcer PUSH Score and Traditional Nursing Assessment in Nursing Home Residents: Do They Correlate?." Clinical Practice in Long-Term Care-JAMDA. (2009): 141-144. Web. 10 Apr. 2012.

Ultrasound and Wound Healing
Summaries by Sarah L, Brianna, and Natalie

Ultrasound is a very common modality used in the outpatient setting for physical therapy. It is often used for soft tissue and bony lesions but it can also be used in wound care. Pulsed ultrasound is used in wounds to help accelerate the inflammatory phase of healing. It stimulates the release of histamine from mast cells which then attract neutrophils and monocytes to the injured area to help clean up and repair the site of injury. Research is still increasing for the use of ultrasound, especially towards wound care. Below are some articles that both support and oppose the use of ultrasound for wound care.

Supporting Articles:

Wollina, Heinid, Naumann, Scheibe, Schmidt, and Neugebauer studied the effects of ultrasound on wound care using three different levels of ultrasound, 34 kHz, 53.5 kHz, and 75 kHz. Twelve different patients over the age of 18 who had chronic venous leg ulcers participated. Non-contact ultrasound was applied to their leg ulcers while submerged in water, for ten minutes, once a day. They measured the microcirculation before applying ultrasound, immediately after and thirty minutes after applying ultrasound. They also used micro-light guide spectrophotometer and contact-free remission spectrophotometer to collect measurements. Overall there was not much of an effect at the levels of 53.5 kHz or 75 kHz, but at continuous-wave low-frequency ultrasound of 34 kHz there was a slight increase in microcirculation. This was most likely due to the increase of oxygenation to that area but further studies are still needed.

Low intensity pulsed ultrasound (LIPUS) and pulsed electromagnetic fields are used in healing bone after fracture.  To determine how effective each is in the healing of bone, the authors conducted a systematic review of literature.  Using the most common outcome measure of radiographic healing of the cortices, both methods were determined to be effective in healing fractures.  LIPUS has strong evidence in supporting its use for fracture healing.  In randomized, controlled clinical trials, it promotes healing in nonunion and acute fractures with the following parameters: burst width of 200 microseconds containing 1.5 MHz sine waves, repetition rate of 1 KHz and spatial average temporal intensity of 30 mV/cm², treatment applied with 20 minutes daily.  Using these parameters and evidence, PTs  can apply LIPUS in the clinic to aid in bone healing after fracture.

Kavros, Liedl, Boon, Miller, Hobbs, and Andrews found that ultrasound was an effective modality for the treatment of chronic wounds in patients with an average age of 71 years. This retrospective study reviewed the charts of 210 patients with below-the-knee, lower extremity wounds of varied etiology. Forty-seven patients were placed in the control group because their wounds were treated with standard wound care alone. The remaining 163 patients were placed in the intervention group because their wounds were treated with MIST ultrasound therapy - a low-intensity, low frequency, non-contact ultrasound technique - in addition to standard wound care. Patients in the ultrasound group had been treated 3 times per week for 90 days or until the wound healed. Results showed that those in the ultrasound group saw better results in regards to wound volume, percent wound closure, and rate of healing as compared to the control group (Kavros et al., 2008).

Opposing Articles:

Watson, Kang, Soares, Chuang, Worthy, Bland, and Iglesias, studied 337 patients who had at least one venous leg ulcer for greater than 6 months or that was larger than a 5cm² area. They aimed to see if low dose, high frequency ultrasound (1 MHz and 0.5 W/cm²) applied once a week to the ulcer for 12 weeks along with standard care would improve wound healing over just standard wound care alone. It was found that applying ultrasound between wound dressings did not improve ulcer healing time nor reduce ulcer recurrence. It also did not improve the quality of life of the patients.

Ultrasound has many physiologic effects on soft tissue and it has been hypothesized that can aid in tissue lesion repair.  Thermal effects of ultrasound include increasing tissue extensibility, controlling pain, increasing blood flow, and reducing muscle spasm.  Non-thermal effects of cavitation and microstreaming are thought to help with tissue healing.  Cavitation causes compression and expansion of gas bubbles in the tissue increasing fluid flow.  Microstreaming increases cell permeability to stimulate repair.  Through article review, Speed has determined that while these events can help with wound and tissue repair in vitro, there is a lack of evidence for success in vivo.  However, this lack of success may be due to flawed study designs and the presence of underlying pathologies in patients.  At this time, the evidence does not support its use in the clinic, but more research need to be in order to validate or definitively dispute its effects on soft tissue lesion repair. 

Ter Riet, Kessels, and Knipschild found that ultrasound was not an effective modality for treating pressure ulcers in nursing home patients. This randomized clinical trial recruited 88 patients with pressure ulcers from 11 different nursing homes and one hospital. Half of the patients were assigned to the ultrasound group and received ultrasound to the wound and the extended wound area. The other half of the subjects were assigned to the sham ultrasound group. A nurse applied and ultrasound transducer to these patient’s wounds, but the beam wasn’t actually turned on. Both groups received treatment for 12 weeks. Results showed that after 12 weeks, 40% of the ulcers in the ultrasound group had closed and 44% of the ulcers in the sham ultrasound group had closed. Closure rates and healing rates were almost equal between the two groups. These data indicate that ultrasound does not speed up the healing of pressure ulcers (ter Riet, Kessels & Knipschild, 1996).

As seen from the evidence above though, ultrasound has been seen to be effective and non-effective for wound care. More evidence is still needed in this area to really confirm the effectiveness and efficacy of ultrasound on wound healing. For now, using ultrasound is often based on personal opinion and experience. One thing is known for sure about ultrasound, is that it does not help in treating DOMS (delayed onset muscle soreness). However, it is seen that ultrasound can also help with managing scar tissue and joint contractures and has been seen to increase bone healing.

References

Kavros, S. J., Liedl, D. A., Boon, A. J., Miller, J. L., Hobbs, J. A., & Andrews, K. L. (2008). Expedited wound healing with noncontact, low-frequency ultrasound therapy in chronic wounds: a retrospective analysis. Advances in skin & wound care, 21(9), 416-23. doi:10.1097/01.ASW.0000323546.04734.31

Speed, C. A. (2001). Therapeutic ultrasound in soft tissue lesions. Rheumatology  (Oxford,             England), 40, 1331-1336.

ter Riet, G., Kessels, A. G., & Knipschild, P. (1996). A randomized clinical trial of ultrasound in the treatment of pressure ulcers. Physical therapy, 76(12), 1301-11. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8959999

Walker, N. A., Denegar, C. R., and Preische, J. (2007). Low-intensity pulsed ultrasound and        pulsed             electromagnetic field in the treatment of tibial fractures: A systematic review.        Journal of Athletic Training, 42(4), 530-535.

Watson, J. M., Kang’ombe, A. R., Soares, M. O., Chuang, L.-H., Worthy, G., Bland, J. M., Iglesias, C., et al. (2011). Use of weekly, low dose, high frequency ultrasound for hard to heal venous leg ulcers: the VenUS III randomised controlled trial. BMJ (Clinical research ed.), 342, d1092. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3050437&tool=pmcentrez&rendertype=abstract

Wollina, U., Heinig, B., Naumann, G., Scheibe, A., Schmidt, W.-D., & Neugebauer, R. (2011). Effects of low-frequency ultrasound on microcirculation in venous leg ulcers. Indian journal of dermatology, 56(2), 174-9. doi:10.4103/0019-5154.80412