What to Look for
in Wound Therapy for your patients with Non Healing Foot
Ulcers
A
checklist to find out if they’ve really "Been There, Done That!"
Physicians and surgeons
regularly see patients with non healing lesions, often in
combination with acute infection, gangrene and pain. Everything
has been tried — nothing works. But is that really true? Has
the patient received aggressive wound treatment, or merely
conventional wound care?
The therapist needs
to have enough different clinical tools available to turn
up the treatment intensity until a positive healing response
is achieved, and not merely classify the wound as unhealable.
Heroic effort is justified!
A clinician with the
familiarity and training in the techniques that can really
make a difference. Instead of trying to coax a difficult
wound to heal with standard wound care, special skills and
an inventive attitude are needed to effectively turn around
the situation and induce a positive healing response.
Many specialists are expert only in their area. Being admitted
to a large teaching hospital does not guarantee satisfactory
wound treatment!
The failure to heal
a lesion on a patient’s foot becomes an enormous quality-of-life
and financial burden for the patient, and a huge financial
liability for the health care system.
If you have been sending
your high-risk patients to a wound or foot clinic, and patients
are often deemed "unhealable", here are some points
that you can ask about to find out if these patients have
really "been there, done that."
What specialized
training did you receive to do this work?
Each profession (nurse,
physiotherapist, massage, chiropodist) has one to four day
seminars every year on various aspects of wound therapy. At
least one such recent workshop would be minimal; hearing a
presentation at an annual convention would not usually be
considered enough training.
What is
the typical outcome for your patients?
It depends on the overall
health of the typical patient in this clinic. In most outpatient
clinics with the right equipment and expertise, the cure rate
should be in the upper 90 percents. But if many patients are
very elderly or in poor health, expect less success.
Will the
patient get therapy at home?
Equipment can often be set up at home so that patients will
benefit from daily treatment.
Travel by the patient to a clinic
with the needed therapeutic expertise and equipment is well
justified. As well as the ability to give high-quality wound
care, to do wound bed preparation and to apply specialized
dressing systems, eight modalities are important in
wound therapy. The experienced clinician will successfully
justify and acquire the needed equipment.
End-Diastolic
Compression
Poor blood circulation
is a significant factor in nearly all recalcitrant foot lesions,
causing a deficit of oxygen and nutrients together with a build
up of fluid and waste metabolites. End-diastolic compression
using Circulator Boot™ equipment is an essential technique for
any clinic that treats at-risk patients. The system includes
a cardiac monitor which is connected to the boot and times the
pneumatic compression pulses, typically 85 mm Hg pressure, to
occur at end-diastole. This increases blood flow in the feet
and legs to induce angiogenesis. It disperses antibiotics through
the tissues and is often the only technique that is effective
against deep infections. The Circulator Boot is arguably the
overall most efficient and cost-effective therapy for foot lesions,
especially when infection is present and other wound-closure
methods have failed.
Bio Stimulation
Laser
With an output power
of at least 250 mW visible and 250 mW infra red light, plus
the ability to uniformly scan the entire wound with an applied
dose of 3 to 4 Joules/cm2,
Low-Level Laser Therapy (LLLT) stimulates granulation tissue
and augments collagen synthesis to accelerate healing.
Galvanic Stimulation
In this form of electro
therapy, a pulsed-DC current, passing though the wound bed,
by means of conductive dressings, accelerates wound healing.
It will usually turn around a stubborn borderline wound to
produce healing, and will significantly shorten the healing
time in wounds that would eventually heal anyway. All
wounds that require daily nursing care should receive either
galvanic or laser stimulation to speed healing and wound closure,
if only as a cost-saving measure.
TENS and Interferential
Stimulators
Electro therapy using nerve stimulation (TENS) or interferential
current techniques can accelerate wound healing somewhat by
relieving the swelling and increasing blood flow to the feet.
Vacuum-Assisted
Closure
A mild vacuum applied intermittently to the wound by means
of an airtight dressing can aid in wound closure. . . .
Local Antibiotic
Injection
An adjunct to end-diastolic compression therapy, the therapist
injects a suitable antibiotic directly into and around the
infected tissues using an ultra-fine needle prior to a therapy
session. The cardio-synchronous compression pulses act to
disperse the antibiotics for effectively eliminating even
the most difficult cases bacterial infections, including cellulitis
and osteomyelitis.
Multi Electrolyte
Soak
Another adjunct to end-diastolic compression therapy, "Sea
Soaks" provides the essential micronutrients needed to
aid in healing. In a soak solution for the foot during a therapy
session, and along with antibiotics and hydrogen peroxide,
this provides a soft debridement that largely replaces
the sharp debridement sessions which can otherwise be damaging
to delicate infected tissues.
In
clinical testing, what do the researchers say about end-diastolic
pneumatic compression?
"Excellent outcomes in patients with severe peripheral
arterial occlusive disease suggest that the wound care
community consider expanded utilization of this modality."
— Zink, J. 2003.
About local antibiotic injection?
"Both osteomyelitis and soft tissue
infections can be successfully treated without any surgical
interventions." — Dillon, RS. 1986.
About laser therapy for pain
control and tissue repair? "
Laser therapy has a positive treatment effect
on tissue repair processes and also, on pain control."
— Parker, J. Meta-analysis. 2000. |
Ideally,
the wound clinic needs to have several modalities available
because each patient's need is different. Patients may not
all respond adequately to each method. In a physician-run
clinic, the physician can determine which methods are
appropriate for the wound therapists to use, depending on
whether the central issues are infection, blood flow or wound
closure.
The status of the wound after
four weeks is generally a good predictor of final healing
potential. So, if a wound has not shown a healing response
after four weeks of wound care, then a more aggressive approach
is indicated. Changing to a more intensive program should
produce a positive healing outcome.
With a results-driven and patient-focused
approach, the successful, well-trained wound therapist puts
out the effort to achieve successful outcomes and therefore
is able to further contribute to the evidence base of good
wound practice. Since these modalities are all time-tested
and well supported by clinical research data, you can ask
for published reports that validate the techniques being used.
Some questions can be helpful
in determining a course of action:
1. Why is the
lesion not healing? — Ischemia, neuropathy, infection, tumour?
2. Is the vascular
status of the foot documented with non-invasive vascular tests?
3. Is the neurological
status documented?
4. Have appropriate
cultures been taken?
5. Is osteomyelitis
present? With the answers to these questions, the proper role
of reconstructive surgery, end-diastolic boot therapy,
multi electrolyte solutions, local antibiotics and local hygiene
becomes apparent.
A chronically diseased foot causes
pain and anxiety which produce an autonomic response that
restricts peripheral blood flow and further inhibits healing.
A psychologist or biofeedback technician, using computerized,
multi mode biofeedback methods, can teach the patient how
to produce a relaxation response that increases peripheral
blood flow and warms the feet. Video tapes are available with
a similar purpose.
Wound therapy cases will benefit
from diagnostic techniques, including Skin Perfusion
Pressure, Doppler and tcPO2.
Because it measures the blood pressure in the micro circulation
adjacent to the wound, Skin Perfusion Pressure is preferred
as the best predictor* of wound healing potential, and as
an ideal secondary measure to verify the effects of therapies
intended to increase peripheral blood flow. Since healing
progress often can be a delayed response, measurements showing
increased circulation can be a strong motivating factor for
the patient to continue with the course of treatment until
achieving success.
Are all of these diagnostics
and therapies justified for the patient? Definitely!
Even the resection of a deeply infected ulcer or the amputation
of a toe is not a natural expected disease progression;
rather it is usually the failure to apply timely and appropriate
therapy. It is the beginning of a never-ending series of clinic
visits, home-care, chronic pain, further amputations, hospitalizations,
prosthesis fittings and disability. The provincial healthcare
systems in Canada cannot afford to sustain overly cautious
wound care!
In contrast, successful healing
of the lesion results in restored quality-of-life and independence.
It is extremely rewarding and satisfying for the patient,
the therapist and the physician!
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