Pamela Scarborough: Welcome to this program this morning titled Biophysical Agents-Energies to Jump Start Chronic Stalled Wounds. My name is Pamela Scarborough. I’m a doctor of physical therapy. Board certified as a diabetes educator and a wound specialist. These other little credentials at the end, the CEEAA, stands for Certified Exercise Expert for Aging Adults of which I am one. I just love those. I had a fun, really good time getting those credentials. I want to thank you for being here as early. You are all bright-eyed. I truly appreciate it. I have nothing to disclose for this particular talk. Let’s look at our objectives this morning. We have three of them. What we’re going to do is describe the biophysical agents that enhance wound closure and healing. Compare and contrast different biophysical agent methods for use with chronic wounds. And identify some of the chronic wounds and patient conditions that are appropriate for biophysical agents. When we think about using exogenous technologies, we don’t usually bring them in when there’s an acute wound. We bring them in when there is a chronic wound. When something has happened that has stalled the healing processes. Dr. Chris Attinger, in one of the articles that he wrote, talked about normal reduction in wound size and that your wound should decrease in size about 10% to 15% per week and that this represents normal healing. You don’t need to change your interventions if you’re getting this amount of closure. However, if you’re not getting this, then you want to think about alternative, adjunctive types of interventions or modalities. What are some of the indications for exogenous energies? You might use them for debridement, decreasing the bioburden or biofilm disruption, edema reduction, increase blood flow to the area, and to facilitate the stalled healing process, which all of these do. All of these will facilitate stalled healing. Let’s look at the types of energies we have. We have our electromagnetic energy which includes electrical stimulation, diathermic, ultraviolet, infrared. We have our mechanical and acoustic energies, which include whirlpool, a very rare indication. I’m not going to speak on whirlpool today because it is rare. Most of us has taken our whirlpools out of our clinical practice because it’s inappropriate for many of our conditions including venous insufficiency. It’s contraindicative for venous insufficiency. Twenty-minute whirlpool is also contraindicative for diabetic neuropathic foot ulcers. That’s the section on whirlpool. Then we have our ultrasound. We have our high frequency ultrasound, your megahertz. Then we have our low frequency ultrasound in kilohertz. Then we have our positive pressure such as your intermittent and pneumatic compression. I have seen topical hyperbaric coming back but we’re not going to talk about hyperbaric oxygen in this particular talk. Then our hyperbaric oxygen where we’re actually doing our dives. Then we have our positive and negative pressure such as your pulse lavage with suction and negative-pressure wound therapy. I’m going to start with one of my favorite energies. And that is electrical stimulation. I’ve been a physical therapist for over 35 years. I’ve used this consistently throughout my career and still use it. I even use it personally to keep my joints in as good shape as I can keep them. It is one of the most cost-effective therapeutically efficacious modalities that we have out there. It’s been used for more than 30 years in chronic wound healing. We have a strength of evidence A, which means double-blind randomized controlled studies on humans related to using this energy. We do have reimbursement for electrical simulation when you can document and show that you have a chronic wound. In addition, in the VA system, there was a document published by the Paralyzed Veterans of America that states that electrical stimulation qualifies as a standalone intervention and is no longer considered an adjunctive intervention. The National Pressure Ulcer Advisory Panel in their clinical practice guidelines for prevention and treatment of pressure ulcers, says that we should consider use of direct contact electrical stimulation in the management of recalcitrant Stage II as well as Stage III and IV pressure ulcers to facilitate wound healing.

[05:09]

Again, strength of evidence A. When we look at electrical stimulation, what we’re doing is we are transferring a current into the wound via electrodes that are attached in some manner to the skin. The evidence supports this delivery of the electrical current into the wound tissue to enhance wound healing. The theory of how it works is called the current of injury. Whenever you or your patients injure their skin, there is an electrical process that is set up within the skin so that that acute injury will close as quickly as possible. Certain cells are called in because of this current of injury. Well, electrical stimulation mimics this in stalled chronic wounds to facilitate the wound healing cascade. When we look at the some of the cellular processes and the physiological responses related to electrical stimulation, one of the ones that I want you to really think about, brings at the front of your mind is it increases blood flow. Micro and macrovascular stimulates the fibroblast to enhance the collagen and DNA synthesis. You increase the number of receptor sites for your growth factor interface. And you can increase the migration and the proliferation of cells at the wound site, particularly the neutrophils, the microphages, and the fibroblast. Some of the physiological affects continued include, so you increase your collagen deposition, you decrease your edema, you decrease wound pain, wound-related pain, you decrease peripheral neuropathy pain, and you have bactericidal effects with this particular energy. One of the problems with electrical stimulation within the research parameters is there are different currents. There’s your low-volt direct current, your high-volt direct current, your transcutaneous electrical nerve stimulation, your microcurrent. It doesn’t matter which current you use. They all work, which is a problem in research. We want to have our parameters very set. Some of the research people that say we’re looking at the strength of evidence for electrical stimulation, they didn’t want to give it a strength of evidence A, because all of the currents worked. We couldn’t say which one work the best. However, traditionally in wound care, we use high volt pulsed galvanic electrical stimulation the most when we’re talking about some of our machinery. What we’re doing is we’re taking these externally applied electrodes. We have to have two electrodes. When you use electrical stimulation you have to have two electrodes. You can apply it directly into the wound such as you see here. You can bracket the wound. Because the skin is gone, the skin impedance is gone, and so the current is going to go directly between the electrodes. Or you can use a stocking or glove electrode placement. This particular patient has lost her left leg. She’s lost her second toe. And we are literally trying to leave her leg to stand on for her to do her pivot transfers from the bed to the wheelchair, from the wheelchair to the commode, from the wheelchair to the shower chair. She still has some quality of life. Imagine what’s going to happen if she should lose her second leg related to functionality. Also, a new technology that I really am so glad has come to us is a dressing that has a microcurrent. And it, again, stimulates this physiologic current of injury to help accelerate wound healing. And everyone of these little dots will emit a small electrical current to enhance the wound healing. We’ve gone beyond using a unit that you either run on batteries or you plug into the wall and now we have this dressing with a current that is actually embedded into the dressing. Indications for electrical stimulation, it does not matter what the etiology of the wound is. It’s good for pressure ulcer, venous insufficiency, arterial insufficiency. I’ve gotten incredible outcomes in people with arterial insufficiency.

[10:03]

Diabetic neuropathic foot ulcers, burns, dehisced surgical wounds, it doesn’t matter. This is one of my patients. A very interesting gentleman. They didn’t want to take him into the long-term care facility where I worked, because he was a physical therapist. They thought he would be difficult. I don’t know what it is about physical therapist. We’re really nice people. But they didn’t want to take him. But we talked them into letting him into the facility. He’s lost his toes already. The toes are gone. All of them are gone. He has a pressure ulcer on his heel. For some reason, the podiatrist had ordered platelet-derived growth factor. Now we know the FDA approved reason for the platelet-derived growth factor. However, this podiatrist wanted this particular medication used on this wound. And I thought, yes, because the wound doesn’t know its etiology. All it knows is if it has blood flow and a clean wound better not. We started with debridement, electrical stimulation using the stocking method. Once we got the wound cleaned up, we started the platelet-derived growth factor and we added infrared light. Now I had a gentleman with an ABI, an ankle-brachial index of 0.51. He’s already lost his toes. He has severe arterial insufficiency. I’m pulling out everything I can to try to ensure that this man doesn’t lose anymore of his foot or his leg. We got him closed in six weeks with an ABI of 0.51. Do you think that’s impressive? I thought it was impressive. Absolutely. When we’re using electrical stimulation, it can be either first line or adjunctive treatment. It should be used in combination with other moist wound healing interventions, electrical stimulation. Now we’re going to talk about diathermy. This is an older energy. It’s been around for a long time. It’s been used in wound care for about 50 years. Anybody in here using diathermy still? Does see any hands? No. Alright. Diathermy is electromagnetic energy that produces heat within the tissues. The heated tissue, it’s heated for about 3 to 5 centimeters below the surface of the skin without overheating the skin or the subcutaneous tissue. The treatment is applied using the specialized machines and these coils, which I’ll show you in just a moment for diathermy. It really does get wonderful outcomes. I’ve used this as a sports medicine physical therapist, and when we look at our sprains and strains, and the same thing for electrical stimulation. Anybody in here ever had a sprained ankle? Anyone ever had a sprained ankle? When you have a sprained ankle, you have thorn your ligaments and/or tendons within under the skin. It is a closed injury. These are some of the modalities or energies that I’ve used as a sports medicine and an orthopedic physical therapist. Diathermy is one of these. What we’re doing is using the specialized machine that has these coils that delivers this electromagnetic energy. What it does is it decreases the joint range of motion. It helps the decreased joint range of motion to increase the joint range of motion. It accelerates healing. There’s pain control, edema control. It actually contributes to bone and nerve healing also. We have our thermal effects and non-thermal effects from the diathermy. When we look at the thermal effects, you get deep heating to the tissue. When we look at the non-thermal effects, you’re not going to get heating but you are going to increase blood flow to the area, increase oxygen and nutrient availability and increase the cell growth and division. What I wanted to show you here, I finally found a photograph that showed you the diathermy coils, because the drums are usually covered and you’re not able to see what’s underneath. I’m one the people that wanted to see what’s underneath. I’m very curious person. This, again, here’s your drum, and of course the drum is going to be covered. You’re not going to see the coils. This is the drum with the cover off. You’re going to have your increased cutaneous circulation. You’re going to have decreased inflammation, edema reduction, lymphedema reduction, accelerates your wound healing. It helps to treat wound-related pain and decrease hematoma formation. These are some of the different electrode variations that you can put on different parts of the body. Phototherapy. Within the light spectrum and what we use specifically for wound care, we have our ultraviolet light.

[15:00]

And we have our infrared light on opposite ends of a light spectrum. That’s what this is depicting, your ultraviolet and your 400 nanometers. Then your infrared is in your 750 to 800 nanometers. The word “photobiomodulation” is what happens in nature and also happens with people. I was just talking with somebody from San Francisco. He says the weather bothers him. He has the seasonal affected disorder. Because we are biological entities, that light affects us very strongly. Some people more strongly than other. Photosynthesis, when we think about what plants do, it is the process of photobiomodulation. This is a term that describes the regulating effects of light energy upon the cellular components including humans. This photo energy is converted into a chemical energy for a biological effect. Within this spectrum, we have something known, as in there’s different names for this, low level laser therapy, low intensity laser therapy. It’s also known as cold laser therapy, photobiomodulation, monochromatic infrared energy. All of these are synonyms for this particular light energy with just in the red spectrum. How many of you ever used this particular device in your clinical practice? Anyone used any of these? Show me hands. Anyone used this? One person, alright. I’m going to tell you a secret. I sleep with one. Is that good? It goes to bed with me. My husband is one side, the machine is on the other side. It keeps this lady’s joints going. When we look at low level light therapy, a summary of the research shows that it reduces pain and inflammation, turns on the synthesis and repair of DNA and RNA, expands collagen production, proliferate nerve growth sprouting. We’ve had people who have said using this energy that their peripheral neuropathy pain has decreased. Let me back up. With electrical stimulation, we’ve also had decreased peripheral neuropathy pain. It also facilitates neovascularization, so you’re going to get increased granulation tissue formation. It reduces in discharges, your lymphatic congestion. It’s going to help with your lymphedema patients. It induces a whole host of other enzymatic responses. It enhances the immune system, diminishes scar tissue and adhesion formation, and increases the ATP production and more. The problem with this particular energy is we’re not able to show in the research the outcomes that we were seeing in clinical practice. I don’t understand why. I’m not a researcher, I’m a clinician. But we were not able to show in our research that this energy is reproducible for the outcomes. It didn’t stop me from using it because I’m getting the outcomes using it, whether the research supported it or not. I will still use it in clinical practice. I may not get reimbursed for it but sometimes it’s beyond reimbursement. How many in here do things in your clinical practice for which you’re not getting reimbursed because it’s the right thing to do? Show me. Almost everyone in here has raised their hands. This was one of my patients with longstanding, a 10-year history of venous insufficiency. He has diabetes. When you touch his skin, he has what’s called lipodermatosclerosis. When you touch his skin, it feels like elephant skin. It is tough. You can tell it’s sclerosed underneath. Here’s the top of the wound on his leg. And look, it’s 360. It goes all the way around. You can see this hemosiderin staining that goes all the way up to his knee. He’s had this five-year non-healing wound. We started with compression and low level light therapy. That’s all we did. Compression, the appropriate compression, I got him in a compression device that he would use and low level light therapy. Here we are two weeks, look at the skin. Can you see what’s happening to the skin? It’s changing. Let’s go back here. Here we have the lipodermatosclerosis. It feels like elephant skin. Look what’s happening here using the laser therapy, low level light therapy. Look at the skin. Look at what the wound is doing. This is where we started. This is where we ended. Eight weeks later, we have arterial insufficiency, diabetes, five-year open wound. Eight weeks later and look at the skin, the texture of the skin.

[20:08]

I don’t care what research says. I’m using this intervention because I get incredible outcomes. This is a nurse who’s lost her left leg to arterial insufficiency. She has arterial insufficiency and venous insufficiency and lymphedema. Look at those toes. If you do a Stemmer’s sign on this lady, you’re going to have a positive Stemmer’s sign which indicates that you have lymphedema. We have an open wound here. Because this is light therapy, you have to be able to get the light through whatever you’re covering the wound with. I don’t want my diodes. I don’t want my low level light therapy pad in that wound. So I put it in a plastic baggy and the light can go right through. In that way I keep my pads clean. And we were able to get her closed also. Ultraviolet light. Anybody in the room used UV light as part of your rehab? Which energy, which UV are you using?

Male Speaker: [Indecipherable] [21:17] UVB for psoriatic lesions.

Pamela Scarborough: UVB. Okay, right. For psoriatic lesions?

Male Speaker: [Indecipherable] [21:27]

Pamela Scarborough: Okay, alright. UVB does help with this kind of things. But what I’m going to talk about particularly right now is UVC. Let’s talk about the properties of UV. It is a component of sunlight. It encompasses the wavelengths between 180 and 400 nanometers. There is the three spectrums. The UVA is the one that tans us. UVB produces a skin erythema. And if we get too much natural UVB, it can be carcinogenic. Then the UVC, what’s wonderful about this particular spectrum is it’s bactericidal and virucidal. Both. What we use UVC for primarily is to stimulate the wound healing but also for the bactericidal effects. That’s really what you want to star for UVC, is the bactericidal effects. The studies for UVC started in the 1940s. We’ve had the research related to pressure ulcers and venous insufficiencies showing that we have the enhanced healing. It’s beneficial for producing this mild inflammatory response that helps with the wound healing. Now UVC, this particular light spectrum, helps to eliminate surface bacterial bioburden. How many of you in the audience are using things like triple antibiotics topically? Anybody in the audience using something like triple antibiotics topically? Alright, several hands are going up. You might want to consider this as an alternative to antibiotics, because you can treat the surface bioburden even when other methods have failed or in conjunction with other topical methods. It’s effective and safe for combating the development of a surface infection. You can use, with infective wounds, where you have poor circulation. When you have poor circulation, one of the things I want you all to think about, whether it’s macro or micro, when we have decrease circulation particularly in the lower extremity, you put the big gun antibiotics on. You put the Cipro on. You put the IV antibiotics on. If there’s no blood flow or decreased blood flow, it doesn’t matter which antibiotic you use. Sometimes you want to use energies to increase the antibiotic delivery to the area. I would recommend electrical stimulation for that. You might also use the UVC to help increase delivery of the antibiotics for the systemic antibiotics. It can be a replacement for topical antibiotics. What’s the problem we’re having with antibiotics worldwide? Particularly in the United States, what’s the problem? Resistance. Resistance. What other interventions can you use when you suspect or having an infection that will allow you not to use antibiotics? This is one of the energies that you can use. You can use it to treat some of the resistant species of bacteria, which I’ll show you in just a moment. I just mentioned that it’s compatible with systemic antibiotics. And it is something that you use in conjunction with your other wound healing practices.

[25:04]

Now look at this with me. One of my colleagues, Teresa Konoker [Phonetic], brilliant. She’s a biologist and a physical therapist and has done some wonderful research for us. She did some research on the bactericidal effects of UVC. Look at this. Staph aureus, 45 seconds, 100% kill rate. MRSA, 90 seconds, 100% kill rate. VRE, 45 seconds, 100% kill rate. Is that impressive to you? It was impressive to me. And we’re not using the energy. Alright, let’s go into a mechanical and acoustic energy. As I said earlier, whirlpool is not used as much. And it is, again, contraindicated for venous insufficiency and diabetic neuropathic foot ulcers. We have two frequencies for use when we’re talking about ultrasound. We have high frequency which is traditional ultrasound, and then we have a newer frequency which is 20 to 120 kilohertz. When we talk about ultrasound and wound healing, it’s been used for 50 years. What happens is the ultrasound oscillates very rapidly beyond human hearing and it causes the molecules and the cells to vibrate. We have our traditional use of high frequency ultrasound. You’re 1 in your 3 megahertz. How many have used this in clinical practice? I see several physical therapists’ hands going up for sure. I used this quite a bit in sports medicine and in musculoskeletal injuries for those closed wounds. Then we have our non-contact low-frequency ultrasound. Anyone using this particular device in your clinical practice now? I’m seeing several hands. Outstanding. Then we have our low-frequency contact. We have non-contact and contact low frequency ultrasound. Show me the hands that are using contact low frequency ultrasound. Okay. When we look at traditional high frequency ultrasound, it increases the mast cell degranulation, increases the vascular permeability, releases the growth factors, increases capillary density. It helps with the calcium uptake and the fibroblast so the fibroblasts become more active, increases collagen synthesis. It actually increases the tensile strength of the elasticity of the collagen. The treatment usually is three to five times a week for 1 minute not to exceed over 15 minutes. Low frequency ultrasound is indicated for locally infected wounds, wounds with impaired circulation, wounds that need debridement. And it is good for almost any type of etiology of wound. One of the things, when this energy first came out and they started doing some of the studies in the lab it was fascinating to me to have an understanding of what low-frequency ultrasound did to bacteria. It actually blows it up. It blows up the bacteria. So my question for the companies that sell the devices and for the researchers was why does it blow up the bacteria but doesn’t damage the fibroblast? This was the answer that I got. Do you all want to know the answer? Anybody want to know the answer? Okay, good, I’ll give it to you. What it does, the fibroblast, the cells that are alive and normal within the wound, the outer casing of the cells, they’re malleable. They’re soft and they’re malleable, like a rubber ball. Bacteria on the other hand, have a hard shell casing. We’re going into Christmas, let’s think about glass Christmas ornaments. When you drop a glass Christmas ornament, what does it do? It shatters. It shatters. This is what happens when this energy hits the bacteria because they have this hard casing, which is to protect them.

[30:03]

But it doesn’t protect them from low frequency ultrasound. That actually get blown up, which is what you’re seeing here. That’s why we don’t damage the good cells that are in the wound when we’re doing the low frequency ultrasound. This time, as far as I know and I don’t think there’s anymore, there are four different low-frequency ultrasound units. They have different kilohertz energies that they deliver. These three are going to do our contact and this particular one can be contact or non-contact low-frequency ultrasound, this one in the middle. Then this particular one is non-contact low-frequency ultrasound. Intermittent pneumatic compression. Who’s using pneumatic compression in your clinical practice? What are using it for?

Female Speaker 1: Lymphedema.

Pamela Scarborough: Lymphedema primarily? Anybody else? Yes, sir?

Male Speaker 1: Arterial insufficiency.

Pamela Scarborough: Venous insufficiency.

Male Speaker 1: Arterial.

Pamela Scarborough: Arterial insufficiency. Anybody using it for venous insufficiency? Three great reasons. Lymphedema, arterial, and venous. When we look at compression, and venous insufficiency specifically, compression is a mainstay of treatment. And of course it can also be used for lymphedema. Do I have any LMD therapists in the room? Any LMD therapists in the room? If you are what I call a purist, when I was taking my lymphedema training, pneumatic compression was considered a no-no. Has anybody ever heard that? It was considered a no-no, because some of the purists felt that the sequential compression devices harm the lymphatic which are very close to the surface of the skin. The lymphatics are very close to the surface. However, we have more sophisticated units now. If you are having trouble with some of your lymphedema patients, getting those legs down, particularly if you don’t have an MLD therapist wrapping, doing the MLD therapy and wrapping for you, then I will suggest that you try this with your lymphedema patients. We have our arm units, the leg units. Look at this one, a full body lymphedema compression device. I’m claustrophobic. I will have a very hard time in there, I have to tell you. Pulse lavage with suction. There are certain things as you go along in your clinical career. Because we have residents in the room, we have seasoned clinicians in the room. There are going to be times when you go through your clinical practice that they’re going to be things that change your practice. As a physical therapist, this was one of the energies that change the practice of wound care for me. Prior to this, prior to pulse lavage with suction, my patients had to go in the whirlpool. That’s what I had. The nastiest of the nasty wounds were sent down to my hydro room, which is how physical therapy actually got into wound care. The nastiest wounds came down to hydro. We clean them up, debrided them, and sent them back to the floor. Pulse lavage with suction was initially used in the operating room to clean out the medullary canal to put in the titanium prosthesis for the joint replacements. In the late ‘80s, the story goes there was a physical therapist that was in OR watching this, light bulb came on. Ding, ding, ding, if we can clean up this stuff out of the medullary canal, could we clean wounds out and not have to do so many whirlpools? Because whirlpools, first of all they’ve very expensive, very time-consuming, and they’re not always appropriate for our patients. So the physical therapist wondered if we lower the pounds per square inch of pressure, would we be able to use this device. Sure enough, this is what we did. And it does wound irrigation and debridement. It cleanses the wound and enhances the soft tissue healing within the wound. The theory and the science of pulse lavage with suction is it does do the cleansing with a gentle pulsing lavage that takes place. You don’t want to go over 15 pounds per square inch. We actually have the research and the evidence that shows if you keep your pulse lavage with suction below 15 pounds per square inch of pressure, that you’re not going to drive bacteria into the wound bed and you’re not going to harm the granulation tissue.

[35:05]

Is anyone using pulse lavage with suction in the room today? Anyone using it? Alright, I do see a hand. I see several hands. Wonderful. I love the synergy. It reduces the bacteria, contamination in the wound bed, reduces your infections. It promotes angiogenesis. When the pulse lavage is hitting that wound bed and it’s hitting the granulation tissue, it’s going to upregulate and excite the fibroblast. It actually contributes to angiogenesis and granulation tissue formation. There was the theory, also, that the negative pressure, this was her first negative pressure, was pulsatile lavage with suction. That suction as we know with our negative pressure wound therapy, stimulates the cells and the granulation tissue formation. This is Dr. Harriet Lawn [Phonetic]. Harriet is truly the queen goddess of pulsatile lavage with suction. She will go places with her probes that I would never go. I’m not that brave. She’ll go into fistulas. I’m just not that brave, but she is. She’s also been a pioneer with this particular energy and holds the patent for the flexible cone. The original cones for pulsatile lavage with suction were hard rigid cones. Harriet actually went to one of the companies and said, “I need a malleable cone, because the wound edges are often not uniform. I need to be able to move around in that wound bed and also not harm the tissue in there.” She got us, the malleable cone. This is one of her burn patients, an outpatient burn patient. This is where hot coffee was spilled on her. This is called injury. And she starts with her pulsatile lavage with suction. In a very short time this is where she is. Now, with this particular energy, you do need to think about pain control. You do need to think about pain control for sure. It eliminates the whirlpool except limited circumstances. Again, this is an energy that changed the practice of wound care for the profession of physical therapy. Negative pressure wound therapy I’m not going to go into this in any great detail, because I feel like we’ve been pretty well educated on this. But I just wanted to mention it, because it is one of the energies that we want to use. The definition of negative pressure wound therapy is the controlled application of a sub-atmospheric pressure to a wound to intermittently or continuously convey pressure through the connecting tubing to a specialized wound dressing to promote healing. How many of you are using negative pressure? Show me hands? Most of us are using it. This is another energy that changed the face of wound care. The proposed mechanism of action, it does provide a moist wound environment, reduces the edema, improves perfusion, decreases a bioburden. The micro deformations that you get upregulates the fibroblasts and contributes to the granulation tissue formation. It decreases the bacterial colonization and enhances the epithelial migration. These are some. I couldn’t even put all of the negative pressure devices in the photograph. This is some. Many of the negative pressure wound devices that we have in our industry right now. What do you need the energy to do? This is your question. What do I need the energy to do? Do you need to debride? If you do, consider contact, low frequency ultrasound or pulsatile lavage with suction. Do you need to decrease the bioburden and the chronic inflammation? If you do, consider electrical stimulation, pulsed lavage with suction, low frequency ultrasound, phototherapy, negative pressure wound therapy. Do you need to decrease the edema? If you do consider compression, negative pressure wound therapy, electrical stimulation, diathermy. Do you need to facilitate this stalled wound to get it going again? Consider all of the energies, e. stim, low frequency ultrasound, diathermy, phototherapy, negative pressure, wound therapy, and pulsatile lavage with suction. Who should apply the energies? Great question. I have nurses asked me this question a lot. Because I have to tell you, physical therapists are little bit possessive about using these energies. Am I right? Yes. I know we are. It’s okay. This is who should use these energies. Should be directed by and under the supervision of a skilled licensed professional. Health care professional who’s educated and trained in a safe and effective selection application and monitoring of these different energies.

[40:13]

You do need to be trained in this. These are the references that go along with this particular talk. We have a few minutes. If someone would like to make comments or ask questions, we have some microphones in the aisle and we’d love to hear from you either comments. If you’ve used this, please comment, or if you have questions. I’d love to hear some comments of people of what you’ve seen in clinical practice. Hello.

Male Speaker 2: That was very nice. I enjoyed it.

Pamela Scarborough: Thank you.

Male Speaker: Thank you for delivering it so nicely. The problem with the application at least in the practical point of view, the electrical stimulation.

Pamela Scarborough: The electrical stimulation.

Male Speaker: What kind of protocol do you use? Where do you do it? The patient come to your office, he’s an outpatient. Do you apply a TENS unit? How do you do it?

Pamela Scarborough: How do you do it?

Male Speaker: What kind of equipment do you use?

Pamela Scarborough: Great question. Steve, would you please take me back home? Please take me back home at the very beginning. Great question. Are you doing it as an outpatient? Are you sending the electrical stimulation home with the patient? And I’ve done both. I’ve actually done both. Let me show you. Here we go. This is going to be something that I’m going to do in a clinical environment or maybe in long-term care, where I’m putting the electrodes on and I’m using it for 30 to 45 minutes. You can even go up to 60 minutes. You cannot overdo electrical stimulation. This is going to be a clinic application. There are other applications that I’ve been known to send the patient home with. This particular unit is a little handheld unit. This stocking is something that the patient can put on themselves. Then they can actually do this everyday at home. This particular gentleman in the long-term care facility, because we are striving so hard to make sure he had no more amputations, we did this, six days a week. My physical therapist’s assistant came in on Saturdays because we were in a limb salvage fight. I felt like we need to do this every single day. Because we are in long-term care, we have that luxury. In general, electrical stimulation is applied three to five times a week. If you think you need to do it every single day, then figure out a way to do it. With a training, you can see it down here, this little device, it was on and off and then they just increased the intensity. This man had peripheral neuropathy so we didn’t have to worry about it. Because electrical stimulation can be kind of shocking, I’m sorry, I couldn’t help myself, when you first put it on. And it can be startling to someone. But he couldn’t feel it because he had neuropathy. That’s what we did with him. Did that answer the question? Traditionally, it’s three to five days a week. This gentleman, we did it six days a week. We were in limp salvage situation. Some people cannot get to their wound and so it’s going to have to be a clinic application. And there is reimbursement under the rehab codes. There is reimbursement if you get your physical therapist involved. This unit, I could take this little bit of unit to my people who had arterial insufficiency and use it on venous insufficiency. Also, this little bit of unit goes from patient to patient to patient. The stockings are one-patient use. That belongs to that patient. Great question. Thank you so much. Any other comments or questions about any of these energies? Alright, I want to thank you very much for your attention this morning at 6 a.m. You’ve been wonderful. Thank you so much.