Physical Therapy in the Treatment of Venous Leg Ulcers: Biophysical Mechanisms
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Patients in group 5 received 1 quasi-CT procedure.
All patients were evaluated using the Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) classification for chronic venous insufficiency (Table 1). Patients from all comparative groups received a single physical therapy procedure.
For HVS in group 1, a constant current generator was used (Ionoson, Physiomed Electromedizin AG, Germany). Double peak, monophasic impulses of 100 µs and a frequency of 100 Hz were applied. The voltage was set at 100. Stimulation was performed with a current that produced no motion effects, only a tingling sensation. Electrodes were made of conductive carbon rubber. The active electrode (cathode) size was matched to wound size, and placed on saline soaked gauze directly on the wound. The passive electrode (anode) was positioned above the knee joint, on the frontal surface of the patient’s thigh. The duration of procedure was 50 minutes (Figure 2).
Patients in group 2 received the US procedure. A Sonicator 730 apparatus (Mettler Electronics Corp, Anaheim, CA) was used to generate the acoustic beam. The power density was 0.5 W/cm2 (spatial average, temporal average). A pulsed wave with a duty cycle of 1/5 (impulse time = 2 ms, interval = 8 ms) set at 1 MHz frequency was used. The procedures were performed in a water bath with a temperature of 34˚C. The ultrasound probe had an area of 10 cm2 and was placed 2 cm above the wound. The duration of a single procedure was dependent upon the ulcer size—1 minute for each 1 cm2 of ulcer area (Figure 3).
For LLLT in group 3, a 810 nm semiconductor GaAlAs laser (CTL-1106MX, Elektronika i Elektromedycyna sp., Poland) emitting a continuous wave was used. The laser head contained a single diode (High Power Devices, Inc, North Brunswick, NJ). The cross section of the beam emitted from the head was rectangular in shape (2 mm x 5 mm, or 10 mm2). The laser was wired to a CTL-1202S scanner (Elektronika i Elektromedycyna sp., Poland). The laser beam scanned the surface at the following frequencies: in the ordinate axis at a frequency of 20 Hz, and in the abscissa axis at a frequency of 0.5 Hz. The average output of the radiation was 65 mW. The output power was checked every week with a Mentor MA10 apparatus (ITAM, Zabrze, Poland). The scanning frequency was set at 0.5 Hz. The scanner was placed 50 cm from the ulcer surface. The duration of a single procedure was relative to wound size, and was adjusted in order to obtain an average dose of 4 J/cm2 (Figure 4).
Patients in group 4 received medical compression stockings (Sigvaris 702, Gianzoni & Cie AG, Switzerland) providing 25 mmHg–32 mmHg of pressure at the ankle. The stockings were placed on the leg at the outpatient clinic in the morning and were worn the entire day (about 10–12 hours). The stockings were taken off at night.
In group 5, common stockings (noncompression) were used for quasi-CT. The stockings were placed on the leg, applying the same methodology as in group 4. Quasi-CT was employed in order to estimate the role of convection and evaporation streams.
The MobIR 3 (Wuhan Guide Infrared Technology, China) infrared camera was used in this study, and is an uncooled long wave detector UFPA (third generation uncooled micro bolometer sensor 8 µm–14 µm) with a thermal sensitivity of 80 mK. The infrared camera was connected to a portable computer through a special interface. All images were stored on the computer for further analysis (Figure 5). Image analysis was performed with Guide IrAnalyser V1.4 researcher software (Test-Therm, Poland).