Using Physical Modalities in the Treatment of Venous Leg Ulcers: A 14-year Comparative Clinical Study
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Index: WOUNDS. 2012;24(8):215–226.
Abstract: Venous ulcers are prevalent, challenging wounds; their incidence is rising with the increasing age of the general population. Physical modalities often are used to help heal these chronic wounds. A prospective study was conducted to investigate the application of high-voltage stimulation (HVS), ultrasound therapy (US), low-level laser therapy (LLLT, 810 nm, 65 mW, 4 J/cm2), and compression therapy (CT), with and without surgical intervention; along with standard of care comprising drug therapy (micronized flavonoid fraction in two 500-mg tablets once daily) and wet dressings of 0.9% sodium chloride on venous leg ulcer healing. Methods. The 305-patient study was conducted between 1994 and 2008 among persons with venous ulcers in 3 facilities in Poland. After surgery involving crossectomy, partial [short] stripping of the greater or short saphenous vein, local phlebectomy, and ligation of insufficient perforators, 4 groups of patients were treated with the standard of care drug/dressing therapy and HVS, US, LLLT, or CT, and 1 group received the drug/dressing therapy only. Four non-surgical groups received HVS, US, LLLT, or CT and drug/dressing therapy, and 1 group received drug/dressing therapy only.
Changes in wound area and volume were compared among all the groups receiving the various treatments using the Gilman index. In all groups therapy lasted 7 weeks. The computed planimetry method for observation of healing process was used. Results. The Gilman index values at 4 weeks were significantly higher in the compression plus surgery compared with other groups (P = 0.01). After therapy for patients from the CT + surgery group, the Gilman index was 1.18 cm (P ≤ 0.001 compared with other groups). The percentage total surface area regression analysis confirmed that compression plus surgery is the most efficient in venous leg ulcer therapy (61.89% reduction after 4 weeks of therapy and 78.19% at the end of study) compared to the other groups (P ≤ 0.001). The HVS and US appeared useful only in conservatively treated patients (P < 0.05). The LLLT did not accelerate reduction of the ulceration surface. Conclusion. Venous surgery plus compression therapy is the most efficient treatment for venous leg ulcers. Compression therapy should be provided to both surgically and conservatively non-surgically treated patients. High-voltage stimulation and ultrasound therapy are useful methods in conservative treatment of venous leg ulcers. For surgically treated patients, these physical modalities are not effective. Low-level laser therapy is not an efficient method for treating venous leg ulcers.
Venous ulcers represent the most prevalent form of difficult-to-heal wounds and require a substantial number of health care resources for their treatment. The incidence of venous ulceration is rising with the increasing age of the general population. The most common cause of lower extremity ulcers is venous insufficiency, which accounts for nearly 80% of all venous ulcers.1
Risk factors for development of venous ulcers include venous disease, obesity, immobility, family history of varicose veins, deep vein thrombosis, previous surgery for varicose veins, and congestive cardiac failure. Up to 50% of patients with chronic venous insufficiency have a history of leg injury.1,2
Physical modalities often are used to help heal chronic wounds such as venous leg ulcers. Although clinical studies have examined the effects of compression therapy on leg ulcers,3-5 the trials evaluating electrical or electromagnetic therapy, ultrasound, and laser irradiation are small, poor-quality, and heterogeneous.