Wound
Healing }

Pathology

Diabetic foot ulcer, pressure ulcer and venous stasis ulcer are the most common chronic skin and soft tissue wounds. A chronic wound is usually one that has failed to heal within three months.

Diagnosis is based on the clinical features of the disease. The incidence is approximately 1%, with chronic wounds mostly affecting people 60 years or older. Accordingly, the number of chronic wounds will rise as the population ages.

Factors that contribute to chronic wounds include poor circulation, (diabetic) neuropathy, bacterial colonization and infection, systemic illnesses, age, repeated trauma, vasculitis, immune suppression (including the use of steroids over a long period), but also emotional stress.

According to the University of Texas Wound Classification system, wounds are categorized into four stages (A: without infection and ischemia; B: with infection; C: with ischemia; D: with infection and ischemia) and four grades (0: pre- or postulcerative lesion completely epithelialized; 1: superficial wounds, not involving tendon, capsule or bone; 2: wounds penetrating to tendon or capsule; 3: wound penetrating to bone or joint). Wound healing is classically divided into four phases (i: hemostasis; ii: inflammation; iii: proliferation; iv: remodeling) with considerable overlapping among individual phases.

These phases are controlled by a wealth of growth factors that are involved in wound healing such as vascular endothelial growth factor (VEGF), epidermal growth factor (EGF) and transforming growth factors α and β (TGF-α and -β), to mention only a few. Inadequate levels of growth factors may also contribute to the formation of chronic wounds.

Therapeutic strategies for chronic wounds are aimed at preventing and treating infection, fighting ischemia, and replacing and/or stimulating growth factors. This can be achieved by surgical wound debridement, application of hyperbaric oxygen, negative pressure wound therapy, and topical and systemic application of molecules such as cell adhesion proteins, cytokines, enzymes, or EGF-like growth factor. Mesenchymal stem cell therapy has become another potential future target for intervention.

Recently radial shock wave therapy (RSWT) was introduced into the management of chronic wounds (Stages/Grades A1 and A2, as well as C1 and C2 with great care), based on its proven abilities to improve the functional microvasculature, stimulate expression of growth factors such as VEGF, and increase cell proliferation. RSWT is particularly interesting for those chronic wounds that are too small for negative pressure wound therapy.

Treatment Procedure

1. PALPATE
Locate the area of pain through palpation and biofeedback.

2. MARK
Mark the area of pain.

3. APPLY GEL
Apply coupling gel to transmit shock waves to the tissue.

4. APPLY SHOCK WAVES
Deliver Radial or Focused Shock Waves to the area of pain while keeping the applicator firmly in place on the skin.

Recommended Settings

Swiss
DolorClast }

  Treatment
Number of treatment sessions 10
Interval between two sessions 2 times a week
Air pressure Evo Blue® 2 to 4 bar
Air pressure Power+ 1.5 to 3 bar
Impulses 200 - 300 impulses / cm2 point
Frequency 8Hz to 12Hz
Applicator 36mm
Skin pressure Light to Moderate

Clinical Proofs

Armstrong DG, Lavery LA, Harkless LB.
Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21:855-859
http://care.diabetesjournals.org/content/21/5/855.full.pdf+html

Ottomann C, Thiele R, Hartmann B.
Beschleunigte. Reepithelisierung einer IIb°-Verbrühung durch extrakorpo rale Stoßwellentherapie – Fallvorstellung [Accelerated reepithelisation of a IIb° scald through extracorporeal sho ck wave therapy]. GMS Verbrennungsmed 2009; 3:1-4
http://www.egms.de/static/pdf/journals/vmed/2009-3/vmed000005.pdf

Rompe JD.  
Extrakorporale Stosswellentherapie, Thieme, Stuttgart, 1997
http://www.amazon.de/Extrakorporale-Sto%C3%9Fwellentherapie-Grundlagen-Indikation-Anwendung/dp/3131136413

Schaden W, Thiele R, Kölpl C, et al.
Shock wave therapy for acute and chronic soft tissue wounds: a feasibility study. Journal of Surgical Research 2007;143:1-12

Wang CJ, Kuo YR, Wu RW, et al.
Extracorporeal shockwave treatment for chronic diabetic foot ulcers. Journal of Surgical Research 2009;152:96-103
 

Risks

Side effects of Radial Shock Wave Therapy (RSWT®) using the Swiss DolorClast®

When performed properly, RSWT® with the Swiss DolorClast® has only minimal risks.
Typical device-related nonserious adverse events are:

  • Pain and discomfort during and after treatment (anesthesia is not necessary)
  • Reddening of the skin
  • Petechia
  • Swelling and numbness of the skin over the treatment area

These device-related nonserious adverse events usually disappear within 36 hours after the treatment.

Accordingly the following contraindications of RSWT® using the Swiss DolorClast® must be considered:

  • Never treat an infected wound with shock waves as they might disseminate bacteria from the wound into the body, possibly resulting in systemic infection and ultimately sepsis
  • Never treat a grade III wound with shock waves as direct exposure of bones or joints to shock waves leads to incalculable risks
  • Never treat a necrotic wound with shock waves as the tissues cannot regenerate and must be removed
  • Treatment over air-filled tissue (lung, gut)
  • Treatment of pre-ruptured tendons
  • Treatments of pregnant women
  • Treatment of patients under the age of 18 years (except for Osgood-Schlatter disease and muscular dysfunction in children with spastic movement disorders)
  • Treatment of patients with blood-clotting disorders (including local thrombosis)
  • Treatment of patients treated with oral anticoagulants
  • Treatment of tissue with local tumors or local bacterial and/or viral infections
  • Treatment of patients treated with cortisone

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