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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 79-82

Combined effect of low-level LASER and kinetic chain activation on wound healing : A case report


Department of Orthopedic Manual Therapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission22-Apr-2022
Date of Decision05-Jun-2022
Date of Acceptance05-Jul-2022
Date of Web Publication30-Jul-2022

Correspondence Address:
Ms. Deviya Narahar Thakur
Post Graduate, Department of Orthopedic Manual Therapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_104_22

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  Abstract 


The management of chronic and nonhealing wounds involves the use of electrotherapy including low-level LASER therapy (LLLT), ultraviolet rays, infrared radiation, and transcutaneous electrical nerve stimulation (TENS). Evidence suggests that kinetic chain activation results in fascial mobilization needed for rapid wound repair. However, the combined effect of electrotherapy and fascial mobilization by kinetic chain activation on wound healing is not known. This case report highlights the effect of a novel rehabilitation model integrating LLLT, TENS, and kinetic chain activation on wound healing. This study was conducted on a 46-year-old female who presented with a nonhealing wound on the plantar aspect of the foot. A positive outcome was observed in terms of pain reduction, improvement in wound size, and functional independence

Keywords: LASER therapy, Physical therapy, Superficial fascia, Transcutaneous electrical therapy, Wound healing


How to cite this article:
Metgud S, Thakur DN, D'Silva PV, Deshmukh SM. Combined effect of low-level LASER and kinetic chain activation on wound healing : A case report. Indian J Phys Ther Res 2022;4:79-82

How to cite this URL:
Metgud S, Thakur DN, D'Silva PV, Deshmukh SM. Combined effect of low-level LASER and kinetic chain activation on wound healing : A case report. Indian J Phys Ther Res [serial online] 2022 [cited 2022 Nov 27];4:79-82. Available from: https://www.ijptr.org/text.asp?2022/4/1/79/353013




  Introduction Top


Chronic wounds impose a significant and often underappreciated burden to the individual, the health-care system, and society as a whole. The role of physiotherapy in wound care has evolved considerably with the advancement in medical practice and a deeper understanding of anatomical connections toward tissue repair. The prevalence of wounds in the community across India with emphasis on chronic lower extremity wounds reported the prevalence to be 4.4/thousand populations. Wound management is a multidisciplinary approach involving various pharmacological, surgical, and physiotherapy approaches along with patient education, maintenance of hygiene, and meticulous care of the affected area.[1],[2],[3]

Remarkable efforts have been made to substantiate the use of physiotherapy to stimulate wound healing in recent years. Some of the most common electrotherapeutic modalities used in wound management include low-level LASER therapy (LLLT), ultraviolet rays, infrared radiation, and transcutaneous Electrical Nerve Stimulation (TENS). There is supporting evidence that LASER therapy works on the principle of photobiomodulation.[4],[5],[6] LLLT is widely used in the management of wounds and ulcers for healing, pain reduction, treating inflammation, improving blood circulation, and enhancing lymphatic drainage.[5] The use of TENS is based on the rationale that an endogenous micro electric field created within the tissues causes the migration of epithelial cells for healing.[1]

The kinetic chain activation technique is a concept developed by Dr. K. M. Annamalai based on the theories of Ida Rolf, Antonio O Carlo, and Tom Meyer. These techniques involve the activation and mobilization of fascia along the fascial chains. There is limited literature available on the effect of fascial mobilization for wound healing.

To the best of our knowledge, the combined effects of electrotherapy and kinetic chain activation technique on pain and healing have not been studied in chronic wounds. Hence, this study aimed to find the same.


  Case Report Top


A 46-year-old female with a body mass index of 35.34 kg/m2, a known case of hypertension for the past 5 years, nondiabetic, had a stone prick to her right heel, with no history of bleeding or break of skin, after which she experienced an increase in pain and swelling on the plantar right foot. The patient visited a tertiary health-care center where she was given oral analgesics but she did not get any relief and hence visited a local hospital where an intra-articular injection was given to the right heel and oral analgesics were prescribed. This gave her temporary relief for 2 days after which her pain aggravated along with redness making weight bearing difficult on the right foot. The patient gave a history of experiencing intermittent episodes of fever, after which she revisited the tertiary care hospital. It was observed during the clinical screening and evaluation that the patient had developed swelling and Grade 3 tenderness over the plantar portion of the right foot. Sensation over the affected region was found to be intact, and the ankle–toe movements were intact. Based on the clinical findings, the patient was suspected to have an abscess in her heel for which a diagnostic surgical intervention was proposed.

Surgical intervention

Under spinal anesthesia, an incision was made to the heel and the abscess (3 cm × 3 cm) was drained. The patient was discharged 2 days later. For the next 20 days, the patient visited a local hospital to change the dressing over the incision site, and each day, a blood-stained discharge was noted at the site. The patient also experienced another episode of fever and developed a constant burning sensation, numbness, and tingling on the plantar aspect of the heel. She got admitted in the tertiary care center again, where a large incision was made again and pus was drained. For the next 2 months, the patient underwent regular debridement and dressing of the wound which continued to give a blood-stained discharge. She was given medications for pain and antibiotics along with other oral medications. Vascular diseases were ruled out through a color Doppler test. No history of claudication pain, gangrene, or ingrown nails was noted. As the burning sensation in the right foot did not subside and there was delayed wound healing, she was referred for physiotherapy. Physiotherapy assessment was done after obtaining the patient's consent, and on examination, it was noted that the muscle strength, sensations, and movements of the foot were intact. The Numerical Pain Rating Scale (NPRS) score as reported by the patient was 6/10 at rest and 8/10 on walking (weight bearing done on the right forefoot). The quality of pain was throbbing and burning in nature. The dimensions of the wound were assessed and noted down. The wound was identified as a surgical wound with delayed healing.

Intervention

The patient underwent ten regular sessions of physiotherapy that included a combination of electrotherapy modalities such as LLLT with TENS and kinetic chain activation technique [Table 1].
Table 1: Summary of 10 days physiotherapeutic intervention for wound healing

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Outcome measures

The NPRS was used to rate pain. Linear dimensions of the wound were measured using a cm scale, the length represented by the maximum extent, and the breadth represented by the perpendicular distance. The depth was measured by inserting a thread vertically inside the wound till it touched the floor and further measuring that distance on the thread using a scale. AutoCAD® software (version 20), Autodesk, Inc, California. was used to measure the volume of the wound in a cubic centimeter.[7]


  Results Top


The pre- and postinterventional measurements of visual analog scale and wound area and depth demonstrated a significant improvement. Postintervention, the NPRS score for pain at rest had come down to 0. Hence, there was 100% relief of pain at rest. The pain experienced during activities was reduced by 75%. The size of the wound also reduced as the length, breadth, and depth of the wound reduced by 32.14%, 35.29%, and 57.14%, respectively. As per the changes seen in the pre- and posttreatment values using AutoCAD, a decrease of volume by 81.24% was seen [Table 2] and [Figure 1].
Figure 1: Pre- and posttreatment intervention images depicting wound size reduction

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Table 2: Pre- and postintervention outcome measure values

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  Discussion Top


The purpose of this study was to find the combined effect of electrotherapy and KCAT on pain and healing of a chronic wound. The results showed a significant reduction in the pain as well as wound size [Table 2].

A two-group study by Hopkins et al. utilized low-level LASER to facilitate superficial wound healing in subjects with induced abrasions on their forearm, in which one group received LLLT (8J/cm2; treatment time: 2 min, 5 s; and pulse rate = 700 Hz) and other group received sham LASER with a 46 diode cluster head. After ten sessions, a 22% greater contraction of the wound was seen in the experimental group.[8] Similarly, in our study, the size of the wound reduced as the length, breadth, depth, and volume of the wound reduced by 32.14%, 35.29%, 57.14%, and 81.24%, respectively.

A literature review conducted by Pranata to explore the effects of TENS on wound healing found that low-frequency TENS was more effective as compared to high-frequency TENS by reducing inflammation and pain.[9] This is in agreement with our study which has also utilized a low-frequency TENS to get similar results.

LLLT has a major role in the activation of fibroblasts through the effect of photobiomodulation. The activated fibroblasts are responsible for the production and alignment of collagen. Furthermore, LASER causes deep heating of the tissues. This deep heating has an inhibitory effect on the growth of microorganisms that may be responsible for prolonging the healing process.[10] LLLT also enhances circulation and lymphatic drainage which promotes the clearance of stagnated interstitial fluid.[4] If not cleared, this interstitial fluid causes isolation of the growth factors responsible for wound healing, thus slowing down the healing process.[1] The reduction in pain and wound healing in this study may be attributed to the numerous effects of LASER.

TENS is widely used in the management of pain in various musculoskeletal and systemic conditions. As per previous literature, it is also known to aid in wound healing by generating an electric field in the tissues which enhances the migration of epithelial cells to the affected site. Moreover, it causes inhibition of inflammatory cytokines which delay wound healing.[1],[5] This supports the finding of our present study.

Jiang and Rinkevich, in a review, have suggested that fascia training helps to restore fiber distribution, orientation, and alignment, and optimal tissue hydration and resilience and have hypothesized that the key to understanding and clinically resolving nonhealing wounds lies in modulating fascia mobility. The plantar fascia is connected to the calf muscles,[11] and while performing the ankle–toe movements, there is shortening and lengthening of calf muscles.[12] This movement of the muscles induces mobilization of the plantar fascia which could have contributed to the healing of the wound. Thus, the highly significant changes in the outcomes may be attributed to a combined effect of the electrotherapy and kinetic chain activation.


  Conclusion Top


The present report highlights the positive clinical implication on the combined effect of electrotherapy and kinetic chain activation technique in wound healing.

Acknowledgment

The authors are grateful to Mr. Manish Desai for his time and assistance in using the AutoCAD software for wound measurement.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cifu DX. Braddom's Physical Medicine & Rehabilitation. 5th ed. Philadelphia: Elsevier; 2016. p. 511-42.  Back to cited text no. 1
    
2.
Frykberg RG, Banks J. Challenges in the treatment of chronic wounds. Adv Wound Care (New Rochelle) 2015;4:560-82.  Back to cited text no. 2
    
3.
Gupta N, Gupta SK, Shukla VK, Singh SP. An Indian community-based epidemiological study of wounds. J Wound Care 2004;13:323-5.  Back to cited text no. 3
    
4.
Cunha JL, Carvalho FM, Pereira Filho RN, Ribeiro MA, de Albuquerque-Júnior RL. Effects of different protocols of low-level laser therapy on collagen deposition in wound healing. Braz Dent J 2019;30:317-24.  Back to cited text no. 4
    
5.
Samaneh R, Ali Y, Mostafa J, Mahmud NA, Zohre RR. Laser therapy for wound healing: A review of current techniques and mechanisms of action. Biosci Biotechnol Res Asia 2015;12:217-23.  Back to cited text no. 5
    
6.
Gürgen SG, Sayın O, Cetin F, Tuç Yücel A. Transcutaneous electrical nerve stimulation (TENS) accelerates cutaneous wound healing and inhibits pro-inflammatory cytokines. Inflammation 2014;37:775-84.  Back to cited text no. 6
    
7.
Eberhardt TD, Lima SB, Lopes LF, Kessler M, Fonseca GG, Soares RS. Using autoCAD software to measure venous leg ulcers: A reproducibility assessment study. J Wound Care 2018;27:458-61.  Back to cited text no. 7
    
8.
Hopkins JT, McLoda TA, Seegmiller JG, David Baxter G. Low-Level Laser Therapy Facilitates Superficial Wound Healing in Humans: A Triple-Blind, Sham-Controlled Study. J Athl Train 2004;39:223-9.  Back to cited text no. 8
    
9.
Pranata S. The effect of transcutaneous electrical nerve stimulation (Tens) towards wound healing. Nurscope Journal of Nursing Research and Scientific Thought 2017;2:1-2.  Back to cited text no. 9
    
10.
Hawkins D, Houreld N, Abrahamse H. Low level laser therapy (LLLT) as an effective therapeutic modality for delayed wound healing. Ann N Y Acad Sci 2005;1056:486-93.  Back to cited text no. 10
    
11.
Jiang D, Rinkevich Y. Furnishing wound repair by the subcutaneous fascia. Int J Mol Sci 2021;22:9006.  Back to cited text no. 11
    
12.
Myers TW. Anatomy Trains. London: Urban & Fischer; 2011.  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Case Report
Results
Discussion
Conclusion
References
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