1. Burn Patient Rehabilitation Prof.Dr: Ehab Kamal Zayed.
october 6 university
Faculty Of Physical Therapy
Lecture of
Burn Patient Rehabilitation
Electrotherapy
In Wound Healing By
Prof.Dr: Ehab Kamal Zayed.

3. “TENS” is an acronym of Transcutaneous Electrical Nerve Stimulation

4. Definition
  TENS is the application of low frequency current in the form of pulsed rectangular currents through surface electrodes on the patient’s skin to reduce pain.

5. Types of TENS 1- Conventional TENS (high TENS)
In this high frequency and low intensity electrical stimulation is applied.
Impulse carried along with the large diameter afferent fibers (Aβ)
Produces pre-synaptic inhibition of transmission of pain impulses along A-delta and C fiber at substantia gelatinosa ( lamina II) of pain gate
• frequency: HZ
• pulse width: µs
• intensity: mA

6. The aim of conventional TENS is to selectively activate Aβ afferents producing segmental analgesia

7. 2- Acupuncture-like TENS (low TENS or AL-TENS)
In this low frequency and high intensity electrical pulses are applied.
It gives a sharp stimulus and like a muscle twitch (not muscle contraction).
This type activates opiate system in hypothalamus and pituitary gland (the periaqueductal gray region (PAG) of the Midbrain and raphe nucleus in the pons and medulla.
• frequency: 1-5 Hz
• pulse width: µ s
• intensity: 30 mA or more

9. 3- Burst TENS:
In this high frequency, short pulse, high intensity electrical current is used
Burst TENS is a series of impulse repeated for 1-5 times/sec.
Each train (burst) lasts for about 70 ms.
The benefit of burst TENS is combination both conventional and acupuncture like TENS.
It stimulate Aβ (closing gate) and A–delta (endorphin)
• frequency: Hz
• pulse width: µ s
• intensity: 30 or more.

10. Other type
 Brief Intense TENS is used for rapid pain relief, and employs Hz with 200 us pulse width settings.
The current delivery is so high with these settings that most patients can only tolerate min. of treatment.
 Uses of TENS types:
High TENS used in treatment of acute soft tissues injuries and pain associated with musculoskeletal disorders.
low TENS used in treatment of chronic pain.

11. LASER
“LASER” is an acronym of Light Amplified by Stimulated Emission of Radiation,

15. Physiologic effect of laser in tissue healing.
It may enhance tissue healing by:
1. Stimulation of the immune system:
- Increasing the number of T cells by using He-Ne laser with power density of 30 mW/cm2
- Increase frequency and affinity of lymphocytes binding with bacteria.

16. 3. Increase mitochondrial activity: with increased ATP synthsis.
2. Reduction of inflammation: by using low power density of 1 J/cm2 stimulating leukocytic phagocytosis
3. Increase mitochondrial activity: with increased ATP synthsis.
4. Increase collagen synthesis: by He-Ne laser at an energy density of a 4 J/ cm2 was most effective in rate of healing.

18. Mitochondria

19. 5. He-Ne increases the procollagen synthesis which acceleration of the mRNA level or enzymatic changes.

22. B. Pain Control
Laser has been successfully for its analgesic effect in various types of acute or chronic pain as:
musculoskeletal pain.
sports injuries.
post-operative pain.
neurogenic and neuropathic pain.

23. Mechanism of action Increase pain thresholds.
Alteration of nerve conduction velocity.
Neuro-pharmacological effect by alteration of level of endogenous opioid.
Increase release and metabolism of serotonin.

24. Techniques of Application
Contact technique :
Is used to treat a series of points around the whole wound margin about 1cm from the edge of wound at a dosage of J\cm2.
This technique is aiming to accelerate margination & wound closure in addition to promotion of blood flow to wound and angiogenesis

25. SCANNING AND GRIDDING TECHNIQUES (Non-Contact):
For wound bed treatment using a dose of 1-2 J\cm squared.
Scanning may be automatic or manual according to the laser unit available.

26. Duration and Frequency of Treatment:
The duration of treatment is determined according to the power of laser unit.
e.g if the laser unit has 30 mW power to irradiate each cm2 with 1.5 J\cm2 each square is irradiate for 50 second.
Laser treatment is given once daily or at alternate days.

29. Ultrasound Non-thermal effects:
Ultrasound with a low average intensity has been shown to intracellular calcium levels and skin and cell membrane permeability, it promote the normal function of a variety of cell types.
Ultrasound mast cell degranulation and their release of chemotactic factor and histamine.

30. Ultrasound promotes macrophage responsiveness, and the rate of protein synthesis by fibroblasts.
intracellular calcium can alter the enzymatic activity of cells and stimulate their synthesis and secretion of proteins.
Vasodilatation from nitric oxide and the resulting blood flow may further enhance healing by increasing the delivery of essential nutrients to the area.

31. Clinical Applications of Ultrasound
1. Soft tissue shortening:
temperature of soft tissue temporarily
extensibility, increase the length gained for the same force of stretch while also
the risk of tissue damage.
Continuous ultrasound of sufficient intensity and duration to increase tissue temperature extensibility.

32. The treatment parameters most likely to be effective are 1-3 MHz frequency depending on the tissue depth, and at intensity from 0.5 to 1.0 W/cm2.
2. Dermal Ulcer:
The treatment parameters found to be effective for this application are 20% duty cycle, 0.8 to 1.0 W/cm2 intensity, 3 MHz frequency, for 5 to 10 minutes.

33. Ultrasound can be applied to a dermal ulcer either by:
Applying transmission gel to the intact skin around the wound perimeter and treating only over this area, or
The wound can be treated directly by covering it with an ultrasound coupling sheet or by
Placing it and the ultrasound transducer in water.

35. 3. Surgical skin incisions:
US accelerate angiogenesis by altering cell membrane permeability, particularly to calcium ions, and by stimulating angiogenic factor synthesis and release by macrophages.
Noncontact kilohertz US enhance angiogenesis and collagen deposition.

36. The treatment parameters found to be most effective were 0. 5 – 0
The treatment parameters found to be most effective were 0.5 – 0.8 w/cm2 intensity, pulsed 20 % for 3-4 minutes, 3 to 5 times a week.
4. Tendons and ligaments injuries.
5. Resorption of calcium deposits.
6. Healing of bone fractures.

37. The END!