Electrical stimulation therapy for the treatment of pressure ulcers in individuals with spinal cord injury: a systematic review and meta-analysis.

To conduct a systematic review and meta-analysis on the effects of electrical stimulation therapy (EST) on healing pressure ulcers in individuals with spinal cord injury (SCI). CINAHL, The Cochrane Library, PubMed, SCOPUS, EMBASE, Nursing & Allied Health and Dissertation & Theses databases were searched for relevant English language articles from the date of inception to 31 January 2014. Separate searches were conducted in Google Scholar and academic journals specialised in wound care. Two reviewers independently assessed study eligibility. Studies were included if EST was used to treat pressure ulcers in individuals with SCI. A total of 599 articles were screened, and 15 studies met the inclusion criteria. A meta-analysis with five studies demonstrated that EST significantly decreased the ulcer size by 1·32%/day [95% confidence interval (CI): 0·58-2·05, P < 0·001] compared to standard wound care (SWC) or sham EST. Another meta-analysis conducted with four studies showed that EST increased the risk of wound healing by 1·55 times compared with standard wound care or sham EST (95% CI: 1·12 to 2·15, P < 0·0001). Because of the wide array of outcome measures across studies, a single meta-analysis could not be conducted. EST appears to be an effective adjunctive therapy to accelerate and increase pressure ulcer closure in individuals with SCI.

Effective management of patients with diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team.

A longitudinal observational study on a convenience sample was conducted between 4 January and 31 December of 2010 to evaluate clinical outcomes that occur when a new Interprofessional Diabetes Foot Ulcer Team (IPDFUT) helps in the management of diabetes-related foot ulcers (DFUs) in patients living in a small urban community in Ontario, Canada. Eighty-three patients presented to the IPDFUT with 114 DFUs of average duration of 19·5 ± 2·7 weeks. Patients were 58·4 ± 1·4 years of age and 90% had type 2 diabetes, HbA1c of 8·3 ± 2·0%, with an average diabetes duration of 22·3 ± 3·4 years; in 69% of patients, 78 DFUs healed in an average duration of 7·4 ± 0·7 weeks, requiring an average of 3·8 clinic visits. Amputation of a toe led to healing in three patients (4%) and one patient required a below-knee amputation. Six patients died and three withdrew. Adding a skilled IPDFUT that is trained to work together resulted in improved healing outcomes. The rate of healing, proportion of wounds closed and complication rate were similar if not better than the results published previously in Canada and around the world. The IPDFUT appears to be a successful model of care and could be used as a template to provide effective community care to the patients with DFU in Ontario, Canada.

Impact of pressure ulcers on individuals living with a spinal cord injury.

OBJECTIVE: To describe the impact of pressure ulcers on the ability to participate in daily and community activities, health care utilization, and overall quality of life in individuals living with spinal cord injury (SCI). DESIGN: Cross-sectional study. SETTING: Nationwide survey. PARTICIPANTS: Participants (N=1137) with traumatic SCI who were >1 year postinjury and living in the community were recruited. Of these, 381 (33.5%, 95% confidence interval, 30.8%-36.3%) had a pressure ulcer over the last 12 months. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measures developed for the Rick Hansen Spinal Cord Injury Registry Community Follow-up Survey Version 2.0. RESULTS: Of the 381 individuals with pressure ulcers, 65.3% reported that their pressure ulcer reduced their activity to some extent or more. Pressure ulcers reduced the ability of individuals with SCI to participate in 19 of 26 community and daily activities. Individuals with 1 or 2 pressure ulcers were more dissatisfied with their ability to participate in their main activity than those without pressure ulcers (P=.0077). Pressure ulcers were also associated with a significantly higher number of consultations with family doctors, nurses, occupational therapists, and wound care nurses/specialists (P<.05). CONCLUSIONS: Pressure ulcers have a significant impact on the daily life of individuals with SCI. Our findings highlight the importance of implementing pressure ulcer prevention and management programs for this high-risk population and require the attention of all SCI-related health care professionals.

The average cost of pressure ulcer management in a community dwelling spinal cord injury population.

Pressure ulcers (PUs) are a common secondary complication experienced by community dwelling individuals with spinal cord injury (SCI). There is a paucity of literature on the health economic impact of PU in SCI population from a societal perspective. The objective of this study was to determine the resource use and costs in 2010 Canadian dollars of a community dwelling SCI individual experiencing a PU from a societal perspective. A non-comparative cost analysis was conducted on a cohort of community dwelling SCI individuals from Ontario, Canada. Medical resource use was recorded over the study period. Unit costs associated with these resources were collected from publicly available sources and published literature. Average monthly cost was calculated based on 7-month follow-up. Costs were stratified by age, PU history, severity level, location of SCI, duration of current PU and PU surface area. Sensitivity analyses were also carried out. Among the 12 study participants, total average monthly cost per community dwelling SCI individual with a PU was $4745. Hospital admission costs represented the greatest percentage of the total cost (62%). Sensitivity analysis showed that the total average monthly costs were most sensitive to variations in hospitalisation costs.

Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury.

OBJECTIVE: To investigate whether electric stimulation therapy (EST) administered as part of a community-based, interdisciplinary wound care program accelerates healing of pressure ulcers in people with spinal cord injury (SCI). DESIGN: Single-blind, parallel-group, randomized, controlled, clinical trial. SETTING: Community-based home care setting, Ontario, Canada. PARTICIPANTS: Adults (N=34; mean age +/- SD, 51+/-14y) with SCI and stage II to IV pressure ulcers. INTERVENTIONS: Subjects were stratified based on wound severity and duration and randomly assigned to receive either a customized, community-based standard wound care (SWC) program that included pressure management or the wound care program plus high-voltage pulsed current applied to the wound bed (EST+SWC). MAIN OUTCOME MEASURES: Wound healing measured by reduction in wound size and improvement in wound appearance at 3 months of treatment with EST+SWC or SWC. RESULTS: The percentage decrease in wound surface area (WSA) at the end of the intervention period was significantly greater in the EST+SWC group (mean +/- SD, 70+/-25%) than in the SWC group (36+/-61%; P=.048). The proportion of stage III, IV, or X pressure ulcers improving by at least 50% WSA was significantly greater in the EST+SWC group than in the SWC group (P=.02). Wound appearance assessed using the photographic wound assessment tool was improved in wounds treated with EST+SWC but not SWC alone. CONCLUSIONS: These results demonstrate that EST can stimulate healing of pressure ulcers of people with SCI. EST can be incorporated successfully into an interdisciplinary wound care program in the community.

Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population.

To implement and evaluate a heel pressure ulcer prevention program (HPUPP) for orthopaedic patients. Program development of HPUPP involved input from administrators, staff and adult patients on an orthopaedic service in an academic tertiary care facility, located in a small urban centre in Canada. Prospective evaluation was conducted. Consensus exercises with clinical staff and administrators (Delphi and Nominal group) were used to, evaluate current practices, select a heel protective device, and develop key aspects of the HPUPP. HPUPP involved an individualised, bedside, staff education program, a team approach to improve patient mobility and use of a heel protective device. A 2-inch foam wedge covered in washable vinyl was placed at the foot of all beds on the orthopedic service. After the program was implemented, the incidence of heel pressure ulcers was 0%, which was a significant reduction compared with pre-implementation levels [13.8% (95% confidence interval 8-18%)]. Key components of the program success were initial and ongoing support from administration and surgeons, incorporation of feedback from clinical staff and patients, and keeping the program simple. Heel PU can be prevented in most orthopaedic patients using a universal heel PU prevention program.

Development of Tissue Integrity indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project.

Objective: To establish structure, process and outcome indicators to evaluate tissue integrity in Canadians with spinal cord injury or disease (SCI/D) in the first 18 months following inpatient rehabilitation admission. Method: A Working Group comprised of Canadian subject matter experts in the Domain of Tissue Integrity was formed to define the construct of tissue integrity. A literature review was conducted and a Driver diagram produced to identify factors that influence tissue integrity in individuals with SCI/D. Facilitated meetings were conducted to identify and achieve consensus on structure, process and outcome indicators. Rapid cycle testing was used to pilot test proposed indicators for face validity and feasibility within a quality improvement context. Results: The structure indicators are the proportion of patients with SCI/D who have access to a mirror for skin checks and the proportion of patients who have access to patient education on tissue integrity; the process indicator is the proportion of patients who completed daily head-to-toe skin checks; the intermediary outcome indicator is pressure injury (PI) incidence during inpatient rehabilitation; and the final outcome indicator is the proportion of individuals with intact skin at 18 months following rehabilitation admission. Conclusion: The set of indicators established for the Domain of Tissue Integrity are specifically focused on aspects of care that can impact the maintenance of tissue integrity and the prevention of PI and align with current practice guidelines. The implementation and evaluation of these indicators nationally have the potential to improve care for Canadians with SCI/D.

A Systematic Review and Meta-analysis of Exercise Intervention for the Treatment of Calf Muscle Pump Impairment in Individuals with Chronic Venous Insufficiency.

Exercise intervention for individuals with chronic venous insufficiency (CVI) and venous leg ulcers (VLUs) is recommended to improve function of the calf muscle pump (CMP). A systematic review with meta-analysis was conducted to measure the effects of exercise (including function of the CMP, ankle strength, range of motion [ROM], and healing rates) for VLUs. Four (4) databases (Cumulative Index to Nursing and Applied Health Literature, 1981; MEDLINE, 1964; Scopus, 1966; and EMBASE, 1947) were searched for relevant articles from the date of index inception to January 2016. All study types that evaluated the effect of exercise on the function of the CMP in patients with CVI were included; narrative and systematic studies were excluded. All data were extracted by 1 reviewer onto a predetermined form and verified by a second reviewer. Data extracted included number of patients, primary diagnosis, patient demographics, study location, wound characteristics, inclusion/exclusion criteria, exercise group details, control group details, co-interventions, primary outcome measures, secondary outcome measures, wound healing measures, blinding, intention to treat, and study design. A total of 1325 articles was screened; 14 met the inclusion criteria (total study participants = 519). CMP hemodynamics were assessed using air plethysmography measurement results from the included studies. A meta-analysis of 8 articles was distilled to 3 with relevant data (83 participants) that found a significant increase on CMP ejection fraction in favor of the exercise group (Hedge's g = 0.83; 95% CI 0.35-1.30, P <.001) compared to control. CMP residual venous fraction also favored the exercise group (Hedge's g = 0.42; 95% CI -0.03-0.862, P = .066). Ankle ROM was higher in the exercise group (116 participants; Hedge's g = 0.62; 95% CI -0.15-1.39, P = .116); however, these differences were not significantly different from controls. Exercise directed at improving calf muscle strength and ankle ROM for individuals with or at risk for VLUs improves CMP hemodynamics and function. Additional research using larger sample sizes to confirm the role of exercise in healing VLUs is warranted.

Effect of ultraviolet light C on bacterial colonization in chronic wounds.

Ultraviolet light C (light wavelength 200 nm to 290 nm) has been shown to kill cultures of antibiotic resistant strains of bacteria such as methicillin-resistant Staphylococcus aureus. To evaluate the ability of ultraviolet light C to reduce the amount and type of bacteria present in chronically infected ulcers, as well as to establish the test-retest reliability of the semi-quantitative swab technique, a prospective, one-group, pre-post treatment study was conducted among patients receiving treatment in several in- and outpatient facilities and nursing homes. Individuals with chronic ulcers exhibiting at least two signs of infection and critically colonized with bacteria (n = 22) received a single 180-second treatment using an ultraviolet light C lamp (wavelength = 254 nm) placed 1 inch from the wound bed. Semi-quantitative swabs taken immediately before and after UVC treatment were used to assess changes in the bacterial bioburden present within the wound bed. Results demonstrated excellent test-retest reliability of the semi-quantitative swab technique used to evaluate the type and amount of bacteria present in chronic wounds (Cohen's kappa = 0.92). Assessment of wound bioburden using semi-quantitative swabs revealed a statistically significant (P <0.0001) reduction in the relative amount of bacteria following a single treatment of ultraviolet light C. The greatest reduction in semi-quantitative swab scores following ultraviolet light C treatment were observed for wounds colonized with the bacteria Pseudomonas aeruginosa and wounds colonized with only one species of bacteria. Significant (P <0.05) reductions in the relative amount of bacteria also were observed in 12 ulcers in which methicillin-resistant Staphylococcus aureus was present. These results confirm previous laboratory studies and demonstrate that ultraviolet light C can kill bacteria such as Pseudomonas aeruginosa, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus present in superficial layers of chronic wounds.

Effect of electrical stimulation on chronic leg ulcer size and appearance.

BACKGROUND AND PURPOSE: Electrical current has been recommended for use on chronic pressure ulcers; however, the ability of this modality to improve healing of other types of chronic ulcers is less well established. The purpose of this study was to examine the effect of high-voltage pulsed current (HVPC) on healing of chronic leg ulcers. SUBJECTS: Twenty-seven people with 42 chronic leg ulcers participated in the study. METHODS: The subjects were separated into subgroups according to primary etiology of the wound (diabetes, arterial insufficiency, venous insufficiency) and then randomly assigned to receive either HVPC (100 microseconds, 150 V, 100 Hz) or a sham treatment for 45 minutes, 3 times weekly, for 4 weeks. Wound surface area and wound appearance were assessed during an initial examination, following a 1- to 2-week period during which subjects received only conventional wound therapy, after 4 weeks of sham or HVPC treatment, and at 1 month following treatments. RESULTS: The results indicated that HVPC applied to chronic leg ulcers reduced the wound surface area over the 4-week treatment period to approximately one half the initial wound size (mean decrease=44.3%, SD=8.8%, range=2.8%-100%), which was over 2 times greater than that observed in wounds treated with sham units (mean decrease=16.0%, SD=8.9%, range=-30.3%-83.7%). DISCUSSION AND CONCLUSION: The results of the study indicate that HVPC administered 3 times a week should be considered to accelerate wound closure of chronic leg ulcers.

Prevalence of pressure ulcers in Canadian healthcare settings.

Although statistics regarding the number of pressure ulcers in the US and other countries are available, little information is known about the number of individuals in Canada who have pressure ulcers. Such information is important to assess the scope and healthcare costs of pressure ulcers and develop public policies. To obtain estimated pressure ulcer prevalence rates in Canada, existing data (gathered between 1990 and 2003) from different healthcare settings across the country were obtained from peer-reviewed published studies and from unpublished studies provided by individuals and pressure ulcer support surface manufacturers. Methods used to gather and report prevalence data in each study were critically appraised using a modified version of published criteria. Retrospective chart audit studies that did not involve direct patient assessment were excluded. The data included information from 18 acute care facilities involving 4,831 patients, 23 non-acute care facilities with 3,390 patients, 19 mixed healthcare settings with 4,200 patients, and five community care agencies that surveyed 1,681 patients. Estimates of pressure ulcer prevalence were 25.1% (95% Confidence Interval, 23.8% to 26.3%) for acute care settings, 29.9% (95% Confidence Interval, 28.3% to 31.4%) in non-acute care settings, 22.1% (95% Confidence Interval, 20.9% to 23.4%) in mixed health settings, and 15.1% (95% Confidence Interval, 13.4% to 16.8%) in community care. The overall estimate of the prevalence of pressure ulcers in all healthcare institutions across Canada was 26.0% (95% Confidence Interval, 25.2% to 26.8%). The Canadian prevalence estimates differed among the healthcare settings and were higher than those reported in the US and the Netherlands. Although additional studies are needed, the data suggest that pressure ulcers are a significant concern in all healthcare settings in Canada.

A comparison of computer-assisted and manual wound size measurement.

Accurate and precise wound measurements are a critical component of every wound assessment. To examine the reliability and validity of a new computerized technique for measuring human and animal wounds, chronic human wounds (N = 45) and surgical animal wounds (N = 38) were assessed using manual and computerized techniques. Using intraclass correlation coefficients, intrarater and interrater reliability of surface area measurements obtained using the computerized technique were compared to those obtained using acetate tracings and planimetry. A single measurement of surface area using either technique produced excellent intrarater and interrater reliability for both human and animal wounds, but the computerized technique was more precise than the manual technique for measuring the surface area of animal wounds. For both types of wounds and measurement techniques, intrarater and interrater reliability improved when the average of three repeated measurements was obtained. The precision of each technique with human wounds and the precision of the manual technique with animal wounds also improved when three repeated measurement results were averaged. Concurrent validity between the two techniques was excellent for human wounds but poor for the smaller animal wounds, regardless of whether single or the average of three repeated surface area measurements was used. The computerized technique permits reliable and valid assessment of the surface area of both human and animal wounds.

Ultraviolet light C in the treatment of chronic wounds with MRSA: a case study.

The prevalence of antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus is rapidly increasing in healthcare facilities and spreading to the community. Methicillin-resistant S. aureus colonize the skin and open wounds and can interfere with wound healing. Recent studies have shown that ultraviolet light C can kill antibiotic-resistant strains of bacteria such as methicillin-resistant S. aureus in both laboratory cultures and animal tissue. This clinical report describes the effects of ultraviolet light C on wound bioburden and closure in three people with chronic ulcers infected with methicillin-resistant S. aureus. In all three patients, ultraviolet light C treatment reduced wound bioburden and facilitated wound healing. Two patients had complete wound closure following 1 week of ultraviolet light C treatment. This case study suggests that ultraviolet light C is a promising adjunctive therapy for chronic wounds containing antibiotic-resistant bacteria such as methicillin-resistant S. aureus.

Clinical Trials Involving Biphasic Pulsed Current, MicroCurrent, and/or Low-Intensity Direct Current.

Significance: This invited critical review will summarize an expansive body of literature regarding electrical stimulation (ES) and wound healing. Several clinical reports have been published in which ES has been evaluated as a therapy to speed the closure of chronic wounds. Different forms of ES have been applied in varying ways and described using inconsistent terminology by researchers and clinicians around the world. It is important to compile this research and to critically appraise the findings so that clinicians who are not familiar with this field can interpret the research. Recent Advances: More recently, ES has been delivered at subsensory levels (termed microcurrent in this review) using very small electrical devices contained within wound dressing. While these newer technologies have obvious technical advances, what research has been published to date about these new devices has not produced findings that suggest this form of ES can accelerate wound closure. Critical Issues: Reviewing a collection of published reports on this subject reveals that not all forms of ES produce beneficial results. Rather, only certain ES protocols such as monophasic pulsed current applied to the wound and biphasic pulsed current current that is applied for 2 h daily to periulcer skin at intensities which produce motor responses have consistently demonstrated positive results. Future Directions: Optimal stimulus parameters and treatment schedule for ES used to treat chronic wounds need to be determined. Researchers publishing in this field should provide detailed information about their ES treatment protocol and use a similar terminology to describe the ES waveform and stimulus parameters.

Electrostimulation: Current Status, Strength of Evidence Guidelines, and Meta-Analysis.

Significance: Delayed healing of skin wounds is a serious problem for the patients, clinicians, and society. The application of interventions with proven effectiveness to increase wound healing is relevant. Recent Advances: This article summarizes the results of effect studies with the application of electrostimulation (ES) as additional treatment to standard wound care (SWC). Therefore, five published narrative reviews are discussed. In addition, 15 studies with a clear randomized controlled trial design are analyzed systematically and the results are presented in four forest plots. The healing rate is expressed in the outcome measure percentage area reduction in 4 weeks of treatment (PAR4). This leads to a continuous measure with mean differences between the percentage healing in the experimental group (SWC plus ES) and in the control group (SWC alone or SWC plus placebo ES). Adding ES to SWC in all wound types increases PAR4 by an extra 26.7% (95% confidence interval [CI] 15.6, 37.8); adding unidirectional ES to SWC increases PAR4 by 30.8% (95% CI 20.9, 40.6) and adding unidirectional ES to the treatment of pressure ulcers increases PAR4 by 42.7% (95% CI 32.0, 53.3). Critical Issues: There is a discrepancy between the proven effectiveness of ES as additional treatment to SWC and the application of ES in real practice. Possible drawbacks are the lack of clinical expertise concerning the proper application of ES and the extra time effort and necessary equipment that are needed. Future Directions: Clinicians concerned about the optimal treatment of patients with delayed wound healing should improve their practical competency to be able to apply ES.

Heel pressure ulcers in orthopedic patients: a prospective study of incidence and risk factors in an acute care hospital.

Heel pressure ulcers (PU) are a major concern in orthopedic patients. A prospective 6-month study was conducted in an acute care hospital in Canada to determine the incidence of heel PU in an orthopedic population, evaluate the effect of patient and care variables on heel PU incidence, and describe the natural history/sequelae of Stage I heel PU. One hundred and fifty (150) patients (average age 70.6 years) admitted for elective orthopedic surgery or treatment of a fractured hip participated in the study. A direct heel skin assessment was performed following admission and before discharge. Patients with a Stage I ulcer were assessed or contacted 1 week following discharge. The incidence of heel PU in this population was 13.3% CI (range 8% to 19%). Incidence was 16% in the hip fracture and 13% in the elective surgery group. PU incidence in the hip fracture group was significantly lower (P = 0.016) for patients receiving heel pressure relief measures (pillows, rolled sheets). In the elective surgery group, PU incidence rates were higher for patients with respiratory disease, lower hemoglobin, low pulse rate, and altered mental status (P <0.05). When both patient groups were combined, only the presence or absence of respiratory disease significantly affected PU incidence. Length of stay was an average of 3 days longer in all groups with a heel PU but the difference was not statistically significant. One week following discharge, 13 of the 17 (76%) Stage I heel PU had resolved, one remained unchanged, and two were assessed as deep tissue injury (11%) and one as Stage II. These incidence rates are similar to those reported in other countries and confirm that efforts to reduce heel PU incidence rates are needed.

Heel ulcer incidence following orthopedic surgery: a prospective, observational study.

People undergoing orthopedic surgery receive care at many points along the healthcare continuum. Although heel pressure ulcer (HPU) incidence in the orthopedic population has been reported to be 13.3%, information is limited. The purpose of this prospective observational study was to evaluate: 1) the cumulative incidence of HPUs in orthopedic patients across the continuum of care, and 2) the outcome of HPUs once they occurred. Of the 72 study participants (average age 76 +/- 16 years, 60% women, 53% required surgery for hip fractures), 57 were recruited consecutively upon admission to a rehabilitation center from one of two acute care facilities and 15 were assessed upon admission to one of the acute care sites and at discharge to the home. All but two study participants were followed-up in the community 1 month after discharge from the acute care or rehabilitation facility. Medical charts were reviewed and study participants underwent a bedside assessment, with direct examination of both heels and staging of the ulcer at admission and discharge. The cumulative incidence of HPUs was 17% (95% CI 8%-26%). All ulcers were identified upon admission to the rehabilitation center; 41% of HPUs were either suspected deep tissue injury (sDTI) or unstageable. Both of the Stage I and two of the five Stage II ulcers were resolved at the time of follow-up; three of the five sDTI or unstageable ulcers were unresolved. HPUs occurred in 17% of people undergoing orthopedic procedures. All ulcers occurred in acute care and severe ulcers persisted while patients received rehabilitation and community care. This is the first study to follow orthopedic patients across the continuum of care.

Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review.

BACKGROUND: Although therapeutic ultrasound is commonly used to treat shoulder injuries, research to date on the ability of ultrasound to improve outcomes for shoulder pathologies is conflicting. OBJECTIVE: This study aimed to systematically and critically review available literature to ascertain whether beneficial effects of ultrasound were associated with certain shoulder pathologies or particular ultrasound treatment protocols. METHODS: Five electronic databases were searched, and the included studies, identified through pair consensus, were randomized controlled trials (RCTs) that utilized ultrasound for soft tissue shoulder injury or pain. STUDY SELECTION AND DATA EXTRACTION: Eight studies included in this review (n=586 patients, median PEDro score=8.0/10) evaluated various parameters, including the duration of patients' symptoms (0-12 months), duty cycle (20% and 100%), intensity (0.1-2.0 W/cm2), treatment time per session (4.5-15.8 minutes), number of treatments (6-39), and total energy applied per treatment (181-8,152 J). DATA SYNTHESIS: Inconsistent outcome measures among studies precluded meta-analysis; however, 3 RCTs showed statistically significant benefits of ultrasound, 2 of which examined calcific tendinitis. Studies that showed beneficial effects of ultrasound typically had 4 times longer total exposure times and applied much greater ultrasound energy per session (average of 4,228 J) compared with studies that showed no benefit of ultrasound (average of 2,019 J). No studies that delivered < or = 720 J per session showed improvement in treatment groups. LIMITATIONS: Current research involving ultrasound treatment protocols that delivered low levels of ultrasound energy do not adequately address whether ultrasound can improve outcomes for shoulder disorders. CONCLUSION: Determining whether therapeutic ultrasound can affect soft tissue shoulder pathologies will require further research and systematic reviews that involve appropriate ultrasound treatment protocols.

A prospective, multicenter study to validate use of the PUSH in patients with diabetic, venous, and pressure ulcers.

Monitoring wound progress is essential for evaluating and documenting treatment outcomes. The Pressure Ulcer Scale for Healing (PUSH) was developed to track pressure ulcer (PU) progress but information about its utility for other types of chronic wounds is limited. A 10-month, descriptive, multicenter study was conducted to examine the responsiveness and concurrent validity of the PUSH when used to monitor wound changes in diabetic foot (DFU), venous leg (VLU), and PU. Using a convenience sample of participants (n = 98, mean age 60 [range 20 to 89] years, the majority [85%] male), PUSH score and acetate wound surface area tracings were obtained at baseline and approximately 4 weeks later from 47 Stage II to Stage IV PU, 23 VLU, and 28 patients with a DFU. After an average of 32 days, wound surface area, total PUSH scores, and individual PUSH component scores decreased significantly between baseline and follow-up (P = 0.000). The mean PUSH score change was significantly different between healing and nonhealing wounds (P = 0.000). A strong relationship (r = .66) was found between total PUSH score and surface area. Results suggest the PUSH tool is a valid, responsive, evaluative tool to monitor and document wound progress of PU, VLU, and DFU. Additional studies to assess use of this tool for DFU and to ascertain the predictive validity of the PUSH tool are warranted.

Best practice recommendations for the prevention and treatment of pressure ulcers: update 2006.

PURPOSE: The purpose of this article is to enhance the professional nurses' knowledge of the best practice recommendations for the prevention and treatment of pressure ulcers. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to: 1. Interpret the pathway to assess and treat pressure ulcers. 2. Differentiate the Registered Nurses' Association of Ontario (RNAO) levels of evidence. 3. Identify the scientific evidence for treatment recommendations.