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Hyperbaric Oxygen Therapy In Ischemic Ulcers

Medical information reviewed by: FILIP CIRCIUMARU, Kinetoterapeut
i.php?p=12. Oxigenoterapia hiperbarica i

Discover the hyperbaric medicine center opened in our clinic. Centrokinetic has the top-performing hyperbaric chamber in Bucharest, with multiple medical and anti-aging uses. The Baroks chamber has 5 seats, and operates at a constant pressure of 2.5 atmospheres, being fully automated and having protocols for each condition, and can be used individually for each patient. 

Hyperbaric oxygen therapy - benefits

Patients who use the clinic's hyperbaric therapy services benefit from:

  • The only medically accredited hyperbaric therapy chamber in Bucharest, which operates at 2.5 atmospheres (those for aesthetic use go to 1 atmosphere and have no medical benefits).
  • A safe medical procedure, without irradiation, without pain, without other side effects. 
  • The specialized medical team consists of recovery doctors, orthopedists, rheumatologists, neurologists, and neurosurgeons, meaning a multidisciplinary team specialized in all diseases that can be treated with hyperbaric therapy. 
  • Premium conditions at a fair price. Our clinic is recognized for the conditions offered and for the care of each patient. But we do not need to pay exorbitant prices to have access to quality medical services. At Centrokinetic you can find an affordable and fair price. But note that we do not have a contract with the National Health Insurance House (we do not offer state reimbursed services)

Centrokinetic is keeping contact with prestigious clinics and universities in Belgium, the Netherlands, France, and Greece to constantly update treatments to provide patients with the best medical solutions.

Treatment protocols for ischemic ulcers

Several treatment modalities and protocols for ischaemic foot ulcers are available. However, little consensus exists on optimal treatment. The aim of this study was to compare Standard Wound Care (SWC) alone vs. SWC with adjunct hyperbaric oxygen therapy (HBOT) in the treatment of ischaemic Diabetic Foot Ulcers (DFUs).

Lower-extremity complications in patients with diabetes mellitus (DM) have become an increasingly significant public health concern. The global diabetic foot ulcer (DFU) prevalence was 6.3%, which was higher in males (4.5%) than in females (3.5%), and higher in patients with type 2 (6.4%) than those with type 1 DM (5.5%). DFUs precede 84% of lower extremity amputations, are associated with increased mortality (by 2.4%), and have a high recurrence rate, with essentially a poor prognosis. Different local wound management options exist, ranging from several dressings to a vast range of advanced treatments used in adjunct to standard treatment of wound care. However, to date, there is no unequivocal evidence for the best local treatment of DFU.

Current Standard Wound Care (SWC) protocols include wound cleansing, optimized glycaemic control, treating infection, improving blood supply, and relieving pressure on the wound site. Ideally, all-natural phases of wound healing, i.e. inflammatory, proliferative phase, and maturation phase, which are all oxygen-dependent, should be supported, but this fails to be the case in clinical reality. In an endeavor to improve healing rates, Hyperbaric Oxygen Therapy (HBOT) has been used. However, its use remains debated, and the evidence for its effectiveness, at least in non-ischaemic diabetic ulcers, is limited. Therefore, this study aimed to compare the efficacy of HBOT added to SWC vs. SWC alone in promoting healing of ischemic DFUs.

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Patients and methods

This single-centre clinical trial included 26 subjects with Type 2 DM (T2DM) presenting to a tissue viability unit with a newly diagnosed ischemic DFU. The study was approved by the institutional Ethics Committee and carried out in accordance with the Declaration of Helsinki, as revised in 2000. All patients gave their informed consent. Inclusion criteria were: adult T2DM and newly diagnosed ischemic DFU. Exclusion criteria were: neuropathic DFU, infected DFU, severe ischemia requiring urgent revascularisation, recent change of medication, chronic alcohol abuse, systemic disease or pernicious anaemia.

Patients were randomised into group A (n=13; SWC with adjunct HBOT) and group B (n=13; SWC only). Patients were matched for age, gender, DM duration, current medication, HbA1c, wound size and location (according to the angiosomes supplying the wound area with arterial blood) [16], using frequency distribution matching to ensure both groups were comparable at baseline. All examinations were carried out by the same investigator to ensure uniformity. Room temperature was kept at 21-23°C to avoid vasoconstriction of digital arteries. Screening process involved review of the patient’s medical history and a lower-extremity physical examination.

Peripheral sensory neuropathy
Semmes-Weinstein 10 g monofilaments were used to detect peripheral sensory neuropathy. Testing was performed on the plantar aspect of the hallux and third digit, as well as on the 1st, 3rd, and 5th metatarsal heads.

Peripheral arterial disease
The vascular assessment was carried out by Spectral Waveform Doppler Analysis (SWDA) and Ankle Brachial Pressure Index (ABI). Peripheral arterial disease (PAD) was diagnosed by measurement of the ankle-brachial index (ABI) and quantitative pedal waveform analysis was obtained. A handheld continuous wave Doppler with an 8MHz probe (Huntleigh, Cardiff, UK) was used. Waveforms were classified as triphasic, biphasic, monophasic discontinuous, and monophasic continuous. Triphasic waveforms were considered normal, whereas biphasic, monophasic discontinuous, and monophasic continuous waveforms were interpreted as abnormal. Measurements were carried out after patients rested for 5 min in the supine position. ABI 0.9-1.29 was normal. PAD was defined as an ABI ≤ 0.89 in either foot. ABI ≥ 1.3 was considered indicative of vascular calcification.
DFUs were categorized according to their type, and only ischaemic ones were included. To ensure this, patients were recruited if they exhibited biphasic/monophasic waveforms, and/or ABI was <0.9.

Procedure for wound measurement

Acetate tracing paper with a printed grid was used to calculate wound area. Sterile probes were used to calculate wound depth. A fine-tipped permanent marker was used to trace the wound outline. Minimal pressure was applied while tracing to prevent distorting the shape and border of the ulceration. A 0.2 cm2 grid was used to calculate the area of the ulcer to increase precision. The Wagner grading system was used to grade ulcerations. In this study, ulcerations included were recorded as a grade 1, 2, or 3.

i.php?p=6. Eficacitatea oxigenarii hiper

Treatment procedure

In group A, 100% oxygen under increased atmospheric pressure was delivered to the lungs of participants through a mask in a multi-place chamber 5 days/week (from Monday to Friday) for approximately 2 h daily, for 40 sessions, as per standard practice and according to our hospital HBOT protocols, under qualified medical supervision. Dressings (calcium alginate) were changed 3 times/week at the HBOT unit.

In both groups, SWC was offered at the tissue viability unit. During each visit, the podiatrist cleansed the wound with a sterile, saline solution, also any superficial dead tissue or callus present at the lesion or in the surrounding areas was debrided with a sterile scalpel. After wound cleansing, calcium alginate was applied. In all patients, wound measurement was conducted after wound cleansing. Dressings were changed every 2 days in both groups.

What are the effects of oxygen therapy on the body?

  • Decreases inflammation
  • Increases the body's oxygen saturation by 20-30%
  • Increases the body's immunity
  • Increases blood circulation and stimulates the formation of new capillaries
  • Decreases toxins in the body
  • Stimulates the production of new blood cells
  • Increases healing rate

Statistical analysis

The analysis was carried out with Statistical Package for Social Sciences version 25 (SPSS; SPSS Inc, Chicago, IL). Data were normally distributed, as shown by the Shapiro Wilks test. The independent sample t-test was employed to compare differences between the 2 groups. Significance was defined at the 5% level (two-tailed p<0.05).

Results

Both groups saw significant improvement by the end of the process. The ulcer area and depth showed a superior improvement in group A.
In group A, the mean ulcer area and depth were significantly smaller than in group B at week 4. There was also a significant difference in mean ulcer depth between the two groups at week 3. Wound surface reduction (3, 75 cm2 in group A vs. 1.05 cm2 in group B) and ulcer depth (0.89 cm in group A vs. 0.19 cm in group B) were more pronounced in group A.

Discussion

The present study has demonstrated that adjunct HBOT enhances the reduction of ulcer area and depth at 4 weeks in T2DM patients with ischaemic DFUs. HBOT is known to ensure hyperoxygenation of ischaemic tissue and restoration from hypoxia. Indeed, fibroblasts, endothelial cells, and keratinocytes are replicated at higher rates in an oxygen-rich environment. Moreover, leukocytes kill bacteria more effectively when supplied with oxygen. Furthermore, it has been postulated that HBOT also improves long-term health-related quality of life in patients with chronic diabetic foot ulcers possibly attributed to better ulcer healing as has been reported in this study.

i.php?p=21. Valoarea terapiei cu oxigen

Conclusions

In conclusion, HBOT as an adjunct promotes healing for ischemic ulcers in patients with T2DM. The results add to the evidence supporting the usefulness of HBOT in DFU management. However, optimal patient selection and long-term outcomes with this type of treatment are still needed before supporting the wider use of HBOT.

About Centrokinetic

Centrokinetic clinic offers all services necessary for a complete rehabilitation process, from the first consultation to the medical specialist to establish the correct diagnosis, to treatment and recovery.

Centrokinetic is the place where you will find clear answers and solutions for your motricity problems. The clinic is dedicated to osteoarticular conditions and is divided into the following departments:

  • Orthopedics, a department composed of an extremely experienced team of orthopedic doctors, led by Dr. Andrei Ioan Bogdan, primary care physician in orthopedics-traumatology, with surgical activity at Medlife Orthopedic Hospital, specialized in sports traumatology and ankle and foot surgery.
  • Pediatric orthopedics, where children's sports conditions are treated (ligament and meniscus injuries), spinal deformities (scoliosis, kyphosis, hyperlordosis) and those of the feet (hallux valgus, hallux rigidus, equine larynx, flat valgus, hollow foot).
  • Neurology, which has an ultra-performing department, where consultations, electroencephalograms (EEG) and electromyography (EMG) are performed. 
  • Medical recovery  for adults and  children, department specialized in the recovery of performance athletes, in spinal disorders, in the recovery of children with neurological and traumatic diseases. Our experience is extremely rich, treating over 5000 performance athletes.
  • Medical imaging, the clinic being equipped with ultrasound and MRI, high-performance devices dedicated to musculoskeletal disorders, and complemented by an experienced team of radiologists: Dr. Sorin Ghiea and Dr. Cosmin Pantu, specialized in musculoskeletal imaging.

Find the latest news by following the Facebook, Instagram and YouTube accounts of the Centrokinetic clinic.

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