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Additional effect of pulsed electromagnetic fields to laser therapy on management of diabetic foot ulcer: A single blind randomized controlled trial

Authors:
  • Jouf University - College of Applied Medical Sciences - Qurayyat

Abstract

Diabetic Foot Ulcer (DFU) is a global health care problem considered as a major cause of morbidity and mortality among diabetic patients. Pulsed Electromagnetic field (PEMF) is a non-invasive technique with potential beneficial effects on wound healing. Laser therapy stimulates cell molecules and is strongly considered as a promising wound healing tool for chronic wounds. The aim of this study was to compare the effect of two therapeutic modalities used to treat infected DFU; the first is PEMF alone compared to PEMF added to infrared laser therapy in diabetic wound healing management. Methods: A prospective, single blind, controlled trial on thirty diabetic foot ulcer patients who were randomly assigned into group A (GA) receiving 2 Gauss (G) Pulsed Electromagnetic Field (PEMF) 10 minutes per session, in addition to the prescribed medical treatment (Diabetic drugs only) and nursing care. Group B (GB) received the same regimen of PEMF in addition to 5 J/cm² Infra-red laser therapy for 12 sessions. Statistical analysis showed that the adjuvant magnetic and laser therapy had more significant reduction in the colony count number in DFU (P< 0.0001). Infrared laser and PEMF are both effective and recommended modalities in reducing the infection of infected diabetic foot ulcer, however combining both modalities has better effect in managing diabetic foot wound infection.
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Bioscience Research
Print ISSN: 1811-9506 Online ISSN: 2218-3973
Journal by Innovative Scientific Information & Services Network
RESEARCH ARTICLE BIOSCIENCE RESEARCH, 2018 15(4):3322-3328 OPEN ACCESS
Additional effect of pulsed electromagnetic fields to
laser therapy on management of diabetic foot ulcer:
a single blind randomized controlled trial
Nesrein A. Abd Elrashid1, Hamada A. Hamada2*,Alshaimaa M. Abdelmoety3, Gaber
S. Soliman4,5 and Rami Abbas6
1Department of Surgery, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
2*Department of Biomechanics, Faculty of physical therapy, Cairo University, Cairo, Egypt
3Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
4Department of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics, Faculty of Physical
Therapy, Cairo University, Giza, Egypt.
5Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences in Al Qurayyat, Jouf
University, Kingdom of Saudi Arabia.
6Department of Physical Therapy, Faculty of Health Sciences, Beirut Arab University, Lebanon.
*Correspondence: Hamada.ahmed@pt.cu.edu.eg Accepted: 18 Oct.2018 Published online: 05 Dec. 2018
Diabetic Foot Ulcer (DFU) is a global health care problem considered as a major cause of morbidity and
mortality among diabetic patients. Pulsed Electromagnetic field (PEMF) is a non-invasive technique with
potential beneficial effects on wound healing. Laser therapy stimulates cell molecules and is strongly
considered as a promising wound healing tool for chronic wounds. The aim of this study was to compare
the effect of two therapeutic modalities used to treat infected DFU; the first is PEMF alone compared to
PEMF added to infrared laser therapy in diabetic wound healing management. Methods: A prospective,
single blind, controlled trial on thirty diabetic foot ulcer patients who were randomly assigned into group
A (GA) receiving 2 Gauss (G) Pulsed Electromagnetic Field (PEMF) 10 minutes per session, in addition
to the prescribed medical treatment (Diabetic drugs only) and nursing care. Group B (GB) received the
same regimen of PEMF in addition to 5 J/cm² Infra-red laser therapy for 12 sessions. Statistical analysis
showed that the adjuvant magnetic and laser therapy had more significant reduction in the colony count
number in DFU (P< 0.0001). Infrared laser and PEMF are both effective and recommended modalities in
reducing the infection of infected diabetic foot ulcer, however combining both modalities has better effect
in managing diabetic foot wound infection.
Keywords: Diabetic foot ulcer, Laser, Pulsed Electromagnetic field
INTRODUCTION
Diabetes is an endocrine disorder that might
affect many systems leading to various
dysfunctions leading to poor sensation and
possibly amputation (TchanqueFossuo et al.,
2016). Diabetic foot ulcers (DFU) are defined as
any breakdown the foot skin of a diabetic person.
(Brem, Sheehan, Rosenberg, Schneider, &
Boulton, 2006). DFU can be considered as a
primary cause of morbidity and mortality affecting
diabetic patients with a worldwide epidemiology.
Recent reporting from WHO (WHO, 2011)
estimates the number of diabetic patient as 347
million, with a proportion of 1 possible
development of diabetic ulcer in each 20 patients.
The Middle East and North Africa (MENA)
represent highest prevalence of diabetes
occurrence where Egypt is ranked among the top
Abd Elrashid et al., PEMF and Laser in DFU
Bioscience Research, 2018 volume 15(4): 3322-3328 3323
10 countries(WB, 2013). The International
Diabetes Federation (IDF) estimates that 7.5
million Egyptian adults are diabetics, and might
reach 13.1 million by 2030(IDF, 2013). The
number of diabetic patients is rising yearly at a
rate greater than expected. It is estimated that the
number of diabetic patients in Africa and the
Middle East to be 35.4 million, with a possible
increase to around 72.1 million by 2040
(Guariguata et al., 2014). Such rise in diabetes
prevalence is also expected to be correlated with
higher rate of occurrence of DFU and
consequently possible secondary amputation
(Ziegler-Graham, MacKenzie, Ephraim, Travison,
& Brookmeyer, 2008).
The physiopathology of DFU make it liable to
be invaded by colonizing microorganisms
resulting in more tissue destruction with a
cascade of inflammatory reactions (Lipsky et al.,
2012) hindering the healing process (Nteleki &
Houreld, 2012). DFU treatment is considered as a
challenge with high prevalence of failures. Lower
Limb amputation is the end result in the
management process for one per six DFU
patients with five year mortality competing with
mortality rates correlated with many cancer such
as breast, prostate, and colon (Beckmann, Meyer-
Hamme, & Schröder, 2014). About 80,000
patients are subjected to foot amputations in the
United States secondary to DFU. Worldwide, it is
estimated that every 30 seconds a lower limb
amputation is executed (Brem et al., 2006). When
examining the rate of lower limb amputations from
diabetes compared to other causes, DFU
amputation exceeds 28 times amputations from
other causes (Ziegler-Graham et al., 2008).
DFU management includes control of blood
sugar level, patient education regarding foot care,
compression, debridement, control of infection,
limb elevation and revascularization surgeries.
Lower limb amputation is usually a result of poor
wound care (Ayello, 2005). It is considered that
failure of wound healing through standard
interventions in less than two weeks must urge a
reevaluation and more robust and advanced
interventions must be implemented. Such
interventions are usually more costly and might
include pulsed electromagnetic fields intervention
and phototherapy (Mulder, Tenenhaus, &
D’Souza, 2014).
Pulsed Electromagnetic field (PEMF) is a
novel non-invasive technique used in wound
healing through introducing micro currents of
electromagnetic fields to the targeted tissues.
PEMF has been claimed to enhance collagen
synthesis, angiogenesis, and bacteriostasis
consequently fostering wound healing (Shupak,
Prato, & Thomas, 2003). PEMF may be beneficial
in addressing wound healing among both
diabetics and non-diabetics and can be useful
also in ulcer prevention and hence reduction of
amputation prevalence and thus requiring more
scientific research to prove its effectiveness
(Callaghan et al., 2008).
Another novel intervention in approaching
DFU include laser light application through
inducing energy at a specific wavelength. It has
been claimed that such intervention might activate
enzymes responsible for cell metabolism by
means of minimal changes in temperature well
known as phototherapy. This energy is also
absorbed by chromophores thus increasing
mitochondrial activity and finally rising ATP as well
(Silveira et al., 2009). Laser therapy has been
claimed to stimulate cell molecules and
atoms(Feitosa et al., 2015), and is strongly
advised as non-invasive tool to address wound
healing in cases of chronic wounds(Tubachi &
Godhi, 2015).
Hence, the aim of this study was to compare
between two well-known forms of electromagnetic
radiations; PEMF and laser therapy in the form of
photons, on DFU among diabetic patients
regarding the wound surface area and bacterial
colony count.
MATERIALS AND METHODS
Study design
The study was a prospective, single blinded,
prepost-test, randomized controlled trial. Ethical
approval was obtained from the institutional
review board at Faculty of physical therapy, Cairo
University before study commencement. The
study followed the Guidelines of Declaration of
Helsinki on the conduct of human research. The
study was conducted between June 2017 and
August 2017.
Participants
Thirty, Type II, diabetic patients suffering also
from diabetic foot ulcers (DFU) were recruited
from the Outpatient Clinic Kasr El-Aini hospital to
be treated in the Outpatient Clinics, Faculty of
Physical Therapy, Cairo University. Patients were
assessed for their eligibility to participate in the
study. The participants had grade-3/Stage-D
diabetic foot ulcers, according to University of
Texas classification of diabetic foot, had a
Staphylococcus bacterial infection, and their age
Abd Elrashid et al., PEMF and Laser in DFU
Bioscience Research, 2018 volume 15(4): 3322-3328 3324
ranged from 45-60 years. The participants were
excluded if they were smokers, alcoholic, suffering
from any autoimmune diseases, on
immunosuppressive drugs, in addition to any
concomitant psychiatric disorders, or
contraindicated for the research-adopted methods
of treatment.
Randomization
All patients underwent a session regarding
their willingness to participate in the study.
Informed consent was obtained from each
participant after explaining the nature, purpose,
and benefits of the study, informing them of their
right to refuse or withdraw at any time, and about
the confidentiality of any obtained information.
All data was coded to assure anonymity was
assured. Participants with DFU were randomly
and blindly assigned into two groups (group A and
group B) by an independent research assistant
who opened sealed envelopes containing a
computer generated randomization card. No
dropouts were recorded after randomization.
Interventions
Participants were randomly assigned into
group A (GA) receiving 2 Gauss (G) Pulsed
Electromagnetic Field (PEMF) 10 minutes per
session in supine position, in addition to the
prescribed medical treatment (Diabetic drugs
only) and nursing care. The device used was
(ASA model PMT Quattro PRO-Italy) at 20 Hz of
frequency. Group B (GB) received the same dose
of PEMF in addition to Infrared laser therapy with
904 nm wavelengths with a 5J/cm² density for 10
minute in supine position, in addition to the
prescribed medical treatment (Diabetic drugs
only) and nursing care. The whole duration of
each treatment session was set by the machine
based on the density selected (5J/cm²). Infrared
laser therapy was applied using automatic
scanning technique on both the wound and the
wound perimeter intact skin. The device used was
ASA model BRAVO Terzaserie He-Ne Italy
wavelength range of 632 nm to 904 nm. Both
groups received 12 sessions of treatment, three
times per week for four weeks.
Outcome measures
Wound surface area as the primary outcome
was measured at the beginning and after one
month of treatment; by tracing the wound
perimeter using the transparency method in which
the patient was positioned in a comfortable
position with exposed foot, a sterilized transparent
film was placed directly and in contact with the
skin around the wound avoiding any movement or
distortion of the foot. The wound margins were
traced using a fine-tipped transparency marker
three times for reliability. After tracing, the other
side of the transparent film was cleaned with
alcohol and the traced wound perimeters were
transferred to an AutoCAD software program in
order to measure the irregular shape areas in cm2.
Additionally, colony count, as secondary outcome,
was measured before and after the whole duration
of treatment (one month); using a sterile swab, the
same pathologist collected specimen from the
wound, placed it in a sterile container, and sent to
the laboratory. In the laboratory, the specimen
was spread over several different types of culture
plates and placed in an incubator at 37°C for one
to two days. The number of colonies was counted.
The bacterial load measurement was done by
multiplying the number of colonies with dilution
factor and the volume of the supernatant obtained
during the tissue homogenization was presented
as log CFU/ml (Zhao et al., 2012).
Sample size and statistical analysis
Results were expressed as mean ± standard
deviation (SD). Comparison of different variables
within and between groups was performed using
paired and unpaired t test in normally distributed
data or Wilcoxon Sign Rank test and Mann
Whitney U test in not normally distributed data
respectively. Statistical Package for Social
Sciences (SPSS) computer program (version 23
windows) was used for data analysis. The alpha
level was set at 0.05.
Table 1:Descriptive statistics and unpaired t-tests for the mean age of the patients in both groups.
Items
Group A
Group B
Level of significance
Mean ± SD
Mean ± SD
t-value
p-value
Age (yrs)
55.13±2.64
56.46±3.22
1.238
0.226
NS
*SD: standard deviation, P: probability, S: significance, NS: non-significant.
Abd Elrashid et al., PEMF and Laser in DFU
Bioscience Research, 2018 volume 15(4): 3322-3328 3325
Table (2): Distribution of sex in both groups:
*Significant at the alpha level (p < 0.05).
Table (3): Median score, U, Z, and P values of the colony account pre and post treatment in both
groups.
Colony account
Median score
Z-value
p- value
pre
Post
Group A
100000
1000
-3.305
0.001*
Group B
100000
100
-3.413
0.001*
U-value
112.5
22
Z-value
0.000
-3.867
p- value
1.00
0.0001*
*Significant level is set at alpha level <0.05
RESULTS
Baseline and demographic data
There were no statistically significant
differences (p>0.05) between subjects in both
groups concerning age (Table 1).
In addition, Chi square revealed no significant
differences between both groups in sex
distribution (p>0.05) (Table 2).
Within groups:
The median score of colony account in the
"pre" and "post" treatment were 100000 and 1000
respectively in the group A. Statistical analysis
using the non-parametric Wilcoxon Signed Rank
tests revealed that there was a significant
decrease in the colony account in the "post" test
in the group A (p <0.05). Meanwhile, the median
score of colony account in the "pre" and "post"
tests were 100000 and 100 respectively in the
group B. statistical analysis using the non-
parametric "Wilcoxon Signed Rank tests" revealed
that there was a significant decrease in the colony
account in the "post" test in the group B (p<0.05)
table(3).
Between groups:
Considering the effect of the tested group
(first independent variable) on colony account,
"Mann-Whitney tests" revealed that the median
score of the "pre" test between both groups
revealed no significant difference between both
groups (p>0.05). Additionally, the median score of
the "post" test between both groups showed
significant difference between the both groups (
p<0.05) and this significant reduction was in favor
to group B (Table 3).
DISCUSSION
The study was conducted to compare the
effect of two therapeutic modalities used to treat
infected DFU; the first is PEMF (2 G) alone
compared to PEMF (2 G) combined with infra-red
laser therapy at 5 J/cm2. Patients in this study
were 30 with type II diabetes mellitus and
suffering from stage 3 DFU. Participants were
distributed into two groups A&B. Group A where
the patients were subjected to 2 Gauss, 10
minutes’ sessions, of Pulsed Electromagnetic
Field Therapy (PEMF) only, for 12 sessions every
other day each. Group B were subjected to the
same treatment regimen as group A in addition to
5 J/cm² of Laser therapy during each treatment
session. The patients in the two groups were
homogenous regarding age and sex with no
significant differences (p= 0.226) and sex (p=
0.256).
PEMF alone showed remarkable effect in
reducing DFU colony count with significant
differences after therapy from 100000 to 1000
(p<0.0001). More marked reduction in the colony
count was found in the intervention group B
receiving a combination of both PEMF and Laser
therapy from 100000 to 100 with evident statistical
significance (p<0.0001). Statistical analysis
showed that the combined effect of magnetic and
laser therapy had more significant reduction in the
colony count number (p<0.0001). Diabetic foot is
Group A
Group B
Chi -Square
Females
Males
Females
Males
X2
p-value
No.
11 (73.3%)
4 (26.7%)
8 (53.3%)
7 (46.7%)
1.292
0.256
Total
15 (100%)
15 (100%)
Abd Elrashid et al., PEMF and Laser in DFU
Bioscience Research, 2018 volume 15(4): 3322-3328 3326
a common complication of diabetes and is usually
robust towards healing and it is easily subjected to
infection, both infection and diabetes are main
reasons for non-healing or delayed healing
sometimes leading to amputation as an end result
to prevent the spread of infection (Guerriero et al.,
2015). When considering drug resistance
bacteria, DFU is considered as a challenging
critical complication affecting patient’s productivity
and normal life. Wound healing is a complex
process requiring several cell activities, mediators
over different healing phases; research potential
in this field is highly recommended. Comparing
the results of the current study with others is
somehow confusing due to the differences in
study designs, selection criteria, healing process
complexity, differences in the parameters and
techniques and the presence of various treatment
modalities.
Despite the lack of consensus on the
underlying mechanism of action of PEMF, it is
postulated to be a promising wound healing
modality (El Rasheed, Mahmoud, Hamada, & El
Khatib, 2017).The current study proved that the
use of PEMFs alone have significantly decreased
infection and colony count after irradiation in
DFUs. These findings came in agreement with
several studies that have proved the positive
effect of PEMF on DFU healing (Cheing, Li,
Huang, Kwan, & Cheung, 2014; Choi, Cheung, Li,
& Cheing, 2016; Guerriero et al., 2015). Other
studies reported also the inhibitory effect of PEMF
on bacterial growth and production(El Rasheed et
al., 2017), Staphylococcus aureus colony-form
reduction(Ahmed, Istivan, Cosic, & Pirogova,
2013)and destroying the glycopolysaccharide
releasing bacteria that stimulate macrophages
and hence body immunity(Ibrahim, Nazal, &
Alrashid, 2011).On the other side Milgram et
al(Milgram, Shahar, LevinHarrus, & Kass, 2004)
who used high intensity PEMF reported no
significant differences in terms of wound
contraction and epithelialization. Our study used 2
Gauss of FEMF differences in results may be
attributed to the differences in the kind of wounds
and the used parameters.
Previous studies proved the Infra-red laser
therapy ability to enhance the healing process of
the wound via its bactericidal effect through
recruiting important growth factors and cytokines
as interleukin-1 and interleukin-8 and stimulating
phagocytic effect of macrophages (Tchanque
Fossuo et al., 2016).This was proved by
significant bacterial reduction on the group treated
with Infra-red laser therapy at 10 J/ccompared
to colony count pretreatment and thus improved
DFU healing process(Choi et al., 2016)21.Many
studies have proved the effectiveness of laser
therapy on wound healing (Feitosa et al., 2015;
Pereira, De Paula, Cielinski, Pilonetto, & Von
Bahten, 2014; TchanqueFossuo et al., 2016).
Minatel et al (Minatel, Frade, França, &
Enwemeka, 2009) reported that Laser irradiation
promoted DFU healing which resisted formerly to
other forms of treatment. On the other hand,
some studies failed to prove that (Lagan,
Clements, McDonough, & Baxter, 2001). The type
of wounds, technique of laser therapy application,
difference in the recruited subjects and the
phototherapy parameters ranges could be the
attributing factors beyond the lack of universal
agreement on laser as a treatment choice of
wound healing.
Other researchers (El Rasheed et al., 2017)
supported the use of combined PEMF and laser
as alternative therapies with antibiotics to manage
wound infection deducing that 10 J/cm2 Infra-red
laser is better than 0.5 G and 20 Hz PEMF
therapy. The two modalities are applied safely
from a distance creating no risk of contact
infection, painless and cheap when compared to
surgical interventions making them highly
recommended in treatment DFU. The current
study results supported that the combination of
PEMS 2 Gauss and laser therapy5 J/cm² had
more significant reduction in the colony count
number (p< 0.0001).
The study results are limited to the selected
sample with the exact parameters used. Further
studies should be encouraged to find out the
underlying mechanism of action of PEMF and
Laser. Long-term follow-up, application of different
treatment modalities, measurement of various
parameters, and inclusion of other kinds of
wounds and population is recommended in further
researches.
CONCLUSION
The combination of 5 J/cm2 infra-red laser and 2
G. PEMF are effective and recommended
modalities in reducing the infection of infected
diabetic foot ulcer. Combining both modalities has
shown more remarkable reduction in wound
infection regarding the same used parameters of
treatment.
CONFLICT OF INTEREST
Authors declare no potential conflicts of
interests.
Abd Elrashid et al., PEMF and Laser in DFU
Bioscience Research, 2018 volume 15(4): 3322-3328 3327
ACKNOWLEGEMENT
The Authors would like to contribute the
participants who enrolled in this study for their
commitment and cooperation.
AUTHOR CONTRIBUTIONS
NAE, HAH, AMA, GSS, and RB proposed the
research idea and design, NAE, HAH, AMA,
performed the practical part, and helped in writing
the manuscript. HAH, AMA, GSS, and RB designed
the experiment, performed the statistics, writing
and reviewing the manuscript. All authors read
and approved the final version.
Copyrights: © 2017 @ author (s).
This is an open access article distributed under the
terms of the Creative Commons Attribution License
(CC BY 4.0), which permits unrestricted use,
distribution, and reproduction in any medium,
provided the original author(s) and source are
credited and that the original publication in this
journal is cited, in accordance with accepted
academic practice. No use, distribution or
reproduction is permitted which does not comply
with these terms.
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Chronic ulcers are a common complication in diabetes. The nature of diabetic foot ulcers makes them difficult to manage and treat. A dynamic management plan is required to treat diabetic lower limb ulcerations. This involves a strategic approach, including mechanical offloading, wound debridement, wound dressing, patient education and surgical intervention. Alternative methods have been developed, of which phototherapy is one. Phototherapy, or low-level laser therapy (LLLT), is a therapeutic treatment modality that has been found to enhance wound healing. Its therapeutic properties have been determined by means of in vitro, in vivo and animal studies. Some studies have shown that the clinical application of phototherapy has a positive effect on the process of wound healing. Therefore, LLLT has the potential to decrease the level of secondary complications, improve wound regeneration, and ultimately improve patient quality of life. This review will discuss the concept of chronic wound management by means of LLLT in patients who suffer from type 2 diabetes.