Whirlpool

Wound Care Information Network

Whirlpool in Wound Care

Author: Carrie Sussman, PT
SUSSMAN PHYSICAL THERAPY INC.
3904 W. 234 PLACE TORRANCE,CA 90505-4616
310\375-8815 310\378-6845 FAX
email: BCSussman@aol.com

Note: This paper on electrical stimulation for wound healing has been excerpted from: Chapter 20, Sussman, C and Byl, N, Whirlpool, Wound Care Collaborative Practice Manual for Physical Therapists and Nurses, Sussman, C. And Bates-Jensen, BM, Aspen Publishers 1998.

Whirlpool is the physical agent most closely identified with physical therapy wound care.

1. Whirlpool may be used at different temperature settings to modify its effect on circulation. Although it is the most commonly used modality, it's effect on wound healing has not been researched.

Whirlpool tanks may be either permanent or portable, full body or extremity. The agitation force and direction of the turbulence may be adjusted to protect granulation tissue from trauma.

2. How does this modality benefit a wound patient:

Objectives of whirlpool treatment include:

vasodilitation
increased blood flow
softening and loosening of necrotic tissue
mechanical debridement
wound cleansing: debris and topical agents
exudate removal --- > reduced infection
pain management

3. Theory behind modality's effectiveness:

Whirlpool effects the Inflammation Phase of healing

Warm water increases vasodilitation of the superficial vessels
Increased blood flow brings oxygen and nutrients to the tissues and removes metabolites
Increased blood flow brings antibodies, leukocytes and systemic antibiotics
Fluid shifts into the interstitial spaces leading to edema
Softening and loosening of necrotic tissue aides phagocytosis
Cleansing and removal of wound exudate controls infection
Mechanical effects of whirlpool stimulate granulation tissue formation
Sedation and analgesia are induced by the warm water

4. How should a physical therapist use this modality on a wound?

This treatment modality is often administered twice daily for 20 minutes, however, once daily treatment should be considered as an appropriate option. Following whirlpool, the wound and surrounding tissues should be rinsed vigorously with clean water to remove residue from the wound and surrounding tissues. The best types of wounds for whirlpool are those that fall into the categories of:

Necrotic
Moderate to heavy exudative wounds
Wounds with debris
Tissue which can tolerate moderate to heavy increased circulatory perfusion
Ischemic wounds where vigorous perfusion to wound and surrounding tissues is desired

Protocol:

Whirlpool temperature Guide

Water temperature range from 33.5 °C to 35.5 0C = 92 °F to 96 °F
Water temperature should not exceed 1 °C above skin temperature in presence of PVD.
Water temperature should not exceed 38 °C in presence of cardiopulmonary disease
Water temperature of 32 °C blood flow of 2.3cc/100 cc of limb volume. Higher temperature gives greater blood flow volume.
When using lower temperatures, avoid chilling by maintaining warm room temperature and use only for single limb, not whole body.

5. Are there any risks or complication with this modality?

Whirlpool may be contraindicated for the following wound situations:

clean granulating wounds - clean granulating wounds are easily traumatized by the force of even a mild agitation
epithelializing wounds
migrating epidermal cells may be damaged by even minimal force
new skin grafts - skin grafts will not tolerate the high shearing forces and turbulence
new tissue flaps - tissue flaps are very sensitive to shearing forces and vasoconstriction which may occur if the water or air temperature cause chilling
venous ulcers - it is undesirable to increase blood volume to an area where blood volume is already a problem - will complicate the problem; in addition, a dependent position will produce more dependent edema and stasis; the hard necrotic fibrin found in a venous ulcer are not effectively debrided by hydrotherapy.
non-necrotic diabetic ulcers - callus will be softened leading to maceration, macerated tissue will not tolerate pressure and wound will be enlarged

6. Should antiseptics be used in the whirlpool?

There remains controversy about the use of antiseptic agents in the whirlpool. Much research indicates that the most commonly used antiseptic agents are harmful to the cells of tissue repair. In addition, they may not be able to reduce the number of bacteria when the bacteria are very numerous. A study by Bohannan found that four times as many bacteria were removed from a venous ulcer when rinsed vigorously with clean tap water than when the wound was only treated in a povodine iodine whirlpool. Patients with chronic wounds may develop allergic responses to the chemical agents.

If antiseptics are to be used, they should be used for necrotic, heavily exudating wounds. Then monitor carefully and continue only until wound is clean. DO NOT OVERUSE.

Commonly used antiseptics in the whirlpool are:

povidine iodine
sodium hypochlorite
HiBiclens ®
Chlorazene ® (chloramine)

7. Are any patients/pathologies prohibited from using this modality?

edema of the extremity
lethargy
unresponsiveness
maceration
upper extremity infection
febrile conditions
compromised cardiovascular or pulmonary function
acute phlebitis
renal failure
dry gangrene - evaluate for ischemia
incontinence of urine or feces, if in full body whirlpool

8. Infection control in hydrotherapy

Proper cleaning of whirlpool equipment and the use of disinfecting solutions selected to kill infectious organisms should be a policy and procedure of all health care facilities.

Proper use of Universal precautions is important in controlling infection. Culturing of whirlpool equipment is not recommended unless there is an episode of unexplained nosocomial infections that can be traced back to use of the whirlpool equipment. A policy to prevent inhalation or contact dermatitis by the hydrotherapy personnel should be developed for each health care facility when using antiseptics and disinfecting agents.

Reference Sources:

The Role of Physical Therapy in Wound Care, C. Sussman, BS PT Chronic Wound Care: A Sourcebook for Health Care Professionals, Krasner, Diane, RN, MS, CETN 1990.
Thermal Agents in Rehabilitation, S. Michlovitz, 2nd ED. 1990.
Wound Healing: Alternatives in Management, Kloth, McCulloch, Feedar 2nd Ed. 1994.
Infection Control in Hydrotherapy, American Physical Therapy Association, 1995.
AHCPR Treatment Guidelines for Pressure Ulcers, 1994.

Reprinted with permission. This paper on electrical stimulation for wound healing has been excerpted from: Chapter 20, Sussman, C and Byl, N, Whirlpool, Wound Care Collaborative Practice Manual for Physical Therapists and Nurses, Sussman, C. And Bates-Jensen, BM, Aspen Publishers 1998.