Changes in skin-physiology after local heat application using two different methods in individuals with complete paraplegia: a feasibility and safety trial

Abstract

Study design:

Interventional feasibility study.

Objectives:

To evaluate safety and effects of local heat preconditioning on skin physiology using water-filtered infrared-A radiation (wIRA) or warm water therapy (wWT) in individuals with spinal cord injury (SCI).

Setting:

Acute and rehabilitation center, specialized in SCI.

Methods:

A convenience sample of 15 individuals (3 women, 12 men) with complete paraplegia from thoracic levels ranging between T2 and T12 received local heat applications either with wIRA or wWT on the thigh (paralyzed area) and on the upper arm (non-paralyzed area). Local heat was applied during three 30-min cycles, each separated by 30 min rest; thus, the treatment lasted for 180 min. Temperature, blood perfusion, and skin redness were measured at baseline, before and after heat application and 24 h after the last application.

Results:

Heat applications with wIRA and wWT were well-tolerated. No burns or any other side effects were detected. Skin temperature (p ≤ 0.008) and blood perfusion (p ≤ 0.013) significantly increased after heat application. Local skin temperature (arm p = 0.004/leg p < 0.001) and blood perfusion (arm p = 0.011/leg p = 0.001) after the first and the second application cycle, respectively, were significantly higher during heat application with wIRA than with wWT. However, skin redness did not change significantly (p = 0.1). No significant differences were observed between the paralyzed and non-paralyzed areas for all parameters immediately, as well as 24 h after the treatment.

Conclusions:

Although both heating methods have been confirmed as safe treatments in this study, further investigations with regard to their efficacy in the context of preconditioning are warranted.

Sponsorship:

The use of the instruments Hydrosun® 750 Irradiator (Hydrosun Medizintechnik, Germany) and Hilotherm-Calido 6 (Hilotherm GmbH, Germany) was sponsored by the Dr. med. h. c. Erwin Braun Foundation and by Hilotherm GmbH, respectively.

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Fig. 1: Schematic time course of the experiment: intervention and measurement.
Fig. 2: Skin temperature (°C) measured at the thigh and upper arm at baseline and at time points T1–T5 on the first day and at time point D2 on the day after intervention with water-filtered infrared-A radiation (wIRA) and warm water therapy (wWT).
Fig. 3: Skin perfusion in arbitrary units measured at the thigh and upper arm at baseline and at time points T1–T5 on the first day and at time point D2 on the day after intervention with water-filtered infrared-A radiation (wIRA) and warm water therapy (wWT).
Fig. 4: Skin redness in arbitrary units at the thigh and upper arm at baseline and at time points T1–T5 on the first day and at time point D2 on the day after the intervention with water-filtered infrared-A radiation (wIRA) and warm water therapy (wWT).

References

  1. 1.

    Berger MJ, Hubli M, Krassioukov AV. Sympathetic skin responses and autonomic dysfunction in spinal cord injury. J Neurotrauma. 2014;31:1531–9.

  2. 2.

    Jan Y-K, et al. Comparison of changes in heart rate variability and sacral skin perfusion in response to postural changes in people with spinal cord injury. J Rehabilitation Res Dev. 2013;50:203.

  3. 3.

    Scheel-Sailer A, et al. Biophysical skin properties of grade 1 pressure ulcers and unaffected skin in spinal cord injured and able-bodied persons in the unloaded sacral region. J Tissue Viability. 2017;26:89–94.

  4. 4.

    Fuyuan L, Yih-Kuen J. Using multifractal detrended fluctuation analysis to assess sacral skin blood flow oscillations in people with spinal cord injury. J Rehabilitation Res Dev. 2011;48:787–99.

  5. 5.

    Liao F, Burns S, Jan YK. Skin blood flow dynamics and its role in pressure ulcers. J Tissue Viability. 2013;22:25–36.

  6. 6.

    Makhsous M, et al. Measuring tissue perfusion during pressure relief maneuvers: insights into preventing pressure ulcers. J Spinal Cord Med. 2007;30:497–507.

  7. 7.

    Wettstein R, et al. Local flap therapy for the treatment of pressure sore wounds. Int Wound J. 2015;12:572–6.

  8. 8.

    Kreutztrager M, et al. Outcome analyses of a multimodal treatment approach for deep pressure ulcers in spinal cord injuries: a retrospective cohort study. Spinal Cord. 2018;56:582–90.

  9. 9.

    DeVivo M, Farris V. Causes and costs of unplanned hospitalizations among persons with spinal cord injury. topics in spinal cord injury. Rehabilitation. 2011;16:53–61.

  10. 10.

    Harder Y, et al. Heat shock preconditioning reduces ischemic tissue necrosis by heat shock protein (HSP)-32-mediated improvement of the microcirculation rather than induction of ischemic tolerance. Ann Surg. 2005;242:869.

  11. 11.

    Contaldo C, et al. The influence of local and systemic preconditioning on oxygenation, metabolism and survival in critically ischaemic skin flaps in pigs. J Plast Reconstructive Aesthetic Surg. 2007;60:1182–92.

  12. 12.

    Rücker M, et al. Local heat shock priming promotes recanalization of thromboembolized microvasculature by upregulation of plasminogen activators. Arteriosclerosis Thrombosis Vasc Biol. 2006;26:1632–9.

  13. 13.

    Mehta S, et al. Local heat preconditioning in skin sparing mastectomy: a pilot study. J Plast Reconstructive Aesthetic Surg. 2013;66:1676–82.

  14. 14.

    Hoffmann G, Hartel M, Mercer JB. Heat for wounds–water-filtered infrared-A (wIRA) for wound healing–a review. GMS German Med Sci. 2016;14:1–22.

  15. 15.

    Künzli BM, et al. Impact of preoperative local water-filtered infrared A irradiation on postoperative wound healing: a randomized patient-and observer-blinded controlled clinical trial. Ann Surg. 2013;258:887–94.

  16. 16.

    Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. JAMA Dermatol. 1988;124:869–71.

  17. 17.

    Brunner E, Langer F. Nonparametric analysis of ordered categorical data in designs with longitudinal observations and small sample sizes. Biometrical J. 2000;42:663–75.

  18. 18.

    Winkel R, Hoffmann G, Hoffmann R. [Water-filtered infrared-A (wIRA) promotes wound healing]. der Chir Z fur alle Geb der operativen Medizen. 2014;85:980–92.

  19. 19.

    Hartel M, et al. Randomized clinical trial of the influence of local water‐filtered infrared A irradiation on wound healing after abdominal surgery. Br J Surg. 2006;93:952–60.

  20. 20.

    Scheel-Sailer A, et al. Challenges to measure hydration, redness, elasticity and perfusion in the unloaded sacral region of healthy persons after supine position. J Tissue Viability. 2015;24:62–70.

  21. 21.

    Scheel-Sailer A, et al. Biophysical skin properties of grade 1 pressure ulcers and unaffected skin in spinal cord injured and able-bodied persons in the unloaded sacral region. J Tissue Viability. 2017;26:89–94.

  22. 22.

    Nicotra A, Asahina M, Mathias C. Skin vasodilator response to local heating in human chronic spinal cord injury. Eur J Neurol. 2004;11:835–7.

  23. 23.

    Claydon VE, Krassioukov AV. Orthostatic hypotension and autonomic pathways after spinal cord injury. J Neurotrauma. 2006;23:1713–25.

  24. 24.

    Lehmann J, de Lateur B. Application of heat and cold in the clinical setting. In: Lehmann J. F. editor. Therapeutic Heat and Cold. 4th edn. Baltimore: Williams & Wilkins; 1990. pp. 633–44.

  25. 25.

    Coombs GB, et al. Acute heat stress reduces biomarkers of endothelial activation but not macro- or microvascular dysfunction in cervical spinal cord injury. Am J Physiol Heart Circulatory Physiol. 2019;316:H722–33.

  26. 26.

    Mak AF, Zhang M, Tam EW. Biomechanics of pressure ulcer in body tissues interacting with external forces during locomotion. Annu Rev Biomed Eng. 2010;12:29–53.

  27. 27.

    Choi JH, et al. Generation of viable embryos and embryonic stem cell-like cells from cultured primary follicles in mice1. Biol Reprod. 2011;85:744–54.

  28. 28.

    Previnaire JG, et al. Severity of autonomic dysfunction in patients with complete spinal cord injury. Clin Autonomic Res. 2012;22:9–15.

  29. 29.

    Krassioukov A. Autonomic function following cervical spinal cord injury. Respiratory Physiol Neurobiol. 2009;169:157–64.

  30. 30.

    Hou S. Autonomic consequences of spinal cord injury. Compr Physiol. 2014;4:1419–53.

  31. 31.

    Harder Y, et al. Improved skin flap survival after local heat preconditioning in pigs1. J Surgical Res. 2004;119:100–5.

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Acknowledgements

We would like to thank all the participants and the patients at the Swiss Paraplegic Centre.

Funding

We would like to thank the Dr. h.c. Erwin Braun Stiftung and the HiloTherm GmbH for providing the instruments used in this study.

Author information

AS-S: study design, data analysis, experimentation, paper preparation, study monitoring. NA: study design, establishment of methods, experimentation, data analysis, paper preparation. DJ: experimentation, data analysis, paper preparation. This study serves as his Master’s Thesis in Medicine at the University of Basel. AW: study design, establishment of methods, experimentation. This study serves as her Master’s Thesis in Medicine at the University of Basel. SA: study design, establishment of methods, data analysis, paper preparation. YH: study design, establishment of methods, manuscript preparation. JK: study design, data analysis and statistics, paper preparation. RW: study design, data analysis, study monitoring, paper preparation.

Correspondence to Anke Scheel-Sailer.

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Conflict of interest

The authors declare that they have no conflict of interest.

Statement of ethics

The study protocol was approved by the Ethics Committee of the Northwest and Central Switzerland (ECNZ 2016–01158) and was registered on clinicaltrial.gov (2014–05 NCT03001531). Each patient signed the consent declaration before undergoing the intervention. This study was conducted following the research principles of good clinical practice.

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Scheel-Sailer, A., Aliyev, N., Jud, D. et al. Changes in skin-physiology after local heat application using two different methods in individuals with complete paraplegia: a feasibility and safety trial. Spinal Cord (2020). https://doi.org/10.1038/s41393-019-0408-8

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