Development and validation of an algorithm for laser application in wound treatment

ABSTRACT Objective: To develop and validate an algorithm for laser wound therapy. Method: Methodological study and literature review. For the development of the algorithm, a review was performed in the Health Sciences databases of the past ten years. The algorithm evaluation was performed by 24 participants, nurses, physiotherapists, and physicians. For data analysis, the Cronbach’s alpha coefficient and the chi-square test for independence was used. The level of significance of the statistical test was established at 5% (p<0.05). Results: The professionals’ responses regarding the facility to read the algorithm indicated: 41.70%, great; 41.70%, good; 16.70%, regular. With regard the algorithm being sufficient for supporting decisions related to wound evaluation and wound cleaning, 87.5% said yes to both questions. Regarding the participants’ opinion that the algorithm contained enough information to support their decision regarding the choice of laser parameters, 91.7% said yes. The questionnaire presented reliability using the Cronbach’s alpha coefficient test (α = 0.962). Conclusion: The developed and validated algorithm showed reliability for evaluation, wound cleaning, and use of laser therapy in wounds.


Introduction
A wound is any interruption in the continuity of the corporeal tissue. The causes are mainly related to trauma or triggered by a clinical condition, specifically by wound dehiscence, traumatic wounds, vasculogenic ulcers, and pressure injuries (1) . Skin wounds affect people at any age; to repair this damaged tissue, the body uses intrinsic, dynamic, organized, and extremely complex biological processes that can occur quickly when the clinical situation is favorable, and the extent and degree of tissue loss are minor. Nevertheless, chronic wound lead to problems that affect the individual's life, generating a negative impact, such as: presence of pain, alterations in the perception of the self-image, self-esteem and in spirituality, negatively modifying quality of life, and contributing to occupational disability, causing awkwardness and embarrassment in social relationships (2)(3)(4)(5) .
Several types of adjunctive treatment for acute and chronic wounds are available. Many research studies highlight the use of laser, ultrasound and phytotherapeutics. The choice of the best treatment depends on intrinsic and extrinsic factors, dynamic processes, and the clinical situation, at each moment of the evolution of the wound healing phases (6)(7) . Laser is currently one of the main resources used by health professionals for treatment of wounds; its effects are based on the proliferation of fibroblasts, osteoblasts and epithelial cells, as well as in the synthesis of collagen, which is fundamental for good healing (7)(8) .
Professionals using laser therapy to treat wounds need to acquire knowledge on the best form of treatment, absolute and relative contraindications, physiological effects, complications, application techniques, and Brazilian biosafety standards. Thus, the professional can offer safe, topical treatment of lesions, obtaining benefits regarding the process of wound healing (9) . Technical and scientific knowledge can be acquired by means of classes, trainings, and scientific articles; practice should be follow clinical guidelines, protocols, and booklets and validated algorithms, based on clinical evidence.
The algorithms consist of a finite sequence of welldefined instructions, systematically performed, which are commonly used in healthcare. Having a complete view of the clinical process, these instruments are simple, direct and easy-to-access (10 , in addition to constituting an indispensable tool for standardization of techniques and quality management, and are an important part of organization processes, acting as a guide for decisionmaking. (10) .
The development of an algorithm for laser wound therapy is favorable, along with an application based on the proposed algorithm for evaluation, wound cleaning, laser therapy, and primary dressing on wounds. These instruments can support a more objective evaluation of the area's characteristics, the choice of the technique for laser application, and facilitate the recording of the lesion's characteristics, ensuring monitoring of the evolution of the wound and assessment of the laser therapy results. This provides several benefits to the wound healing process and to patient safety, as well as greater safety for the professional during the application of the treatment. The objective of this study was the development and validation of an algorithm for laser therapy for wound care.
The wound evaluation steps, including measurement, wound margin type, tissue type, exudate type and amount present, (30) and signs of infection were analyzed in the first stage of the algorithm. The second step determined the procedures that precede laser therapy, which provided inclusion of suggestions for wound cleaning techniques, according to the type of tissue found (i.e., devitalized, granulation and epithelial tissue) (7,(22)(23)(24) . In the third step, the aim was to propose suggestions for laser therapy parameters, as Finally, the participants answered questions whose options were dichotomous, "yes" and "no", and were related to the algorithm's ability to support professional Cronbach's alpha coefficient (α> 0.70) evaluated the reliability of the questionnaire, (32) and the Chi-square test was used for associations between variables. The level of significance was established at 5% (p <0.05).

Results
The participants' ages ranged from 28      * The use of "saline solution" or "saline + antiseptic" in the presence of exudate may be considered in the "wound cleaning" stage, only in countries where standards for wound treatment do not include the use of antiseptics. The use of an antiseptic in this step is highly recommended.

Participant Suggestions
Number 2 (Physiotherapist) Question 2: Choose lighter fill colors (example, green with black font) for easier reading Number 8 (Nurse) Question 2: I had difficulty reading because of the font size, especially in the wound assessment.
Number 10 (Physiotherapist) Question 25: I consider the presented material of great relevance. I just got the impression that the title "Assessment and treatment of wounds using laser therapy", considering the fact that the laser is present as part of a "management" involving other therapeutic procedures, such as debridement and coverage, which even underestimates the material presented. Maybe something such as this: "Laser therapy in wounds: assessment, preparation, and application" to indicate that the algorithm goes beyond the details of the laser.

Number 16 (Physician)
Question 7: Signs of inflammation, and not infection, should be the text used. These are cardinal signs of inflammation.
Number 20 (Nurse) Question 4: In the item "tunnel measuring", the measurement should be in cm³ Question 10: Add the "*" to the "jet" description in the cleaning item Question 18: Include saline, as described in the literature

Discussion
Professionals who provide care to wound patients need to be in a position to adapt to technological changes and globalization, which provide ideological, cultural and social changes in individuals. To successfully handle change, it is necessary to seek excellence in the profession. The accelerated increase of knowledge, and the volume of information generated, require a professional profile with learning capacity and rapid adaptation to the current context, developing skills and strategies to perform assistance based on scientific and technological evidence (21) .
In the present study, the proposed algorithm was evaluated by means of a questionnaire developed by the researchers, based on another study with the same purpose, published in the literature (34) . Most participants' responses were considered positive, with "excellent" and "good" responses. Regarding the assessment of the ability of the algorithm to support decisions in the evaluation, cleaning and laser parameters to be used, the participants found that the instrument was able to support professional decision-making.  (34) .
In the present study, the majority of the In this study, we had as a limitation of this study the lack of verification of the algorithm by means of its application during the clinical care.

Conclusion
The developed and validated algorithm presented reliability for evaluation, cleaning, and the use of laser therapy in wounds, showing a viable basis for the application's development.