E- Stim Wound Healing


Evidence: Article Summaries

Article #1: Effect of electrical stimulation on chronic leg ulcer size and appearance.

This study had 27 participants with a total of 42 chronic leg ulcers. After being randomly assigned, half of the participants received HVPC and the other half received a sham treatment and each were for 45 minutes, 3 times a week for 4 weeks. The parameters for HVPC were 100 microseconds, 150 V, and 100 Hz. The wound size and appearance were evaluated and documented at the initial evaluation, 1-2 weeks later after receiving conventional wound therapy, after 4 weeks of either HVPC or the sham treatment, and then again a month later. The results showed that HVPC reduced the wound surface area by half after 4 weeks of treatment. This was two times greater than those wounds that were treated with the sham treatment. This shows that HVPC can in fact increase wound closure for chronic leg ulcers if administered 3 times a weeks and at the same parameters.

Article #2: High voltage electrical stimulation as an alternative treatment for chronic ulcers of the lower limbs.

This study only had three participants that had lower extremity chronic ulcers. They received HVPC for fifteen weeks and it was shown that all ulcers were reduced. This shows HVPC can be an effective therapeutic option for chronic ulcers.

external image en_a25fig01a.jpg
external image en_a25fig01b.jpg

Clinical studies have strongly suggested that electrical stimulation treatment of wounds can improve blood flow and wound tensile strength, reduce edema, inhibit unwanted bacteria growth, direct epithelial migration, and promote protein and DNA synthesis in fibroblasts.

One theory suggests that the deep underlying cells of a wound naturally develop a positive charge, while the surrounding skin has a negative charge, creating a sort of “skin battery”. This gives the underlying cells a way to naturally migrate to the skin/wound surface. With the assistance of electrical stimulation and proper electrode placement, this process can be further facilitated. In all cases, saline soaked gauze is applied at the treatment area.

Figure 1 shows the electrode configuration for autolysis, a process by which negatively charged neutrophils are attracted to the injury site by the positive electrode being placed upon the wound. The neutrophils solubilize necrotic tissue near the wound surface.

Figure 2 details the setup for antimicrobial effects. For reasons unknown, it is believed that negatively charged neutrophils migrate to the negative electrode.


Screen_shot_2012-03-26_at_5.05.29_PM.png


Figure 3 is the setup used for additional granulation formation. By placing the negative electrode at the wound site, positive fibroblast cells migrate to the site. Fibroblasts create more granulation tissue by providing additional collagen synthesis.


Screen_shot_2012-03-26_at_5.06.00_PM.png

Figure 4 shows stimulation setup used for epithelialization. In this case granulation has occurred, but epidermis layering across the surface of the wound has stopped. By placing the positive electrode over the surface, negatively charged epidermis cells migrate across the wound surface.

Along with these configurations, a study was recently performed with mice to compare vascular endothelial growth factor (VEGF) production using sensory and motor electrical settings. VEGF was monitored because of the effect it has on angiogenesis and subsequent wound healing processes. Using sensory (direct current, 600 microamperes) and motor (monophasic current, pulse duration 300 microseconds, 100 Hz, 2.5-3.0 mA) group distinctions, one hour treatments were performed every other day. The sensory group produced a significantly higher VEGF production than the control and motor groups after seven days, suggesting that sensory settings could be more beneficial to wound healing.

Article #5: Chronic Dermal Ulcer Healing Enhanced with Monophasic Pulsed Electrical Stimulation

The purpose of this study was to compare healing of chronic dermal ulcers treated with pulsed electrical stimulation with healing of wounds treated with false electrical stimulation and to evaluate patient tolerance to the therapeutic protocol. The study was randomized, double-blind, and multicenter. Forty-seven patients, aged 29 to 91 years, with 50 stage II, III and IV ulcers were randomly assigned to either a treatment group or a control group that used fake ultrasound. The study included wounds that received 30 minutes of pulsed cathodal electrical stimulation twice daily. In order for any wound had to have necrotic tissue or drainage that was not serosanguinous. This protocol was continued for 3 days after the wound was debrided or exhibited serosanguinous drainage. After that point the polarity of the electrode on the wound was changed every 3 days until the wound healed to a stage II classification. The pulse frequency was then reduced, and the electrode polarity was changed every day until the wound was healed. Patients in the control group were treated with the same protocol, except the treatment they received was fake. Four weeks later,wounds in the treatment group were 44% the initial size and control group wounds were 67% the initial size. The healing rates per week for the treatment and control groups were 14% and 8.25%, respectively. The results of this study indicate that pulsed electrical stimulation has a beneficial effect on healing stage II, III and IV chronic dermal ulcers.
chart_1.png
The above chart shows an added section of the study. After the initial four weeks were up, they took patients who had previously been treated with the fake estim and switched them to real estim. As you can see, the healing rapidly improved after switching to the real treatment.

http://ptjournal.apta.org/content/71/9/639.full.pdf+html

Article #6: Acceleration of Wound Healing with High Voltage, Monophasic, Pulsed Current

This study was designed to determine whether high voltage electrical stimulation improves healing rate. Sixteen patients with stage IV ulcers participated in the study. The patients were assigned randomly to one of two groups, a Treatment Group or a Control Group. Patients in the Treatment Group received daily electrical stimulation from a high voltage generator. Patients in the Control Group had the electrodes applied daily but received no stimulation. The patients in the treatment group healed at a rate of 44.8% a week and completely healed over a time of about seven weeks. The ulcers of patients in the other group actually increased. This study's findings support the use of high voltage electrical stimulation for wound healing.


external image images?q=tbn:ANd9GcTFT25aLCWwlZMGNb5zyHTI7AtBs5FGEdY5IGGDpqDIAfqCdJJc
felt_tip_marker.png
open_wound.pngclosed_wound.png
http://ptjournal.apta.org/content/68/4/503.long



Article 7: This study compared the effects of degenerate waveform electrical stimulation to normal skin healing in 20 subjects. Subjects received a 5mm punch biopsy wound which was allowed to heal for 14 days, when it would receive a 6mm punch biopsy which would encompass the original site. Each subject then received a 5mm punch biopsy in the contralateral arm, receiving electrical stimulation treatment on days 0, 2, 4 and 7. It was excised at 14 days as well with a 6mm biopsy.
Each sample underwent analysis of transcription genes involved in different phases of wound healing, tissue healing morphology and protein expression. CD3 counts were higher in NSD group because the ESD group had progressed past the inflammatory stage. “mRNA transcripts expression of integrin α5, MMP-2, CD99, CTGF, TGF-β, progranulin, and protein expression by CD31, VEGF, and COLIV showed that the healing process is more efficient by ES. The decreased expression of alpha-SMA and Ki67+ cells demonstrates further progression of ESD14 samples through the second stage of wound healing while the increased mature collagen indicated its active participation in the final stages of wound healing.” This article supports the use of degenerate waveform electrical stimulation for wound healing.


Table 1. Summarized results from the transcriptional and translational analysis of NSD14 and ESD14 samples compared to normal skin

Stages of wound healing
mRNA transcripts investigated for transcriptional studies (qRT-PCR)
Protein expression studies for translational analysis (IHC)
% of fold change in NSD14 in comparison to normal skin
% of fold change in ESD14 in comparison to normal skin
  1. 1. Down-regulation, ↓; Up-regulation, ↑.
Inflammation
IL-10 (anti-inflammation)

10↑
400↑
VIP (anti-T-cell migration analysis)

50↓
350↑

TUNEL (apoptosis)
300↑
60↑


CD3+ (T-lymphocytes)
100↑
20↑
Proliferation and granulation tissue formation
Krt 17 (re-epithelialization)

25↑
350↑
TGF-β (angiogenesis)

10↑
100↑
CCN2 (fibroblast migration)

100↑
500↑
Progranulin (neovascularization)

25↑
350↑
CD99 (endothelial cells)

25↑
200↑
MIF (macrophage inhibition)

20↑
100↑
MMP 2 (angiogenesis)

40↑
400↑
MT2A (angiogenesis)

30↑
300↑
CGRP (neurocutaneous communication)

50↓
60↑
SP (T cell migration)

50↑
20↑
NPY (neurocutaneous communication)

50↑
30↓
PGP 9.5 (neurocutaneous communication)

10↑
70↑
Integrin α5 (matrix remodeling and angiogenesis)

30↑
500↑

Alpha-SMA (myofibroblastic proliferation and wound contraction)
2,800↑
900↑

CD31 (blood vessels)
20↑
100↑

Melan A (melanocyte formation)
40↓
15↑

Langerin (antigen processing and neurocutaneous communication)
5↑
15↑

VEGF (angiogenesis)
70↑
280↑

Ki67 (proliferation)
340↑
80↑
Remodeling and maturation

Herovici analysis
35↓
20↓
Collagen I (mature collagen)

Herovici analysis
30↑
15↑
Collagen III (immature collagen)
Collagen IV (basement membrane formation and remodeling)
Collagen IV
125↑ by qRT-PCR
600↑ by qRT-PCR
20↓ by IHC
100↑ by IHC
Fibronectin (ECM formation and remodeling)

150↑
1,100↑
IFN-γ (anticollagen synthesis)

20↑
100↑


Article 8: This study consisted of 35 patients divided into a treatment group (FREMS) of 20 and a control group of 15. Ulcers were of variable stage and number, all located below the knee. FREMS is a type of electrical stimulation that automatically changes pulse frequency and duration during treatment. The FREMS group had treatments 40 minutes in duration, 5 times per week for 3 weeks. The FREMS group had significant reduction of leg ulcer surface, score of ulcer, ulcer vicinity, and pain. Ulcer vicinity was not significant in the second month, however.
FREMS
Control
P value
Pre-treatment
Post-treatment
Pre-treatment
Post-treatment
Surface of leg ulcer
6.18 ± 1.72
1.13 ± 1.58
5.91 ± 1.16
3.17 ± 1.83
P < 0.001
Score ulcer
10.50 ± 1.23
0.25 ± 0.55
10.68 ± 1.10
3.52 ± 1.50
P < 0.001
Vicinity
11.85 ± 1.92
1.15 ± 1.13
11.66 ± 2.25
1.66 ± 1.34
NS
VAS
7.84 ± 1.70
1.68 ± 1.63
7.47 ± 1.61
5.21 ± 1.18
P < 0.001

Video

http://www.youtube.com/watch?v=3ait-yklQ4w <-- 1:35-5:30

Post Professionals' Opinions

Debra Rico & Teresa Gunnison

"I have used estim several times for wounds in the past. I typically used estim when the wound would "stall" during it's healing process. Many times we see wounds that are chronic and they get stuck in the inflammatory phase and never move on the proliferative phase which is granulating tissue and contraction. There are many factors that prevent the wound from progressing on infection, poor blood flow, etc."

Basically when she feels like the wound isn't progressing she would use high voltage pulsed current (HVPC) which is a type of e-stim.

"I would typically start with the negative polarity in the wound and the positive electrode somewhere else. The intensity would be at around 150volts as long as the patient would be able to tolerate it. I would not use this on someone who was very painful such as a venous stasis ulcer unless their pain was well controlled.
"There are several different ways to set up the estim. The way that worked for me was to take saline soaked gauze (either with a hydrogel or just plain saline) I would open the 4x4 up all the way, get it wet/jelled and lightly pack it into the wound. Take a carbon electrode (they are the ones that usually come with the machine) and secure it on top of the gauze. This could be with an ace wrap. Tape is tough to use since things are usually wet and it does not stick well. The stim would be set for 30min. I use to apply it daily, but with insurance, I do not know how feasible this is anymore. I would then switch polarities the next week, with positive electrode on the wound I would set it to 100v. "

She said that basically "you are trying to jump start the wound to get it to granulate."

"The body can simply "wall it off" and the estim just increases blood flow. Once I would get a good granulating bed I would stop the estim. It has served its purpose. I have heard of using alligator clips and foil with gauze for an electrode but I always had the things I needed in the clinic."
-Debbie Rico

Parameters


Characteristics
Indication
Electrode Placement
Polarity
Frequency
Amplitude
Pulse Duration
Duty Cycle
Duration of Dx
Frequency of Rx
HVPC
Monophasic, pulsed
Pain, wound healing. Increase bloodflow
One in wound and one 180° from wound
(-) and (+); Their placement can be switched
60-125pps
Comfortable
90-100 msec
1.5 sec on and off
30-45 minutes
AMAP; every day or 3-5 times a week
Micro
Monophasic or biphasic direct current
Pain, wound and bone healing
Monopolar,
bipolar
(-), (+), or dual
.1 to varies for max (200-1000 pps)
adjustable
adjustable

2 hours
Varies

E-stim is not the standard initial wound treatment.
It can be used if standard wound care treatment has been tried for at least 30 days and there are still no measurable signs of the wound healing
Wounds need to be evaluated every 30 days anyways by the doctor
E-stim can be used for Stage 3 or Stage 4 ulcers, such as: pressure, venous stasis, arterial, and diabetic
Stage 3= Full thickness wound involving damage up to the fascia (in the subcutaneous level)
Stage 4 wound= Full thickness wound involving damage through the fascia and up to or to the bone

HVPC for Chronic Diabetic LE Wound
HVPC for Chronic Diabetic LE Wound

"The MicroVas was pre-programmed at 45 minutes for each treatment. Four emitter pads are placed strategically over the wound and major muscle groups as follows: rectangular (5 inch x 8 inch) pads on the anterior and posterior upper thigh; round (4-inch diameter) pads on the anterior compartment and posterior gastrocnemius muscle; smaller rectangular (3 inch x 5 inch) pads just above the ankle, overlying the path of the dorsalis pedis and the posterior tibial arteries; and square (3 inch x 3 inch) pads on the pedal arch on the top and bottom of each foot. Emitter pads were secured with enough pressure to ensure full contact between the pad and the lower extremity without compromising blood flow. In all instances, one emitter pad was placed directly over the wound, which first was covered with saline-soaked gauze. The opposing emitter pad was placed 180º from the wound (see Figure 1a-c). This form of HVPC creates a current that passes through the limb, in many cases creating muscular contraction, and produces a standardized biphasic, symmetric, square pulse wave"

Teresa said that she too has had some experience with e-stim for wound care and that she has "both positive and negative feelings about e-stim." She also mentioned that she has "looked online for e-stim info for wounds and much of it has not changed over the past 25 years."

I have seen HVPC create granulation tissue each time I've used it which is great. It helps close tunnels and fill in deep wounds. The down side is that a few of the times it closed a wound that had undiagnosed osteomyelitis, so the wound opened up again within a few weeks. Because HVPC tends to be used when traditional wound care fails, I guess osteomyelitis needs to be considered, but it is difficult to diagnose. Also, HVPC is a time consuming treatment if the patient receives it in the clinic. It really needs to be done for an hour 5-6 times per week. I had a patient with a portable hi-volt stim unit and she was able to manage at home with a little bit of training but her wound never closed. She also had and still deals with osteomyelitis, among other comorbidities. I think its best use might be for arterial wounds and diabetic wounds that need a jump start to kick in the inflammatory phase of wound healing."
-Teresa Gunnison

Diabetic Wound
Diabetic Wound
Arterial Wound
Arterial Wound


References:
Aleksandar, Jankovic, and Ivana Binic. "Frequency rhythmic electrical modulation system in the treatment of chronic painful leg ulcers." Archives of Dermatological Research. 300.7 (2008): 377-383. Web. 3 Apr. 2012. <http://www.springerlink.com.proxy.kumc.edu:2048/content/43h6p7061u127v78/fulltext.html>.

Asadi, Mohammad Reza. Effect of sensory and motor electrical stimulation in vascular endothelial growth factor expression of muscle and skin in full-thickness wound. Journal of Rehabilitation and Research Development. Pages 195 — 202. Volume 48 Number 3, 2011.

Burdge, Jeremy J., Jodi F. Hartman, and Michelle L. Wright. "Cath Lab Digest." A Study of HVPC as an Adjunctive Therapy in Limb Salvage for Chronic Diabetic Wounds of the Lower Extremity. HMP Communications, 18 Aug. 2009. Web. 28 Mar. 2012. <http://www.o-wm.com/content/a-study-hvpc-adjunctive-therapy-limb-salvage-chronic-diabetic-wounds-lower-extremity?page=0,2>.

Dr. Timm. "The Foot and Ankle Tribune: Wound Care at FFLC." The Foot and Ankle Tribune. Family Foot and Leg Center, 12 Oct. 2011. Web. 28 Mar. 2012. <http://familyfootandlegcenter.blogspot.com/2011/10/diabetic-pressure-wounds-are-prevalent.html>.

Edschrank. "Estim for Wound Care." YouTube. YouTube, 03 Feb. 2011. Web. 28 Mar. 2012. <http://www.youtube.com/watch?v=3ait-yklQ4w>.

Houghton, P. E., Kincaid, C. B., Lovell, M., Campbell, K. E., Keast, D. H., Woodbury, M. G., & Harris, K. A. (2003). Effect of electrical stimulation on chronic leg ulcer size and appearance. Physical therapy, 83(1), 17-28. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12495409

Kloth LC, McCulloch JM. Promotion of wound healing with electrical stimulation. Adv Wound Care. 1996 Sep-Oct;9(5):42-5. Program of Physical Therapy, Marquette University

Rico, D. (2012, March 26). Current Concepts on Wound Care, Clinical Education.

Silva, E. de F. H. da, Martins, C. C., Guirro, E. C. de O., & Guirro, R. R. de J. (2010). High voltage electrical stimulation as an alternative treatment for chronic ulcers of the lower limbs. Anais brasileiros de dermatologia, 85(4), 567-9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20944924

Sebastian, Anil, Farhatullah Syed, Donna Perry, Vinayagapriya Balamurugan, James Colthurst, Iksander H. Chaudry, and Ardeshir Bayat. "Acceleration of cutaneous healing by electrical stimulation: Degenerate electrical waveform down-regulates inflammation, up-regulates angiogenesis and advances remodeling in temporal punch biopsies in a human volunteer study." Wound Repair and Regeneration. 19.6 (2011): 693-708. Web. 3 Apr. 2012. <http://onlinelibrary.wiley.com.proxy.kumc.edu:2048/doi/10.1111/j.1524-475X.2011.00736.x/full>.

"The Differences Between Arterial And Venous Ulcers." Hub Pages. Hub Pages Inc. Web. 28 Mar. 2012. <http://rnmsn.hubpages.com/hub/The-Differences-Between-Arterial-And-Venous-Ulcers>.

Vanhoose, L. (2012, March 27). Wound Care, Physical Therapy Interventions. KUMC, Kansas City, Kansas.