We found multiple articles that provided support for HVPC but nothing against.
The first article focuses on patients with spinal cord injuries, who have also ended up with pressure ulcers. Patients with Spinal cord injuries typically have pressure ulcers that are very slow healing and therefore increase the cost of their hospital stay. “The objective of this study was to assess the efficacy of HVPC for healing of pressure ulcers in patients with SCI.” Patients were stratified into groups according to their ulcer classification. The study group received treatment for 1 hour per day, for 20 days straight. The researchers used a twin peaked pulse, with a frequency of 100 pps and an intensity of 200 volts. A foil electrode was placed over the ulcer, after the ulcer was packed with saline soaked gauze. The results showed that the HVPC group showed a significantly greater decrease in wound surface area than the placebo group. All of the grade 2 ulcers healed in both groups, but the time was shorter for the HVPC patients. All of the grade 3 ulcers in the HVPC showed continual decrease in size, but the placebo group had some with increased size.
The limitations of this study included the placebo group had the greatest number of sacral/coccygeal
ulcers and the HVPC group had the most gluteal/ishcial tuberosity ulcers. Another limitation could have been the age of the patients in the respective groups may have affected the healing times. However, the clinical implications of this study are that HVPC, with other interventions, may help to decrease the time of wound healing in pressure ulcers on patients with spinal cord injuries. [1]
A second meta-analysis reviewed 15 articles about electrical stimulation and chronic wound healing. There were 591 ulcers treated with electrical stimulation (ES) and 212 in the control groups. The average follow up time was just over 6 weeks. The average wound size was 8.8 cm2 for the ES group and 9.2 cm2 in the control groups. The researchers found a large overlap of the confidence interval between types of electrical stimulation. The researchers analyzed 15 published articles and concluded that electrical stimulation was better for treating wound than control groups, however they did not find a significant difference between types of ES, so it is unclear which type of ES is most effective for wound therapy.[2]
A study very relevant to physical therapy pertains to people who are dependent for mobility and often develop pressure ulcers on weightbearing surfaces like the occiput, sacrum, ischial tuberosity, or calcaneus. Electrical stimulation therapy (EST) delivers a low level of electrical current directly to, or surrounding, the wound. This has been shown to induce therapeutic actions at every stage of wound healing. This single blind study compared wound size and appearance after 3 months of standard wound care (SWC) versus standard wound care plus EST. The standard wound care group received nutritional intervention, an optimal wound dressing protocol, and continence management. The SWC plus EST group received the same SWC with the addition of EST. The EST included filling the wound cavity with saline soaked silver nylon and, in 11 of the 16 subjects, a single electrode was placed over the wound and a second larger electrode was placed at least 20cm away. The other 5 subjects used a bipolar set up or an electroconductive sock. They used High Voltage Pulsed Current (HVPC) to provide 20 minutes at 100Hz, followed by 20 minutes at 10Hz, and then 20 minutes off time for 8 hours a day for 3 months. This study showed that SWC plus EST showed significant decrease in wound surface area at 3 months when compared to SWC alone. Four wounds in the SWC only group increased in size, but none with EST did. Eighty percent of the stage III-X ulcers were half as big in the EST group, compared to 36% in the SWC group. There was no difference between groups after one month, EST saw insignificantly better outcomes after 2 months, and EST was significantly better after 3 months. Fourteen of the 16 subjects in the EST group were followed until complete wound closure. This allowed the researchers to see the average time for complete healing when SWC and EST were used was 4.5 months when only 39% of the SWC group saw complete healing after 6 months. This study provides good evidence that adding HVPC electrical stimulation to standard wound care can significantly decrease healing time of pressure ulcers. [3]
A final study was retrospective and evaluated HVPC along with a multidisciplinary approach to limb salavage for diabetic patients. The wounds were in the lower extremity and the size of the wounds were compared with and without the HVPC; the wounds treated with the additional HVPC healed faster. [4]
[1] Griffin, J. W., Tooms, R. E., Mendius, R. a, Clifft, J. K., Vander Zwaag, R., & el-Zeky, F. (1991). Efficacy
of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury.
Physical therapy, 71(6), 433-42; discussion 442-4. Retrieved from http://www.ncbi.nlm.nih.gov/
pubmed/2034707
[2] Gardner, S.E., Frantz, R.A., Schmidt, F.L. (2002). Effect of electrical stimulation on chronic wound healing:a meta-analysis. Wound Repair and Regeneration, 7(6), 495-503.
[3] Houghton, P. E., Campbell, K. E., Fraser, C. H., Harris, C., Keast, D. H., Potter, P. J., Hayes,
K. C., et al. (2010). Electrical Stimulation Therapy Increases Rate of Healing of Pressure
Ulcers in Community-Dwelling People With Spinal Cord Injury. YAPMR, 91(5), 669-678.
Elsevier Inc. doi:10.1016/j.apmr.2009.12.026
[4] Burdge JJ, H. J. (2009). A study of HVPC as an adjunctive therapy in limb salvage for chronic diabetic wounds of the lower extremity. Ostomy/Wound Management, 30-38
from Kari Langsenkamp:
ReplyDeleteLikewise, I discovered many articles that provided support for HVPC and none that refuted HVPC effectiveness. My aim was to find articles from the year 2012 or later (which limited my search), but here are two that I found that support HVPC.
The first study I looked at was a prospective comparative study. The objective of this study was “to analyze the efficiency of high voltage pulsed current (HVPC) with early application in three different sites, in the regeneration of the sciatic nerve in rats submitted to crush injury.” The sciatic functional index (SFI) was used to assess the rats’ functional recovery weekly, for 7 weeks. 57 rats were given cathodal HVPC at a voltage of 100V and a frequency of 50Hz, 20min/day, 5days/wk. The rats were divided into 5 groups (a ganglion group, a muscle group, a ganglion + muscle group, a sham group, and a control group). The results of this study provide evidence that early application of HVPC can have a positive effect in treating “the spinal cord region and the sciatic nerve root ganglion with a dispersive electrode on the contralateral lumbar region or on the gastrocnemius.”
The second article I looked at gives a good description of the effects of electrical stimulation and how it enhances wound closure and healing. It explains that HVPC is the current with the most evidence for wound healing, making it the most frequently used modality for wound healing in the United States. The article states that “many, if not most, wound etiologies benefit from the application of ES energy.” Wounds that have shown improvement from ES (HVPC) include: pressure ulcers, venous insufficiency leg ulcers, arterial insufficiency ulcers, diabetic neuropathic foot ulcers, dehisced surgical wounds, and failing flaps and grafts.
1. Leoni ASL, Mazzer N, Guirro RRJ, Jatte FG, Chereguini PAC, Monte-Raso VV. High voltage pulsed current stimulation of the sciatic nerve in rats: Analysis by the SFI . Acta Ortop Bras. 2012;20(2):93-7. Available from URL: http://www.scielo.br/aob.
2. Scarborough, Pamela. "E-Stimulation: An Effective Modality to Facilitate Wound Healing." e-Publications@Marquette. 6.4 (2012): 28-32. Web. 6 Apr. 2013.
Sara Nelson and Nick Wedel
ReplyDeleteWe found 2 articles that had been published since 2012 supporting the use of HVPC in wound care, but could find no articles that refuted it.
In the first article, they looked at the use of high-voltage electrical stimulation (HVES) in the management of stage III and IV pressure ulcers among patients with SCI. These patients had pressure ulcers that were no longer responding to standard wound care and were chronic in nature (11-14 months). The objective of this study was “to demonstrate the effectiveness of ES in the treatment of recalcitrant pressure ulcers.” According to this article, patients with SCI have increased risk for pressure ulcers due to several factors: paralysis, loss of sensation, poor nutrition, anemia and skin maceration related to incontinence. They also show impaired healing processes in areas below the spinal cord injury level. They followed 3 patients with SCI and stage III or IV pressure ulcers throughout an HVES treatment regimen. All participants saw complete healing of their chronic pressure ulcer within 7-22 weeks after beginning the HVES treatment. Treatments were 60 minutes per session, 3-5 times per week and the HVES was set with an intensity of 100mA and a frequency of 100pps. Polarity was negative at the first session and reversed weekly from that point on. All other parameters were maintained throughout the duration of the study. At the 6 month follow-up after the wounds had completely healed, all patients stated their pressure ulcer had not re-occurred. Overall, this study showed evidence that HVES is an effective way to help heal long-standing pressure ulcers in patients with SCI that have become unresponsive to standard wound care procedures. In the future, hopefully more studies will investigate the best protocol to heal these wounds most effectively with HVES.1
In the second article the researchers wanted to find the efficiency of several different modalities including high volt pulsed current stimulation, ultrasound therapy, low-level laser therapy and compression therapy on venous leg ulcers. This was in conjunction with no surgical intervention and standard wound care that consisted of 1000mg tablets of micronized flavonoid and wet dressings of .9% sodium chloride. Patients in this study had to be >18 years of age and have a venous ulcer due solely to venous insufficiency with no comorbidities and an ABI of 1.0 – 1.3. Groups A-G were all randomized. All patients in groups A-E then received surgery that included crossectomy, partial stripping of the greater or short saphenous vein, local phlebectomy, and ligation of insufficient perforators. Group A and F received HVPC e-stim with impulses of 100 us at a frequency of 100 Hz and a voltage of 100V. This was provided once a day for 50 minutes, 6 days a week for 7 weeks. Groups B and G received ultrasound at .5 W/cm2 with 1/5 duty cycle and 1 mHz in 34 degree water bath. The time was 1 minute for each 1 cm2 or ulcer area and done once a day, 6 days a week for 7 weeks. Groups C and H received laser therapy 50 cm from the wound at a frequency of 20 Hz and the average output was 65mW. The average dose was adjusted to obtain an average of 4 J/cm2, once a day, 6 days a week for 7 weeks. Groups D and I received compression stockings providing 25 to 32 mmHg of pressure at the ankle and were put on at the clinic in the morning and worn 10-12 hours and removed at night. Treatment lasted 7 weeks. Groups E and J received the standard of care of drug therapy and saline soaked gauze bandages. The greatest decrease in wound size was seen in group D which healed in about 3 weeks and the least was in groups J and H. HVPC and US appeared useful in conservatively treated patients. In conclusion the best treatment was compression therapy in both surgical and non-surgical patients. HVPC and US were useful in conservative treatments and laser therapy was not efficient in treatment of a venous leg ulcer.2
References for previous comment:
ReplyDelete1. Recio AC, Felter CE, Schneider AC, McDonald JW. High-voltage electrical stimulation for the management of stage III and IV pressure ulcers among adults with spinal cord injury: demonstration of its utility for recalcitrant wounds below the level of injury. The journal of spinal cord medicine. 2012;35(1):58–63.
2. Jakub Taradaj, MD, PhD, Andrzej Franek, MD, PhD, Edward Blaszczak, MD, PhD, Anna Polak, MD, PhD, Daria Chmielewska, MD, PhD, Piotr Krol, MD, PhD, Patrycja Dolibog, MD, PhD. Using Physical Modalities in the Treatment of Venous Leg Ulcers- A 14-Year Comparative Clinical Study. Medscape (Wounds). 2012;24(8):215-226. http://www.medscape.com/viewarticle/769427
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