Ultrasound and Wound Healing
Summaries by Sarah L, Brianna, and Natalie

Ultrasound is a very common modality used in the outpatient setting for physical therapy. It is often used for soft tissue and bony lesions but it can also be used in wound care. Pulsed ultrasound is used in wounds to help accelerate the inflammatory phase of healing. It stimulates the release of histamine from mast cells which then attract neutrophils and monocytes to the injured area to help clean up and repair the site of injury. Research is still increasing for the use of ultrasound, especially towards wound care. Below are some articles that both support and oppose the use of ultrasound for wound care.

Supporting Articles:

Wollina, Heinid, Naumann, Scheibe, Schmidt, and Neugebauer studied the effects of ultrasound on wound care using three different levels of ultrasound, 34 kHz, 53.5 kHz, and 75 kHz. Twelve different patients over the age of 18 who had chronic venous leg ulcers participated. Non-contact ultrasound was applied to their leg ulcers while submerged in water, for ten minutes, once a day. They measured the microcirculation before applying ultrasound, immediately after and thirty minutes after applying ultrasound. They also used micro-light guide spectrophotometer and contact-free remission spectrophotometer to collect measurements. Overall there was not much of an effect at the levels of 53.5 kHz or 75 kHz, but at continuous-wave low-frequency ultrasound of 34 kHz there was a slight increase in microcirculation. This was most likely due to the increase of oxygenation to that area but further studies are still needed.

Low intensity pulsed ultrasound (LIPUS) and pulsed electromagnetic fields are used in healing bone after fracture.  To determine how effective each is in the healing of bone, the authors conducted a systematic review of literature.  Using the most common outcome measure of radiographic healing of the cortices, both methods were determined to be effective in healing fractures.  LIPUS has strong evidence in supporting its use for fracture healing.  In randomized, controlled clinical trials, it promotes healing in nonunion and acute fractures with the following parameters: burst width of 200 microseconds containing 1.5 MHz sine waves, repetition rate of 1 KHz and spatial average temporal intensity of 30 mV/cm², treatment applied with 20 minutes daily.  Using these parameters and evidence, PTs  can apply LIPUS in the clinic to aid in bone healing after fracture.

Kavros, Liedl, Boon, Miller, Hobbs, and Andrews found that ultrasound was an effective modality for the treatment of chronic wounds in patients with an average age of 71 years. This retrospective study reviewed the charts of 210 patients with below-the-knee, lower extremity wounds of varied etiology. Forty-seven patients were placed in the control group because their wounds were treated with standard wound care alone. The remaining 163 patients were placed in the intervention group because their wounds were treated with MIST ultrasound therapy - a low-intensity, low frequency, non-contact ultrasound technique - in addition to standard wound care. Patients in the ultrasound group had been treated 3 times per week for 90 days or until the wound healed. Results showed that those in the ultrasound group saw better results in regards to wound volume, percent wound closure, and rate of healing as compared to the control group (Kavros et al., 2008).

Opposing Articles:

Watson, Kang, Soares, Chuang, Worthy, Bland, and Iglesias, studied 337 patients who had at least one venous leg ulcer for greater than 6 months or that was larger than a 5cm² area. They aimed to see if low dose, high frequency ultrasound (1 MHz and 0.5 W/cm²) applied once a week to the ulcer for 12 weeks along with standard care would improve wound healing over just standard wound care alone. It was found that applying ultrasound between wound dressings did not improve ulcer healing time nor reduce ulcer recurrence. It also did not improve the quality of life of the patients.

Ultrasound has many physiologic effects on soft tissue and it has been hypothesized that can aid in tissue lesion repair.  Thermal effects of ultrasound include increasing tissue extensibility, controlling pain, increasing blood flow, and reducing muscle spasm.  Non-thermal effects of cavitation and microstreaming are thought to help with tissue healing.  Cavitation causes compression and expansion of gas bubbles in the tissue increasing fluid flow.  Microstreaming increases cell permeability to stimulate repair.  Through article review, Speed has determined that while these events can help with wound and tissue repair in vitro, there is a lack of evidence for success in vivo.  However, this lack of success may be due to flawed study designs and the presence of underlying pathologies in patients.  At this time, the evidence does not support its use in the clinic, but more research need to be in order to validate or definitively dispute its effects on soft tissue lesion repair. 

Ter Riet, Kessels, and Knipschild found that ultrasound was not an effective modality for treating pressure ulcers in nursing home patients. This randomized clinical trial recruited 88 patients with pressure ulcers from 11 different nursing homes and one hospital. Half of the patients were assigned to the ultrasound group and received ultrasound to the wound and the extended wound area. The other half of the subjects were assigned to the sham ultrasound group. A nurse applied and ultrasound transducer to these patient’s wounds, but the beam wasn’t actually turned on. Both groups received treatment for 12 weeks. Results showed that after 12 weeks, 40% of the ulcers in the ultrasound group had closed and 44% of the ulcers in the sham ultrasound group had closed. Closure rates and healing rates were almost equal between the two groups. These data indicate that ultrasound does not speed up the healing of pressure ulcers (ter Riet, Kessels & Knipschild, 1996).

As seen from the evidence above though, ultrasound has been seen to be effective and non-effective for wound care. More evidence is still needed in this area to really confirm the effectiveness and efficacy of ultrasound on wound healing. For now, using ultrasound is often based on personal opinion and experience. One thing is known for sure about ultrasound, is that it does not help in treating DOMS (delayed onset muscle soreness). However, it is seen that ultrasound can also help with managing scar tissue and joint contractures and has been seen to increase bone healing.

References

Kavros, S. J., Liedl, D. A., Boon, A. J., Miller, J. L., Hobbs, J. A., & Andrews, K. L. (2008). Expedited wound healing with noncontact, low-frequency ultrasound therapy in chronic wounds: a retrospective analysis. Advances in skin & wound care, 21(9), 416-23. doi:10.1097/01.ASW.0000323546.04734.31

Speed, C. A. (2001). Therapeutic ultrasound in soft tissue lesions. Rheumatology  (Oxford,             England), 40, 1331-1336.

ter Riet, G., Kessels, A. G., & Knipschild, P. (1996). A randomized clinical trial of ultrasound in the treatment of pressure ulcers. Physical therapy, 76(12), 1301-11. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8959999

Walker, N. A., Denegar, C. R., and Preische, J. (2007). Low-intensity pulsed ultrasound and        pulsed             electromagnetic field in the treatment of tibial fractures: A systematic review.        Journal of Athletic Training, 42(4), 530-535.

Watson, J. M., Kang’ombe, A. R., Soares, M. O., Chuang, L.-H., Worthy, G., Bland, J. M., Iglesias, C., et al. (2011). Use of weekly, low dose, high frequency ultrasound for hard to heal venous leg ulcers: the VenUS III randomised controlled trial. BMJ (Clinical research ed.), 342, d1092. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3050437&tool=pmcentrez&rendertype=abstract

Wollina, U., Heinig, B., Naumann, G., Scheibe, A., Schmidt, W.-D., & Neugebauer, R. (2011). Effects of low-frequency ultrasound on microcirculation in venous leg ulcers. Indian journal of dermatology, 56(2), 174-9. doi:10.4103/0019-5154.80412

Biofeedback

Biofeedback

                Electromyographic biofeedback is a modality that seems to be gaining increased popularity in clinical settings.  It is a therapeutic procedure that uses electronic or electromechanical instruments to accurately measure, process, and feedback reinforcing information via auditory or visual signals.  In clinical practice, it is used to help the patient develop greater voluntary control in terms of either neuromuscular relaxation or muscle reeducation following injury. (Prentice,  Therapeutic Modalities in Rehabilitation)

IN FAVOR

The article “Management of Stress Urinary Incontinence With Surface Electromyography-Assisted Biofeedback in Women of Reproductive Age” by Rett et al. was a case study of twenty-six women of reproductive age.  The purpose of the study was to test the ability of a biofeedback-assisted pelvic floor muscle exercise (PFME) program as a viable conservative alternative to surgery.  The twenty-six women were treated for twelve therapy sessions using a surface electromyography assisted biofeedback unit. All women were of reproductive age.  Results were determined from a seven day voiding diary, a one hour pad test, pelvic-floor muscle strength measurements, sEMG amplitudes, a leakage index, and a quality of life questionnaire.  All variables were taken before and after intervention.  Results that were found were that the frequency of urine loss, the occurrence of nocturia, and the number of pads required decreased significantly after intervention.  What they defined as an “objective cure” was found in 61.5% of the women.  There was also a significant improvement in the quality of life, in pelvic-floor muscle strength, and in the sEMG amplitudes of all contractions during the intervention. They concluded that a short-term intervention of PFME with sEMG-assisted biofeedback could be helpful in treating symptoms of SUI in women of reproductive age and that this may be a reasonable conservative management option.

Rett, M. et al. (2007).  Management of Stress Urinary Incontinence With Surface Electromyography—  

             Assisted Biofeedback in Women of Reproductive Age.  Journal of the American Physical           

             Therapy Association. 87: 136-142.

The goal of this randomized-controlled, double-blind investigation of patients with chronic low back pain was to determine the effectiveness and efficacy of respiratory feedback in comparison to a strict placebo group. Participants were randomized either to a respiratory feedback (RFB) or a non-contingent respiratory feedback group. RFB is considered to be a valuable tool to train individuals to calm their breathing in order to become more relaxed. Those in the non-contingent group received a constant signal corresponding to a breathing rate of roughly 8 breaths/min which was independent of the participants breathing (i.e. not prompted by the participant). This is a type of pseudo-feedback, in which biofeedback signals mask actual body processes. The participants performed a HEP 30 min per day for 15 days. A respiratory associated relaxation index (RI) was utilized to quantify the level of relaxation through calmed breathing. Compared to placebo (non-contingent) RFB, real RFB induced a higher RI, higher reductions in pain at rest and during activity, and in psychopathological symptoms. Results did not, however, display significant difference between-groups, although symptom reductions were more evident in the RFB group from pre-posttest.

Kapitza,K. P., Passie, T., Bernateck, M., & Karst, M. (2010). First non-contingent respiratory 

               biofeedback     placebo versus contingent biofeedback in patients with chronic low back pain: a 

               randomized, controlled, double-blind trial. Applied psychophysiology and biofeedback, 35(3), 

               207-17. doi:10.1007/s10484-010-9130-1.

               

             The article “A randomized controlled trial of anorectal biofeedback for constipation” by Hart et. al. was a study to examine the efficacy of anorectal biofeedback v. a biofeedback control for treating constipation.  Twenty-one subjects with pelvic floor dyssynergia were placed in either the biofeedback treatment group or the biofeedback control group.  The treatment group received pelvic floor and external sphincter training using a rectal biofeedback probe.  The control group was administered upper trapezius relaxation training using biofeedback.  The study showed that overall constipation severity scores of the treatment group improved by 35.5% and obstructive defacation scores decreased by 37%.  Irritable Bowel Syndrome Quality of Life scores for the treatment group improved by 28% while the control group decreased 13%.  Although the study shows benefits to biofeedback, it was greatly underpowered because there were only 21 subjects.  Further research should be conducted.

Hart, Stacy L., Janet Waimin Lee, Julia Berian, Taryn R. Patterson,  Amanda del Rosario, Madhulika G.

Varma.  A randomized controlled trial of anorectal biofeedback for constipation.  Int J.

Colorectal Dis, 8 Nov., 2011.  DOI 10.1007/s00384-011-1355-9. 

ARTICLES AGAINST

The article by Moreland and Thomson was a literature review and meta-analysis conducted to examine the efficacy of EMG biofeedback compared with conventional physical therapy for improving upper-extremity function in patients who suffered a stroke.  A literature search was conducted from the years 1976-1992 of single-blinded randomized control trials.  Six studies were selected that met nine different criteria.  Because all of the analyses were statistically non-significant, the studies to date did not conclusively demonstrate that EMG biofeedback was superior to conventional therapy.  The estimated size of the effect was small therefore it was recommended that therapists consider factors such as cost, ease of application, and patient preference when deciding between the two forms of treatment.

Moreland, J, Thompson, M.  Efficacy of Electromyographic Biofeedback Compared With Conventional                   Physical Therapy for Upper-Extremity Function in Patients Following Stroke:  A Research                   Overview and Meta-analysis.  Physical Ther. 1994. Jun ;(74)6: 534-543.

The objective of this literature review and meta-analysis was to find a complementary and alternative medicine (CAM) for Raynaud’s Syndrome. Although the study was inconclusive as to what  type of CAM was most effective in treating Raynaud’s the only conclusion is came to was that biofeedback was actually not only not significant in a change of frequency, duration and severity of Raynaud attacks, it actually favored the control. Many trials had to be excluded, however, due to their lack of quality of statistics. Only one study that was included which demonstrated more significance towards the control versus biofeedback. Therefore, still, this is not conclusive in determining that biofeedback in not a useful tool.

Malenfant,D., Catton, M., & Pope, J. E. (2009). The efficacy of complementary and alternative medicine                    in the treatment of Raynaud’s phenomenon: a literature review and meta-analysis.             

                  Rheumatology (Oxford, England), 48(7),791-5. doi:10.1093/rheumatology/kep039

             The article “Behavioral and Physical Treatments for Migraine Headache” by Goslin et. al. is a meta-analysis of comparative clinical trials of behavioral and physical treatments of migraine headaches.  The studies in this review were prospective, controlled trials of behavioral or physical treatments whose purpose was to prevent attacks of migraine headaches or relieve symptoms.  Biofeedback treatments were not described in detail, but simply as thermal biofeedback combined with relaxation training and EMG biofeedback.  The biofeedback techniques did not prove to be statistically significant for treating migraine headaches when compared to a control.

 

Goslin RE, Gray RN, McCrory DC, et al. Behavioral and Physical Treatments for Migraine Headache.                           Rockville (MD): Agency for Health Care Policy and Research (US); 1999 Feb. (Technical 

                 Reviews,   No. 2.2.) Summary

               

Mallory Mahoney, Adam Mathers, Brandon Smith

IFC for Pain Management

IFC, or interferential current, is a type of electrical stimulation that uses two different channels at the same time. When setting it up, the electrodes for the respective channels should be set up in a crossing pattern so that the electrical currents cross. When two waves combine at the same point, they have a summative result. Setting each channel at a different frequency results in a varied summation at each time point and makes a beat frequency. This type of electrical stimulation is used for pain, edema, and muscle rehab depending on the beat frequency that is produced.

Articles in Favor of IFC:

Goats, G.C. article explained the basics of how IFC works while incorporating older studies that supported the effectiveness. Some of the studies were aimed at determining dosage; therefore, already assuming IFC works. Goats explained that interferential therapy is theoretically effective for stimulating muscle, increasing blood flow, and accelerating bone healing. Case studies and observational evidence support edema reduction, incontinence control, and pain reduction from IFC. Take into consideration that this article was published many years ago so new studies may be more pertinent to today. Nonetheless, this article drew upon numerous studies that specifically identified IFC as an effective method of therapy. It’s obvious that IFC has great potential as a therapeutic intervention but further research is needed to fully understand how it fits in the clinic.

Goats, G. C. (1990). Interferential current therapy. British journal of sports medicine, 24(2), 87-92. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1478878&tool=pmcentrez&rendertype=abstract

The article by Jorge, Parada, Ferreira, and Tambeli analyzed the effect of interferential current therapy on inflammatory pain and edema in rats.  They used formalin injections, which evoked a local release of histamine and serotonin which activated nociceptors, and carrageenan injections, which produced a mechanical hyperalgesia.  Both injection types resulted in edema.  They rats were divided into groups, based on which injection they received and when the interferential current treatment was given, before or after.  Edema was monitored in separate groups.  For each group, there was one control group, which had the interferential current off, and one in which there were no electrodes at all. 

In the groups with the formalin injection, a significant effect was found only in the nociceptive behavior in the group receiving the interferential current for the hour after the injection.  In the groups with Carrageenan injections, the interferential current showed significant effects while on, but once discontinued, those effects disappeared.  There was not a significant change in the amount of edema with any of the groups.  Both formalin and carrageenan mimic the human inflammatory pain state brought on by traumatic pain.  This information would be most appropriate for pain relief post-surgical or after other trauma induced pain.

Jorge S, Parada C, Ferreira S, Tambeli C. Interferential therapy produces antinociception during application in various models of inflammatory pain. Physical Therapy [serial online]. June 2006;86(6):800-808. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed February 27, 2012.

This article by Jarit, Mohr, Waller, and Glousman looked at the effect of IFC versus placebo effect on post-op knee surgery patients. The results looked at edema (girth measurement), range of motion, pain rating, and amount of pain medication taken. All subjects using IFC had significantly less pain than the placebo group. In general, the IFC group also took less pain medication, had greater range of motion and had less edema. The theory behind the greater ROM is that the patients that had IFC had less pain and were therefore able to tolerate more physical therapy. This article shows that IFC is a significantly effective way to decrease the amount of pain a patient is experiencing. However, there were some limitations to this study and more research needs to be done to have a greater picture of the benefits of IFC.

Jarit, G.J., Mohr, K.J., Waller, G., Glousman, R.E. The Effects of Home Interferential Therapy on Post-Operative Pain, Edema, and Range of Motion of the Knee. Clinical Journal of Sports Medicine. Jan 2003: 13(1): 16-20.

Articles Against IFC:

IFC is widely used in clinical practice to treat pain and there is a great deal of anecdotal support for its efficacy.  Unfortunately, there aren’t any high quality studies with sound methodological design that have substantiated its use. This can partly be attributed to the difficulty in adhering to strict methodological protocols (such as blinding subjects and therapists) when using therapeutic interventions like IFC.  But, more importantly, the absence of such high quality studies is more readily attributable to the lack of understanding concerning IFC’s mechanism of action and the attendant lack of standardization with regard to its application – such as electrode placement, stimulation frequency and intensity, or length of treatment time.  Beatti et al began a systematic review in 2008 of RCTs conducted since 1980 which had examined the efficacy of IFC. Of the 59 studies they found, only nine met their inclusion criteria. The studies used the outcome measures of pain intensity, pain threshold, and ROM, but, unfortunately, were of average methodological quality, and had findings that were either contradictory, inconclusive, or unpersuasive.  Beattie et al concluded that IFC may have an effect in reducing pain, but more rigorous, high quality research is needed to substantiate its efficacy.

Beatti, A.  et al. (2010). The analgesic effect of interferential therapy on clinical and experimentally induced pain. Physical Therapy Reviews, 15(4), 243-252.

This systematic review included randomized controlled trials that aimed to determine IFC’s effectiveness in treating musculoskeletal pain. The results were inconclusive, indicating that IFC alone was not shown to have significantly better results than other therapies. Keep in mind that the studies that used IFC as the ONLY intervention were very small. IFC as an adjunct to other interventions was found to be more effective for reducing pain than the control or placebo treatments. Optimal dosage for IFC is not clear. The results also imply that there are potential long-term benefits from IFC like in chronic conditions; currently IFC is mostly used for short-term pain. Heterogenity in the population was the main limit to this meta-analysis. Overall the evidence is weak to proclaim that IFC is truly effective.

Fuentes, J. P., Armijo Olivo, S., Magee, D. J., & Gross, D. P. (2010). Effectiveness of interferential current therapy in the management of musculoskeletal pain: a systematic review and meta-analysis. Physical therapy, 90(9), 1219-38. doi:10.2522/ptj.20090335

Furlan reviewed 154 eligible studies relating to interferential current, either independently or as a cointervention, for subjects clinically diagnosed with a painful musculoskeletal condition.  Twenty studies were included in a qualitative synthesis and fourteen studies were included in a meta-analysis.  A lack of consensus was found within the articles.  Some of the articles indicated that interferential current was not significantly different from the placebo or from a cointervention of interferential current and manual therapy.  There was also conflict between studies over the same condition, some showing a significance, others not.  The meta-analysis results indicated that interferential current may be beneficial for pain management when combined with other therapies, however independently it did not show a significant improvement.

Furlan, A. D. (2011). Evidence for Interferential Current to Treat Musculoskeletal Pain Remains Weak. Clinical Journal of Sport Medicine, 21(3), 278-279. Retrieved February 27, 2012, from http://ovidsp.tx.ovid.com.proxy.kumc.edu:2048/sp-3.5.1a/ovidweb.cgi?QS2=434f4e1a73d37e8c6a

Kylie Palermo, Rick Hill, Kate Wiens, Sarah Jarvis

High Voltage Pulsed Current

High Voltage Pulsed Current (HVPC) can be used for treatment of dermal wounds, edema managment, muscle weakness, and pain management depending on the parameters the machine is set to. HVPC is a twin-peaked, pulsed, direct current. We found it difficult to stick to one specific injury and the effects HVPC has. Therefore, a summary of articles that both support and refute the use of HVPC for some of the reasons listed are presented below.

Articles that Support

Among the uses of HVPC can be edema management. Mendel et al. demonstrates this in Influence of High Voltage Pulsed Current on Edema Formation following Impact Injury in Rats.

This study used four 30-minute treatment sessions of HVPC at 120 pps on rats in order to determine the effect on reducing edema. HVPC was performed on one leg of each rat after both legs were put under trauma. After two treatments, leg measurement was significantly decreased in the treated leg as compared to the untreated leg (p=0.0057). Thus, this article shows that HVPC can be used to decrease edema.  

HVPC is the "gold standard" stimulation modality for wound healing.  A study in Cairo, Egypt by Ahmed studied the effect of HVPC on chronic pressure ulcers and the optimal duration for enhancing healing.  This study included sixty participants suffering from chronic pressure ulcers, monitored for a treatment period of five weeks.  Participants were divided into four equal groups.  Each group received HVPC seven days a week for a different amount of time, and one group served as the control, receiving sham HVPC.  The wound surface area was measured at initial treatment, three weeks, and five weeks, and served as the dependent variable.  The independent variable was varied HVPC treatment times.  Wound surface area decreased in the 60 minute and 120 minute groups, seven days a week.  These two groups proved to be the optimal duration for enhancing healing of chronic pressure ulcers.

Again, HVPC is recognized as a "gold standard" stimulation modality for wound healing.  A study published in the Journal of the American Physical Therapy Association looked at the effectiveness and efficiency of HVPC for treating and healing pressure ulcers in patients with spinal cord injury.  Seventeen patients were included in the study.  They were divided into a placebo HVPC group or a group that received HVPC.  The treatment lasted 20 days for one hour each day.  This study as well as the one above, measured wound surface area to see if the treatment of HVPC was helping with pressure ulcers.  Pressure ulcers on the spinal cord patients were measured at initial treatment, 5, 10, 15, and 20 days after the start of treatment.  There was a reduction in the size of the pressure ulcers after treatment from the HVPC group compared to the placebo, meaning HVPC is a good choice as a modality treatment among patients with pressure ulcers that suffer from spinal cord injury.  

Articles that Refute

High voltage pulsed current can be used for several purposes, but Butterfield et al. found that it does not provide a significant effect for helping delayed-onset muscle soreness (DOMS). This article examined the effects HVPC has on pain, ROM loss, and strength loss due to the DOMS. The randomized control trial tested 28 college students in which there was a control group that received sham treatments where they believed they were being given a nonsensory treatment and an experimental group that received 3 30-minute treatments of HVPC at 125 pps over 48 hours. The DOMS was induced by having the subjects perform concentric and eccentric knee extension exercises with their right leg. Subjects were not allowed to use any other form of treatment such as ice, massage, or pain medications. Pain was less during the HVPC treatment but did not have a significant affect 24 to 72 hours post-exercise (p=0.67). There was also no significant decrease in loss of ROM as compared to the control group (p=0.38) or decrease in loss of strength (p=0.25).

In the article by Michlovitz, Smith, and Watkins, the researchers wanted to compare ice versus ice and high voltage pulsed stimulation (HVPS) for the treatment of ankle sprains (Michlovitz, Smith, & Watkins, 1988).  There were 30 subjects used in this study all of which had either grade I or grade II ankle sprains.  All 30 subjects were given treatment within 30 hours of their injury and were treated once daily for 3 days.  The subjects were randomly assigned and separated into 3 groups of 10, group 1’s treatment only consisted of 30 minutes of ice, group 2’s treatment consisted of ice and HVPS (28 pps, negative polarity, current to comfort without contraction,) and group 3’s treatment consisted of ice and HVPS (80 pps, negative polarity, 30 minutes.)  The results of this experiment found that there was no significant difference between the duration of injury between the groups and that there were no significant differences between the groups in volumetric or ROM measures.  Overall this study concluded that there were no significant differences between treatment effects among groups sprains (Michlovitz, Smith, & Watkins, 1988).

In the study by Mendel, Dolan, Fish, Marzo, and Wilding, the researchers investigated whether the use of subsensory High-Voltage Pulsed Current (HVPC) applied almost continuously for 3 days immediately after a lateral ankle sprain decreased the time lost to the injury (Mendel, Dolan, Fish, Marzo, & Wilding, 2010).  This study was a multicenter, randomized, double-blind, placebo-controlled trial that collected data from 9 colleges and 1 professional training site.  There were 50 subjects in this study and they were randomly given HVPC or the placebo in addition to traditional acute/subacute care.  This study found that there was no difference between the 2 groups in regards to the time lost to injury and it was actually found that in the subjects that had grade I ankle sprains the treatment group that was being administered the live HVPC actually lost more time to injury than did the placebo group.  The conclusion of the study was that the use of subsensory HVPC does not decrease the time lost to injury in regards to lateral ankle sprain injuries (Mendel, Dolan, Fish, Marzo, & Wilding, 2010).

Sources

Ahmad, E.T., "High Voltage Pulsed Galvanic Stimulation: Effect of Treatment Duration on Healing of Chronic Pressure."  Faculty of Physical Therapy, Cairo University, Cairo, Egypt. (2008): Vol. XXI-n.3. <http://www.ncbi.nlm.gov/pmc/articles/PMC3188162/pdf/Ann-Burns-and-Fire-Disasters-21-124.pdf> 

Butterfield, David L., David O. Draper, Mark D. Ricard, J. W. Myrer, Earlene Durrant, and Shane S. Schulthies. "The Effects of High-Volt Pulsed Current Electrical Stimulation on Delayed-Onset Muscle Soreness." Journal of Athletic Training 32.1 (1997): 15-20. PubMed. NCBI. Web. 04 Mar. 2012. <http://www.ncbi.nlm.nih.gov.proxy.kumc.edu:2048/pubmed/16558426>.

Griffin, Judy W., Tooms, R., Mendius, R., Clifft, J., Zwaag, V., El-Zeky, F.  "Efficacy of High Voltage Pulsed Current for Healing of Pressure Ulcers in Patients with Spinal Cord Injury."  Journal of the American Physical Therapy Association (1991): 71:433-422.   <http://ptjournal.apta.org/content/71/6/433.long>   

Mendel, Frank C., Juli A. Wylegala, and Dale R. Fish. "Influence of High Voltage Pulsed Current on Edema Formation following Impact Injury in Rats." Physical Therapy 72 (1992): 668-73. PubMed. Web. 4 Mar. 2012. <http://www.ncbi.nlm.nih.gov.proxy.kumc.edu:2048/pubmed/1508974>.

Mendel, F. C., Dolan, M. G., Fish, D. R., Marzo, J., & Wilding, G. E. (2010). Effect of high-voltage pulsed current on recovery after grades I and II lateral ankle sprains. Journal of sport rehabilitation, 19(4), 399-410. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21116009

Michlovitz, S. L., Smith, W., & Watkins, M. (1988). Ice and high voltage pulsed stimulation in treatment of acute lateral ankle sprains*. The Journal of orthopaedic and sports physical therapy, 9(9), 301-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18796993

-Brittany Brown, Lauren Mulsow, Zac Snow, Andrew Towell