Transcript Effects of ES in Wound Repair Process in Proliferative Phase

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BIOLOGICAL EFFECTS OF ESTR
Effects of ES in Wound Repair Process in Proliferative Phase
6. Increase Angiogenesis
promote neovascularization (Ottani et al, 1988)
angiogenesis in skin flap (Pollack, 1989; Lundeberg, 1988)
endothelial cells migration - promote angiogenesis (Li & Kolega, 2002)
7. Increased tensile strength
Produces better collagen matrix organization,
collagen maturation,
2x higher breaking strength in rabbit skin wound (Assimacopoulos, 1968)
8. Stimulates wound contraction
increase wound contraction rate (Ottani et al, 1988)
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BIOLOGICAL EFFECTS OF ESTR
Effects of ES in Wound Repair Process in Proliferative Phase (Epithelialzation)
1. Migrates and stimulates keratinocytes, Promote epithelialization
HVPCS increase epithelialization in rabbit dermal wound (Brown et al, 1989)
HVPCS increase rRNA expression in rat dermal wound (Lee et al, 1999)
2. Produces a smoother, thinner scar
reduces fibrosis and scar by decrease of Mast Cell (Reich et al, 1991; Weiss et al, 1989)
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Nucleolar organizer regions (NORs)
13, 14, 15, 21 and 22 th chromosomes
Secondary constriction in short arms
rDNA – rRNA, Proteins
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Roles of NORs
rRNA production
2 subunits of rRNA
(small rRNA, large rRNA)
Transformation
(into smaller subunit)
Ribosome synthesis
(in cytoplasm)
Protein synthesis
NOR ↑ = Cell Proliferative Activity ↑
AgNOR
marker of cellular activity and proliferation
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INDICATIONS
1. Acute and Chronic Pain
Caused by trauma, inflammation(arthritis, neuritis), tissue degeneration,
impaired circulation,
Post surgical pain,
Phantom pain,
Cancer pain
2. Muscle Spasms
Muscle spasm associated musculoskeletal injury,
Dyskinesia,
Inflammation,
Pain etc.
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INDICATIONS
3. Wound
• Chronic wounds
Stage I, II, III, IV pressure ulcer
Venous, arterial insufficiency
Diabetic ulcers due to pressure, insensitivity and dysvascularity
Ischemic wound
• Traumatic wounds
• Infected wounds
• Surgical wound
• Skin flaps and Donor Sites
• Burn wounds
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INDICATIONS
4. Edema
Traumatic strains and sprains,
Synovitis,
Tendinitis,
RA,
Inflammatory diseases
Intraarticular hemorrhage,
Acute hematoma,
Edema associate Injury and Surgery
5. Conditions associate limit of ROM
Pain, Edema, Contracture, Calcium deposit bursitis,
Degenerative changes etc.
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INDICATIONS
6. Muscular Weakness
Disuse atrophy associate Trauma, Prolonged immobilization
Weakness associate Degenerative arthritis, chronic inflammatory joint
diseases, CVD, Head injury, SCI etc
7. Vascular Disturbances
Volkman’s ischemic contracture,
Sudeck’s atrophy,
Venous insufficiency
Peripheral arterial occlusive disease
Vascular Disturbances due to inflammatory diseases of connective tissue,
Degenerative arthritis, Spasticity etc
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CONTRAINDICATIONS
* Similar to other electrical stimulation devices
1. Circulation Impairment
2. Pregnancy females
3. Stimulate across the heart, particularly patients who have demand type
cardiac pacemaker
4. Seizure
5. Metal implants
6. Menstruation
7. Nerve sensitivity
8. Over Cancerous lesion
9. Over infection (osteomyelitis etc)
10. Wound with hemorrhage
11. Over topical agents (povidone, mercurochrome, metal ions)
12. Over the carotid sinus
13. Over laryngeal muscle
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14. Along regions of the phrenic nerve
PRECAUTIONS
1. Stimulation may cause unwanted tension on muscle fibers/tendons
2. Muscle fatigue if insufficient duty cycle
3. Improper electrodes can burn or irritate
4. Intense/prolonged stimulation may result in muscle spasm or
soreness
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HVPCS DEVICES
1. Pulse Rate Control : 1-140 pps
2. Waveform and Pulse Duration : Fixed
3. Pulse mode :
• Continuous pulse (train of pulse)
• Reciprocate pulse (1:1-1:5)
• Surge pulse mode : intensity modulation
4. Polarity Switch : Positive and Negative
5. Intensity Control : 1-500 V
6. Pad/Probe Mode Switch :
• 2 Active electrodes :
1 electrode : 2.5s (5s , 10s)
2 electrode : 2.5s (5s , 10s)
7. Outlet :
• Active Pad
• Probe
• Dispersive Electrode
8. Indicator Light :
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ELECTRODES
Active electrode
• Carbon pad electrodes and Sponges, 2,3,4 inches in diameter
• Probe electrode
Intraoral electrode, Intraoral electrode ball end
Vaginal electrode
Prostatic (anal) electrode
Spot electrodes small, Large
• Metal Roller electrodes, small, large
Dispersive electrode
• Carbon pad electrodes and Sponges, 5x8, 8x10 inches
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ELECTRODES
* Electromesh Garment
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ELECTRODES
Material
• Metal
• Carbon impregnated silicone electrodes are recommended
but will develop hot spots with repeated use (self-adhesive vs. nonadhesive)
tin with overlying sponge has a decreased conformity and reduced
conductivity
Size
• based on size of target area
• current density is important
- the smaller the electrode size, the greater the density of current
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APPLICATIONS
Pulse Rate
depends on conditions
• Neuromuacular Stimulation
Re-educate a muscle :
Muscle strength augmentation
Muscle contraction <15pps
Tetanic contraction 35-50 pps
Amplitude
Sensory level
Motor level
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APPLICATIONS
Electrode Placement
• Monopolar
two electrodes of unequal size
smaller is generally over the treatment site
larger serves as a dispersive pad located proximal to the treatment area
• Probes
one hand-held active lead
advantages: can locate and treat small triggers
disadvantages: one on one treatment requires full attention of the trainer
• Bipolar
two electrodes of equal size, both are over or near the treatment site
• Water bath immersion
used for irregularly shaped areas
* Electromesh Garment
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Acute Pain
due to surgery, trauma, inflammation (tendonitis, bursitis, neuritis etc)
Parameters
Settings
Settings
• Mode
Continuous
Continuous
• Pulse Rate
50-120 pps
2-15 pps
• Polarity
+ or + or • Amplitude
Sensory Stimulation
Painful Stimulation
• Tx Time
30 min or more
1-10 min/point
• Electrode Placement Monopolar
Probe, Spot
• Active Electrode
Painful site (Nerve trunk, Paravertebral) Trigger Points
• Dispersive Electrode
Proximal
Convenient
Area
• Electrode Placement
• Active Electrode
• Dispersive Electrode
Bipolar
Distal
Proximal
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Chronic Pain
due to low back pain, degenerative joint diseases (Shoulder, Hip etc.)
Parameters
Settings
• Mode
Continuous
• Pulse Rate
2-5 pps
• Polarity
+ or • Amplitude
Motor Stimulation
• Tx Time
30-45 min
• Electrode Placement Bipolar
• Active Electrode
LI 4
• Dispersive Electrode LI 10
Settings
Continuous
2-15 pps
+ or Painful Stimulation
1-10 min/point
Probe, Spot
Trigger Points
Convenient Area
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Impaired Joint ROM
due to Capsulitis, Calcific Bursae, DJD, Sprain & Strain, Post Surgical immobilization
Parameters
Settings
Settings
• Mode
Continuous
Surge (2-10:5-30 s)
• Pulse Rate
80-125 pps
35-50 pps
• Polarity
+ or + or • Amplitude
Sensory Stimulation
Motor Stimulation
• Tx Time
30 min
10 min, tid
• Electrode Placement Bipolar
Bipolar
• Active Electrode
Both electrodes on affected joint
Muscle group
• Dispersive Electrode
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Muscle Spasm
due to Acute muscle trauma, Abnormal joint motion, Soft tissue inflammation
Parameters
Settings
Settings
• Mode
Continuous
Continuous
• Pulse Rate
100-125 pps
50-120 pps
• Polarity
+ or + or • Amplitude
Motor Stimulation
Sensory Stimulation
• Tx Time
30-60 min
30 min or more
• Electrode Placement Bipolar
Monopolar
• Active Electrode
Both electrodes on muscle in spasm
Painful area
• Dispersive Electrode
Convenient area
• Electrode Placement
• Active Electrode
• Dispersive Electrode
Monopolar
Muscle in spasm
Convenient area
Bipolar
Both electrodes on
Painful area
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Muscle Disuse Atrophy
due to Arthritis (RA, OA etc), Amputees, Post Trauma, Immobilization
Parameters
Settings
• Mode
Surge (2-10:5-40 s)
• Pulse Rate
35-50 pps
• Polarity
+ or • Amplitude
Motor Stimulation
• Tx Time
10-20 reps
• Electrode Placement Bipolar
• Active Electrode
Both electrodes on muscle group
• Dispersive Electrode
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Swelling (Intraarticular Effusion)
due to Trauma (Sprain, Strain), Soft tissue injury and inflammation (Arthritis, Bursitis,
Tendonitis etc)
Parameters
Settings
• Mode
Continuous
• Pulse Rate
2-4 pps
• Polarity
+ or • Amplitude
Motor Stimulation
• Tx Time
20-30 min
• Electrode Placement Monopolar
• Active Electrode
on Motor Point
• Dispersive Electrode Convenient area
Bipolar
Sandwich
* Attempt to increase venous/lymphatic return by muscular contractions (“milking”)
Use only during subacute/chronic stages as muscle contraction and/or joint movement
may be contraindicated
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Swelling (Intraarticular Effusion)
due to Trauma (Sprain, Strain), Soft tissue injury and inflammation (Arthritis, Bursitis,
Tendonitis etc)
Parameters
Settings
• Mode
Continuous
• Pulse Rate
80-120 pps
• Polarity
• Amplitude
Sensory Stimulation
• Tx Time
20-30 min
• Electrode Placement Monopolar
• Active Electrode
on Swollen area
• Dispersive Electrode Convenient area
• Electrode Placement
• Active Electrode
• Dispersive Electrode
Bipolar
Sandwich
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Peripheral Circulatory Disorders
due to Reynaud’s disease, Volkman’s ischemic contracture, Venous insufficiency,
Reflex Sympathetic Dystrophy etc
Parameters
Settings
• Mode
Continuous
• Pulse Rate
50-100 pps
• Polarity
+ or • Amplitude
Minimal Sensory Stimulation
• Tx Time
20-30 min
• Electrode Placement Bipolar
• Active Electrode
Both electrodes on target area
• Dispersive Electrode
Settings
Surge (2-5:5-15 s)
30-50 pps
+ or Motor Stimulation
20-30 min
Bipolar
Both electrodes on
calf muscle
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Peripheral Circulatory Disorders
due to Reynaud’s disease, Volkman’s ischemic contracture, Venous insufficiency,
Reflex Sympathetic Dystrophy etc
Parameters
• Mode
• Pulse Rate
• Polarity
• Amplitude
• Tx Time
• Electrode Placement
• Active Electrode
• Dispersive Electrode
Settings
Continuous
2-5 pps
Painful Stimulation
30-45 min, bid
Bipolar
LI 4
LI 10
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ELECTRICAL STIMULATION FOR WOUND HEALING
Procedure of Electrical Stimulation for Wound Healing
1. Have supplies ready before undressing the wound.
2. Position patient for ease of access by staff and comfort of both.
3. Remove the dressing and place in an infectious waste bag.
4. Cleanse wound thoroughly to remove slough, exudate and any petrolatum products
5. Sharp debride necrotic tissue, if required, before electrical stimulation
6. Open gauze pads and fluff, then soak in normal saline solution, squeeze out excess liquid.
An alternative is to use an amorphous hydrogel impregnated gauze.
Hydrogel sheets can also be used to conduct current under the electrodes
7. Fill the wound cavity with sterile gauze including any undermined/tunneled spaces.
Pack gently.
8. Place an electrode over the gauze packing cover with dry gauze pad and hold in place with
bandage tape.
a. Monopolar (over wound)
b. Bipolar (bilateral wound)
c. Underwater (Water bath immersion – irregular region, crushing injury in hand & foot etc)
d. Acupuncture point (An alternative protocol with reported healing, for placing the active
electrode on the web space of the hand between thumb and first finger instead of over the
ulcer. This may be more comfortable for the patient with PVD (Kaada).
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ELECTRICAL STIMULATION FOR WOUND HEALING
Procedure of Electrical Stimulation for Wound Healing
9. Connect an alligator clip to the foil.
10. Connect to stimulator lead
11. Dispersive electrode placement:
Usually placed proximal to the wound
• Place over soft tissues, avoid bony prominences
• Place a washcloth, wetted with water and wrung out, under the dispersive electrode
• Place against skin and hold in good contact at all edges with a nylon elasticized strap.
• If placed on the back, the weight of the body plus the strap can be used to achieve good
contact at the edges
• Dispersive pad should be larger than the sum of the areas of the active electrodes and wound
packing.
• The greater the separation between the active and dispersive electrode the deeper the current
path.
Use for deep and undermined wounds
• Dispersive and active electrodes can be close together but should not touch.
Current flow will be shallow. Use for shallow, partial thickness wounds
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ELECTRICAL STIMULATION FOR WOUND HEALING
Protocol of Electrical Stimulation for Wound Healing
1. Inflammation phase
Expected outcomes : Autolysis, progresses to the Proliferation phase
Parameters of Stimulation :
• Polarity : Positive
• Pulse rate : 100 - 128 pps
• Intensity : 100-150 volts (submotor)
• Duration : 60 minutes
• Frequency : 5-7 x per week, once daily
* Infected wound, use Negative
Fig.9. Autolysis. Macrophages (-), Neutrophils (-)
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ELECTRICAL STIMULATION FOR WOUND HEALING
Protocol of Electrical Stimulation for Wound Healing
1. Inflammation phase, Infected wound
Expected outcomes : Bacteriocide
Parameters of Stimulation :
• Polarity : Negative
• Pulse rate : 100 - 128 pps
• Intensity : 100-150 volts (submotor)
• Duration : 60 minutes
• Frequency : x5-7/week, once daily
Fig.10. Infection. Bacteriocide (Negative)
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ELECTRICAL STIMULATION FOR WOUND HEALING
Protocol of Electrical Stimulation for Wound Healing
2. Proliferative phase
Expected outcomes : Granulation, progresses to Contraction and Epithelization phase
Parameters of Stimulation :
• Polarity : Negative
• Pulse rate : 100 - 128 pps
• Intensity : 100-150 volts (submotor)
• Duration : 60 minutes
• Frequency : x5-7/week, once daily
* Infected wound, use Negative
Fig.11. Granulation formation. Fibroblast (+)
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ELECTRICAL STIMULATION FOR WOUND HEALING
Protocol of Electrical Stimulation for Wound Healing
3. Proliferative phase (Epithelization phase)
Expected outcomes : Epithelization, progresses to to Remodeling phase
Parameters of Stimulation :
• Polarity : Positive (*alternate every three days ie 3 days negative followed by 3 days positive)
• Pulse rate : 64 pps
• Intensity : 100-150 volts (submotor)
• Duration : 60 minutes
• Frequency : x5-7/week, once daily
Fig.12. Epithelialzation. Keratinocyte (-)
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ELECTRICAL STIMULATION FOR WOUND HEALING
Table 2. Clinical studies of wound healing by HVPC (High Voltage Pulsed Current )
Author
Study Type
Feedar & Kloth (1985)
Alon et al (1986)
Kloth & Feedar (1988)
ES
Wound Type
% heal/ Duration
Heal Rate/wk
10 Wound
5 wound
100% /7.3 wk
5 control
13.8% /10.6 wk
Case series
80 pps
15 Diabetic ulcer
80% /10.5 wk
RTC
105 pps, 100-150 V 16 IV ulcer
change pol
9 ES
100% /7.3 wk
RTC
44.8%
7 placebo
11.6%
Griffin et al (1991)
RCT
100 pps, 200 V
1 hr/day for 20 days
17 SCI pressure ulcer
8 ES
28.9% /7.4 wk
80% /4 wk
37.5%
Anode
22.2%
Franek et al (2000)
RCT
100 pps, 100 V
50 min 7 weeks
9 control
79 crural ulceration
33 ES
52.0% /4 wk
wd size 59.03% ↓ 7
wk
Cathode 1-3 week
32 topical medicine wd size 34.733% ↓
Anode
14 Unna's boot
7 wk
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wd size 24.76%
↓7
CLINICAL APPLICATIONS
Recommended Parameter Settings for Wound Healing
Parameters
• Mode
• Pulse Rate
• Polarity
• Amplitude
• Tx Time
• Tx Frequency
• Electrode Placement
• Active Electrode
• Dispersive Electrode
Settings
Continuous
50-200 pps
- then +
Sensory Stimulation (100-200V)
30-120 min
3-4 times, 5x/week, 1-8 weeks
Monopolar
Over wound
Remote site
Source Selkowitz DM : Electrical Current. In Cameron MH : Physical Agents in Rehabilitation
from Research to Practice. Philadelphia, WB Saunders, p.401, 1999
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Wound Healing
Parameters
• Mode
• Pulse Rate
• Polarity
• Amplitude
• Tx Time
• Tx Frequency
• Electrode Placement
• Active Electrode
• Dispersive Electrode
Settings
Continuous
50-200 pps
- then +
Sensory Stimulation (100-200V)
30-120 min
3-4 times, 5x/week, 1-8 weeks
Monopolar
Over wound
Remote site
Source Selkowitz DM : Electrical Current. In Cameron MH : Physical agents in Rehabilitation
from Research to Practice. Philadelphia, WB Saunders, p.401, 1999
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CLINICAL APPLICATIONS
Recommended Parameter Settings for Chronic Ulcer, Stage Ⅲ or Ⅳ
Parameters
Settings
• Mode
• Pulse Rate
• Polarity
• Amplitude
• Tx Time
• Tx Frequency
• Electrode Placement
• Active Electrode
• Dispersive Electrode
Continuous
50 pps
Negative
Sensory Stimulation (150V)
30-120 min
3-4 times, 5x/week, 8 weeks
Monopolar
Over wound
Proximal to wound
After Day 6
• Pulse Rate
• Polarity
• Amplitude
80 pps
Positive
Sensory Stimulation (100V)
Source Unger PC : A randomized clinical trial of the effect of HVPC on wound healing.
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Phys Ther 71(6):S118, 1991.
Reading
• 과학적 발견의 해부. 엔도르핀 발견의 드라마
Anatomy of a Scientific Discovery
Jeff Goldberg 저
이 공주 역
범양사, 1993.
• 생명과 전기
The Body Electricity
Robert Becker, Gary Selden
공 동철 역
정신세계사, 1994.
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