Report Editor High-Volt Pulsed Current: Treatment of … july 2012 international journal of athletic therapy & training ... Report Editor High-Volt Pulsed Current: Treatment of Skin

32 july 2012 international journal of athletic therapy & training

© 2012 Human Kinetics - IJATT 17(4), pp. 32-34

High-volt pulsed current (HVPC) was developed in the 1940s by American scien-tists at Bell Laboratories. HVPC consists of twin-peak, monophasic pulses of very short duration (less than 200 ms) that are driven at 150 to 500 volts. The primary purpose for administration of HVPC is to accelerate the healing process for cutaneous wounds. It is

also used for prevention of edema formation, muscle reeducation, muscle spasm reduc-tion, and pain modula-tion.

Dermal WoundsThurman 1 was the author of one of the earliest reports of the therapeutic use of HVPC on humans, which doc-umented a beneficial effect on healing of a

septic diabetic abscess in a single patient. HVPC is believed to augment weak endog-enous skin voltage, which promotes wound healing. Wound management with HVPC involves administration of high-frequency, low-amplitude stimulation, which creates a skin stimulus that many patients describe as a “pins and needles” sensation. Most of the

Lindsey E. Eberman, PhD, ATC, LAT, Report Editor

High-Volt Pulsed Current: Treatment of Skin Wounds and Musculoskeletal Injuries

THERAPEUTIC MODALITIES

David O. Draper, EdD, ATC, FNATA; Kenneth L. Knight, PhD, ATC, FACSM; and Justin H. Rigby, MS, ATC • Brigham Young University

research on HVPC has been focused on man-agement of pressure ulcers. The combination of HVPC with whirlpool treatment has been reported to have no greater effect on pres-sure ulcers than HVPC alone.2 Pressure ulcers treated by HVPC for 45 minutes per day and five times per week have been reported to completely heal within 7.3 weeks, while those not treated with HVPC increased in size by 29%.3 Other researchers have reported that pressure ulcers treated with HVPC (220 V; 100Hz) for 1 hour per day over a 20-day period decreased by 80%, compared to 52% for a control group.4

Theory: How HVPC Works

HVPC involves a strong electromagnetic force that always exceeds 150 volts (maximum of 500 volts). A “galvanotaxis effect” induces the migration of polarized cells toward either the cathode or anode. The migration of neu-trophils, macrophages, lymphocytes, and platelets is believed to stimulate the “inflam-matory phase” of the tissue healing response. Subsequent migration of fibroblasts to the wound site enhances synthesis of new tissue during the “proliferation phase” of the heal-ing response. Migration of epidermal cells and keratynocytes is beneficial during the final “remodeling and maturation phase” of the healing response. 5

The primary purpose for administration of high-volt pulsed current is to accelerate the healing process for skin wounds.

High-volt pulsed current may also be ben-eficial for prevention of edema formation, muscle reeducation and spasm reduction, and pain modulation.

Proper treatment parameter selection is important to derive optimal therapeutic benefits from high-volt pulsed current.

Key PointsKey Points

international journal of athletic therapy & training july 2012 33

Administration of HVPC for Treatment of Dermal Wounds

The following are recommended procedures for admin-istration of HVPC for promotion of dermal wound healing. 3,6,7

1. Irrigate the wound bed with saline solution.

2. Apply a clean, saline-moistened gauze sponge over the wound.

3. Apply the dispersive sponge electrode approxi-mately 30 cm (12 in) from the wound site.

4. Apply the active sponge electrode directly on top of the saline moistened gauze covering the wound

5. Pulse rate:

a. Proliferation phase: 100-128 pps

b. Remodeling and maturation (Epithelialization) phase: 64 pps

6. Polarity: negative

a. During the epithelialization phase, alternating the polarity between negative and positive every 3 days has demonstrated best results.3

7. Set duration timer.

8. Inform the patient that treatment is being initiated.

9. Slowly increase current intensity.

10. Dosage: current intensity should be increased to a level just below that which elicits muscle contrac-tion (usually 100-150 V).

11. Treatment duration: 45-60 min.

12. Treatment frequency: one time per day, 5-7 treat-ments per week.

13. Duration of therapy: until treatment goals have been achieved.

Rational for Other Therapeutic Applications

Electrical stimulation of deep excitable tissues without eliciting pain presents a clinical challenge. The elec-trical stimulus duration must be very short, and its amplitude must be very high to avoid depolarization of nerves that convey pain impulses.

Anti-Edema Effect

HVPC is used to limit edema formation and for reso-lution of edema after it has formed. The anti-edema effect is believed to result from repulsion of nega-

tively charged albumin proteins beneath the cathode, thereby altering the osmotic effect that would other-wise promote outflow of fluid from the capillaries into the interstitium. Laboratory research on the effect of HVPC on edema has produced conflicting findings. Michlovitz et at.8 reported no difference in edema control when HVPC was included with the application of ice, compression, and elevation for the treatment of acute ankle sprains. Cosgrove et al.9 reported no dif-ference between HVPC and placebo current for edema formation in rats that were subjected to blunt trauma. Conversely, Taylor et al.10 reported that HVPC was effective in decreasing histamine-induced fluid leakage from blood vessels in hamster cheek pouches. Dolan et al.11 reported that 3 hours of HVPC, or a combination of HVPC and cold water immersion, was effective in limiting edema formation by 50% in rats that were subjected to blunt trauma. Ideally, HVPC treatment should be administered as soon as possible after injury occurrence, and it should be maintained the period that edema formation occurs.11

Muscle Reeducation and Spasm Reduction

Elicitation of a tetanic contraction for muscle reedu-cation involves administration of high-frequency and high-amplitude electrical stimulation. HVPC is not as effective as other modes of neuromuscular electri-cal stimulation for this purpose, because its average current is not as great as that generated by low-volt stimulators.12 We recommend that an HVPC stimulator should only be used for muscle reeducation when no other type of electrical stimulator is available.

HVPC for Pain Modulation

HVPC does not appear to be effective for reduction of delayed-onset muscle soreness;13,14 however, HVPC may help to relieve pain associated with muscle spasm.

Administration of HVPC for Treatment of Musculoskeletal Injuries

The following are recommended procedures for admin-istration of HVPC for treatment of a musculoskeletal injury.6

1. Set pulse rate:

a. Re-education and pain management:

< 15 pps for individual or twitch contractions

> 50 pps for moderate to tetanic contractions

34 july 2012 international journal of athletic therapy & training

b. Edema reduction

120 pps

2. Set polarity: negative over motor point (monopo-lar).

3. Set duty cycle.

4. Set treatment duration.

5. Inform the patient that treatment is being initiated.

6. Slowly increase current intensity.

a. Ask patient to indicate when increasing inten-sity becomes uncomfortable.

b. Decrease intensity slightly after level that elicits discomfort has been determined.

c. Increase intensity to a level that elicits a muscle contraction.

7. Skin resistance will decrease after 5–10 seconds, after which intensity may be increased.

8. If treating a motor point, move the anode electrode probe to locate the motor point.

a. Identify the location that elicits a maximal contraction.

b. Pause 5-10 seconds in each area to overcome skin resistance.

9. Possible causes of patient discomfort:

a. Too much current

b. Insufficient moistening of electrode sponge

c. Area of denuded skin

d. Patient hypersensitivity

10. Dosage:

a. Reeducation and pain management: maximal current that is comfortable

b. Edema reduction: 90% of visible motor threshold

11. Duration of treatment:

a. 15 min for pulsed current, or if patient will exercise vigorously after treatment

b. 15-30 min if current surge mode is used or if patient will not exercise after the treatment

12. Frequency of treatment: As often as three times per day (separated by 3-4 hours)

13. Duration of therapy: Continue until treatment goals have been achieved.

14. For the edema reduction, electrodes can be used in water or larger electrodes may be used to cover a greater surface area.

SummaryHVPC is an appropriate therapeutic modality for pro-motion of skin wound healing or for clinical manage-ment of swelling and muscle spasm associated with a musculoskeletal injury.

References 1. Thurman BF, Christian EL. Response of a serious circulatory lesion to

electrical stimulation. Phys Ther. 1971;51(10):1107-1110.

2. Akers TK, Gabrielson AL. The effect of high voltage galvanic stimula-tion on the rate of healing of decubitus ulcers. Biomed Sci Instrum. 1984;20:99-100.

3. Kloth LC, Feedar JA. Acceleration of wound healing with high voltage, monophasic, pulsed current. Phys Ther. 1988;68(4):503-508.

4. Griffin JW, Tooms RE, Mendius RA, Clifft JK, Vander Zwaag R, el-Zeky F. Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury. Phys Ther. 1991;71(6):433-442.

5. Belanger Y. Electrophysical Agents: Evidence Behind Practice. Baltimore, MD: Lippincott, Williams & Wilkins; 2010.

6. Feedar JA, Kloth LC, Gentzkow GD. Chronic dermal ulcer healing enhanced with monophasic pulsed electrical stimulation. Phys Ther. 1991;71(9):639-649.

7. Knight K, Draper D. Therapeutic Modalities: The Art and Science. Bal-timore: Lippincott Williams & Wilkins; 2008.

8. Michlovitz SL, Smith W, Watkins M. Ice and high voltage pulsed stimu-lation in treatment of acute lateral ankle sprains. J Orthop Sports Phys Ther. 1988;9(9):301-304.

9. Cosgrove KA, Alon G, Bell SF, et al. The electrical effect of two com-monly used clinical stimulators on traumatic edema in rats. Phys Ther. 1992;72(3):227-233.

10. Taylor K, Mendel FC, Fish DR, Hard R, Burton HW. Effect of high-voltage pulsed current and alternating current on macromolecu-lar leakage in hamster cheek pouch microcirculation. Phys Ther. 1997;77(12):1729-1740.

11. Dolan MG, Mychaskiw AM, Mendel FC. Cool-water immersion and high-voltage electric stimulation curb edema formation in rats. J Athl Train. 2003;38(3):225.

12. Rauh J. Comparison of Muscular Forace Production as a Result of Vol-untary Contraction and Three Electrical Stimulators. Terre Haute, IN: Physical education, Indiana State University; 1982.

13. Butterfield DL, Draper DO, Ricard MD, Myrer JW, Durrant E, Schulthies SS. The effects of high-volt pulsed current electrical stimulation on delayed-onset muscle soreness. J Athl Train. 1997;32(1):15-20.

14. Wolcott C. A comparison of the effects of high volt and microcur-rent stimulation on delayed onset muscle soreness. Phys Ther. 1991;71:S117.

David Draper is a professor of Athletic Training in the Exercise Science Department at Brigham Young University in Provo, Utah. He won the William G. Clancy Jr. MD award in 2001 for his outstanding research.

Kenneth Knight is a retired professor of Athletic Training in the Exercise Science Department at Brigham Young University in Provo, Utah. He is a Hall of Fame member of the National Athletic Trainers’ Association.

Justin Rigby is a doctoral student in the Exercise Science Department at Brigham Young University.