Tauqeer veryessential to focus the effects of ES

Tauqeer Hussain* and Mustafa SajjaniWound Healing by Electrical Stimulation: AReview of Clinical EvidenceAbstract: There are many useful effects which has beenshown by Electrical Stimulation (ES) in wound healingmethods .To secure gain for clinical practice it is veryessential to focus the effects of ES on dermal woundhealing. Direct current(DC) and high-voltage pulsed current(HVPC) ES has been described including modalitiesof ES in several different applications. However thereare many methods and no one method has been promoteas the most ideal for the wound healing treatment.Therefore, this review target to examine the level of evidence(LOE) for the application of many various types ofES to enhance cutaneous wound healing in the skin. Forthe diagnostic of revalent clinical studies a huge searchwas also conducted using Pubmed.In the majority of studies the result is positively receivedby all types of ES on cutaneous wound healing. High voltagepulse current used as monophasic in which it delivereddouble with the maximum high peak range (150-500v).Ittransferred by a device with both anode and cathodedevices placed on wound.Howerver,the studies elaboratecontrasting differences in the parameters and types of ESapplication, which lead to an inability to generate sufficientdata to support any one standard therapeutic approach.Although variations in the type of duration, currentand dosing of ES,the majority of studies showed aserious improvement in wound area reduction, or also acceleratehealing compared to standard o care or local perfusionimproved by sham therapy . More, better-designedclinical trials are needed to improve of our understandingof the optimal dosing, timing and type of ES to be used.Keywords: electrical stimulation, wound healing, treatment,wounds, current.1 IntroductionElectrical stimulation is defined as the application of electricalcurrent through electrodes placed on the skin eithernear or directly on the wound. Electrical stimulation can*Corresponding Author: Tauqeer Hussain: HochshuleFurtwangen University, VS , e-mail:[email protected] Sajjani: Hochshule Furtwangen University, VSr, e-mail:[email protected] infection, improve cellular immunity, increase perfusion,and accelerate cutaneous wound healing. Variousdifferent applications of electricity have been defined includinglow-intensity direct current, high-voltage pulsedcurrent and direct current. Electrical stimulation deviceshave varying currents, voltages, modes and length of timeof application as different wounds need to be treated differently.Different electrical stimulation devices are usedand methods of application are used such as electrodeplacement, dressing and practitioner-assisted. Howeverin majority of the trials the electrodes are applied directlyon the skin or on the wound. Most of the studiesshowed positive outcomes using electrical stimulationto accelerate wound healing.The studies in different researchpapers showed that high voltage pulsed current ismost beneficial for pressure ulcer treatment while a limitednumber of studies showed that high voltage pulsedcurrent has positive results when used in ischemic, diabeticand chronic leg ulcers. However, that does not meanthat other types of wounds such as acute wounds or venousulcers would respond differently to this therapy. Additionally,high voltage pulsed current and direct currentstimulation exhibit higher levels of evidence when comparedto other electrical stimulation techniques.It is hardto identify which wound types respond better to treatmentand the ideal anatomical location, frequency, durationand time to commence the application of Electricalstimulation for each wound type, however further trialsare needed for better understanding of optimal dosing,timing and type of Electrical stimulation to be used.2 Methods2.1 Literature SearchWhen we initially searched on pubmed the wound healingby electrical methods it showed us 637 researches andthen when we applied the first filter to get the researchesfor the recent five years, it showed us 220 researches. Weare only concerned for the recent five years researches as itincludes the best and the latest methods used for woundhealing by electrical methods. Furthermore we appliedone more filter that was human just because our research2 Tauqeer Hussain and Mustafa Sajjani, Human Machine Interfaceis based on human species only and eventually the figurereduced to 141 researches. In the last we activatedthe review filter to further cut down our research and wegot 25 researches ultimately. After going through the differentresearches, we only found 3 to 4 researches thatreally concerned our topic and quite related to electricalmethods for wound healing.2.2 Data analysisOur main focus will be on the pulsed current and directcurrent that are used for wound healing. External electriccurrent applied to a wound is believed to mimic thebody’s natural bioelectricity. Different electrical stimulationdevices are used and methods of application are usedsuch as electrode placement, dressing and practitionerassisted.However in majority of the trials the electrodesare applied directly on the skin or on the wound. After goingthrough several research papers we came to know thatsome of the studies have used continuous direct currentwhile others used high voltage pulsed current to minimizethe risk of skin burn and achieve greater current penetration.Overall, the incidence of adverse effects was very lowand showed positive results. Different types of current, includingbidirectional currents have been used to promotehealing but there is not sufficient summary about theireffects nor consensus on best parameters to be used. Inmost of the studies the therapy was provided in a hospitalor at the clinic while in one of the study the patientswere provided with electrical stimulation device to use athome. The data was recorded by the number of hours thedevice was used and these data were downloaded fromthe device when the patients visited the clinic weekly.3 ResultPulsed current is bidirectional or unidirectional flow ofelectrons, and has monophasic waveform or biphasicwaveform. Monophasic pulsed current is also describedas low-voltage and high-voltage. Biphasic pulsed currentis bidirectional and it has two waveform symmetric orasymmetric. Low voltage pulsed current devices transfercontinuous direct current, lower voltages (20-35V) andbiphasic and monophasic waveforms of longer duration.The parameters used are a duration of 132 microsecondsand 64 pulses per second.High-voltage pulsed current delivers a monophasic pulsedcurrent in which the pulses are delivered in doubles. Ithas a high peak voltage (150-500V) and each pulse is ofshort duration (less than 200 micro seconds). High voltagepulsed current is transferred by a device with both positiveand negative electrodes placed on the skin or woundsite.A randomized controlled trial was conducted by Peter inwhich 40 patients were treated for 12 weeks with diabeticfoot ulcers. Patients were randomly divided to receivehigh-voltage pulsed current or sham therapy. Patientswere treated every hour for 8 hours each day over the 12week study. Most patients healed in the electrical stimulationgroup( 65% compared to the sham group), howeverthe difference was not significant. Patients who used thedevice at least three times a week were more likely to healas compared to the patients who received sham therapyand who used the device 0,1 or 2 times a week. Anotherrandomized controlled trial was conducted by Houghtonwhich involved 27 patients with chronic leg ulcers. Highvoltage pulsed current was delivered at 150V,100 pps and100 microsecond duration. Patients were treated 3 times aweek for 4 weeks and the treatment lasted for 45 minutes.The treatment group wounds were significantly reducedin size.The unidirectional flow of charged particles is knownas continuous direct current, which flows for 1 secondor longer, and is produced by solar cells, thermo couplingsand batteries. Pulsed direct current is a monophasicpulsed waveform that flows from 1ms to 1 second.In order to avoid damaging healthy tissue while treatingwound a low intensity direct current (20-100 microamps)is used. A study by Gault was conducted for 8 weeksusing continuous low intensity direct current to treat 76patients with ischaemic skin ulcers. The negative electrodewas directly applied onto the wound for three daysin order to debride necrotic tissue. Three times daily fortwo hours the current ranging from 200-800 microampswas used. Forty-eight of the hundred ulcers were completelyhealed. One of the recent study used a wirelessmicro current stimulation device for the treatment of legand diabetic foot ulcers, this study was conducted on 47patients. The treatment was applied 2 to 3 times a weekfor 60 minutes per session combined with standard woundcare. The study demonstrated that within 3 months majorityof the cases were successful as the wounds werehealed completely. Different wounds can be treated at thesame times by this device, and the device is contactlessand pain free.Tauqeer Hussain and Mustafa Sajjani, Human Machine Interface 33.1 Pulsed CurrentTable 1: Pulsed CurrentAuthor Type ofWoundType ofESParametersOutcomeFeeder1 ChronicdermalulcersMonophasicpulsedvs sham29.2V, 29.2mA,132 s,polarityreversedevery3 daysthendailyreversalwith 64ppsReductioninwoundsize.WoundareareductionES66% vs.sham33% (p< 0.02)Peter 2 Diabeticfoot ulcersHighvoltagepulsedvs sham50V,100 sEnhancedwoundhealingwhenusedwithstandardcareHoughton 3 ChroniclegulcersHighvoltagepulsedvs sham150V,100s,100HzAcceleratewoundclosure.Woundarea reductionES 44%vs sham16%.3.2 Direct Current4 DiscussionAfter going through several research papers we cameacross few research papers that were quite related to ourtopic. These research papers focus only on the electricalmethods that have been used for wound healing andhow successful these treatments are. The recorded studiesindicate reasonable variability in the parameters of ElectricalStimulation application that leads to difficulty indeveloping sufficient evidence to support any one standardtherapeutic approach. Most of the studies statedsuccessful positive outcomes using electrical simulationto accelerate wound healing. The studies in different researchpapers showed that high voltage pulsed current ismost beneficial for pressure ulcer treatment while a limitednumber of studies showed that high voltage pulsedcurrent has positive results when used in ischemic, diabeticand chronic leg ulcers. However, that does not meanthat other types of wounds such as acute wounds or venousulcers would respond differently to this therapy. Additionally,high voltage pulsed current and direct currentstimulation exhibit higher levels of evidence when comparedto other electrical stimulation techniques. Pressureulcers, venous ulcers, vascular ulcers and diabetic footwounds are mainly been evaluated by electrical stimulation.The variation in outcome measurements, type of electricalstimulation and how the therapy was dosed in thetrials leads to difficulty in interpreting these data. Mostof the studies were small and had short treatment periodtherefore many of the studies did not use completewound healing as the final outcome. Based on the studiesand findings until now it is of note that not all applicationsand modalities of electrical stimulation have aneffect on all phases of wound healing. Electrical stimulationinduces the migration of keratinocytes, which addsto the skin's first line of defense against pathogens, thisis a key process in wound healing. In one of the studythey showed that after one hour period the physiologicalelectrical field enabled human dermal fibroblasts to beginmigrating towards the anode, in a direction opposite tothat of keratinocytes, which migrate towards the cathode.This is also supported by another study, where theyidentified that applying the anode in the wound could enhancewound healing. Further studies were conducted todetermine whether the anodal or cathodal micro amperagedirect current electrical stimulation were more appropriatefor wound repair. Anodal micro amperage directcurrent decreases the wound surface area faster, allowingfor faster wound healing as compared to cathode microamperage direct current therefore it concludes that anodalelectrical stimulation is more effective than cathodalelectrical stimulation. It is necessary to treat the woundas soon as it occurs and to treat with exact frequency.Different wounds are treated differently such as differentvoltages and currents are used and also the duration oftreatment time varies.Unidirectional electrical stimulation is most beneficial forpressure ulcers whereas bidirectional electrical stimulationis beneficial for venous leg ulcers and diabetic footulcers. Compliance is a factor that affects wound healingin electrical stimulation studies. In most of the studies,therapy was provided in a hospital or at the clinic, so pa4Tauqeer Hussain and Mustafa Sajjani, Human Machine Interfacetients who kept their clinic appointment determined themain measure of compliance. In one of the study performedthe patients were provided with electrical stimulationdevice to use at home. The data was then recordedby the number of hours the electrical simulation devicewas used. These data were downloaded from the electricalstimulation device when the patients visited the clinicweekly. A higher proportion of wounds were healed in patientswho were co-operative in the electrical stimulationtreatment group - 71%, while the result of wound healingin patients who were non co-operative in the electricalstimulation treatment group were 50%.Electrical stimulation can be performed by a single experiencedpractitioner and there is often no pain associatedwith the treatments. It is hard to identify which woundtypes respond better to treatment and the ideal anatomicallocation, frequency, duration and time to commencethe application of ES for each wound type.5 ConclusionElectrical stimulation therapy is considered safe and easyto use, as electrical stimulation decreases bacterial infection,increases local perfusion and accelerates wound healing.No device-related complications or negative effectshave been reported till now. Electrical stimulation applicationis relatively cost effective as compared to othercomparative treatments. Majority of the studies showedthat electrical stimulation increased wound healing or improvementin wound area reduction, however further trialsare needed for better understanding of optimal dosing,timing and type of Electrical stimulation to be used.References1 Feedar J.A., Kloth L.C., Gentzkow G.D. Chronic dermal ulcerhealing enhanced with monophasic pulsed electrical stimulation.Phys. Ther. 1991;71:639–649. PubMed2 Peters E.J., Lavery L.A., Armstrong D.G., Fleischli J.G.Electric stimulation as an adjunct to heal diabetic foot ulcers:A randomized clinical trial. Arch. Phys. Med. Rehabil.2001;82:721–725. doi: 10.1053/apmr.2001.23780. PubMedCross Ref3 Houghton P.E., Kincaid C.B., Lovell M., Campbell K.E.,Keast D.H., Woodbury M.G., Harris K.A. Effect of electricalstimulation on chronic leg ulcer size and appearance. Phys.Ther. 2003;83:17–28.PubMed 457–472.4 Gault W.R., Gatens P.F., Jr. Use of low intensity direct currentin management of ischemic skin ulcers. Phys. Ther.1976;56:265–269. PubMed5 Wirsing P.G., Habrom A.D., Zehnder T.M., Friedli S., BlattiM. Wireless micro current stimulation—An innovative electricalstimulation method for the treatment of patientswith leg and diabetic foot ulcers. Int. Wound J. 2013 doi:10.1111/iwj.12204. PubMed Cross