Current Approach

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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 Volkmans ischemic
contracture, Sudecks 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 14. Along regions of the phrenic nerve

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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 (11-15)
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. non-adhesive) 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 lt15pps
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
Bipolar Active Electrode Distal
Dispersive Electrode 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

Settings Mode
Continuous
Continuous Pulse Rate
2-5 pps
2-15 pps Polarity
or -
or - Amplitude
Motor Stimulation
Painful Stimulation Tx Time
30-45 min
1-10 min/point Electrode Placement
Bipolar
Probe, Spot Active Electrode
LI 4
Trigger Points Dispersive Electrode
LI 10
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
(2-105-30 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
Monopolar
Bipolar Active Electrode Muscle
in spasm Both
electrodes on
Dispersive Electrode
Convenient area
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 (2-105-40 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
Bipolar Active Electrode
on Motor Point
Sandwich Dispersive Electrode
Convenient area 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 Bipolar
Active Electrode
Sandwich
Dispersive Electrode

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CLINICAL
APPLICATIONS Recommended Parameter Settings for
Peripheral Circulatory Disorders due to
Reynauds disease, Volkmans ischemic
contracture, Venous insufficiency,
Reflex Sympathetic Dystrophy etc
Parameters Settings
Settings
Mode Continuous
Surge
(2-55-15 s) Pulse Rate
50-100 pps
30-50 pps Polarity
or -
or - Amplitude
Minimal Sensory Stimulation Motor
Stimulation Tx Time
20-30 min
20-30 min Electrode Placement
Bipolar
Bipolar Active Electrode Both
electrodes on target area Both
electrodes on Dispersive Electrode

calf muscle

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CLINICAL
APPLICATIONS Recommended Parameter Settings for
Peripheral Circulatory Disorders due to
Reynauds disease, Volkmans ischemic
contracture, Venous insufficiency,
Reflex Sympathetic Dystrophy etc
Parameters Settings
Mode Continuous
Pulse Rate 2-5 pps
Polarity -
Amplitude Painful
Stimulation Tx Time
30-45 min, bid Electrode Placement
Bipolar Active Electrode LI 4
Dispersive Electrode 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 ES
Wound Type heal/
Duration Heal Rate/wk Feedar Kloth
(1985) RTC
10 Wound
5 wound
100 /7.3 wk

5 control 13.8 /10.6
wk Alon et al (1986) Case series
80 pps 15 Diabetic ulcer
80 /10.5 wk Kloth Feedar (1988) RTC
105 pps, 100-150 V 16 IV ulcer
change
pol 9 ES 100
/7.3 wk 44.8

7 placebo 28.9 /7.4 wk
11.6 Griffin et al (1991) RCT
100 pps, 200 V 17 SCI pressure
ulcer
1 hr/day for 20 days 8 ES
80 /4 wk 37.5
Anode
9 control
52.0 /4 wk 22.2 Franek et al (2000)
RCT 100 pps, 100 V
79 crural ulceration
50 min 7 weeks
33 ES wd size 59.03 ? 7 wk

Cathode 1-3 week 32 topical medicine
wd size 34.733 ? 7 wk
Anode
14 Unna's boot wd size 24.76 ?
7 wk Houghton et al (2003) RCT
100 pps, 150 V 27 (42) chronic ulcer

45 min, 3 times/wk 4 wk 14 ES
wd size 44.3 ? 4 wk
Cathode
13 placebo wd size 16.0
? 4 wk


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CLINICAL
APPLICATIONS Recommended Parameter Settings for
Wound Healing
Parameters Settings
Mode Continuous

Pulse Rate 50-200 pps
Polarity - then
Amplitude Sensory
Stimulation (100-200V) Tx Time
30-120 min Tx Frequency
3-4 times, 5x/week, 1-8 weeks
Electrode Placement Monopolar Active
Electrode Over wound Dispersive
Electrode 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 Settings
Mode Continuous

Pulse Rate 50-200 pps
Polarity - then
Amplitude Sensory
Stimulation (100-200V) Tx Time
30-120 min Tx Frequency
3-4 times, 5x/week, 1-8 weeks
Electrode Placement Monopolar Active
Electrode Over wound Dispersive
Electrode 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 ? or ?
Parameters Settings
Mode Continuous

Pulse Rate 50 pps
Polarity Negative
Amplitude Sensory
Stimulation (150V) Tx Time
30-120 min Tx Frequency
3-4 times, 5x/week, 8 weeks Electrode
Placement Monopolar Active Electrode
Over wound Dispersive Electrode
Proximal to wound After Day 6 Pulse
Rate 80 pps Polarity
Positive Amplitude
Sensory Stimulation (100V)

Source Unger PC A randomized clinical trial of
the effect of HVPC on wound healing.
Phys Ther 71(6)S118, 1991.
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Reading
??? ??? ??. ???? ??? ??? Anatomy of a
Scientific Discovery Jeff Goldberg ? ? ??
? ???, 1993.
??? ??
The Body Electricity Robert Becker, Gary
Selden ? ?? ? ?????, 1994.

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