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There are many useful effects which has been shown by Electrical Stimulation (ES) in wound healing methods .To secure gain for clinical practice it is very essential to focus the effects of ES on dermal wound healing. Direct current(DC) and high-voltage pulsed current (HVPC) ES has been described including modalities of ES in several different applications. Bidirectional currents are promising as they have fewer adverse effects and are less invasive in their electrode placement than unidirectional currents.
Methods: Our main focus will be on the pulsed current and direct current that are used for wound healing. However there are many methods and no one method has been promote as 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 of ES to enhance cutaneous wound healing in the skin. For the diagnostic of relavent clinical studies a huge search was also conducted using Pubmed.
Results: Howerver,the studies elaborate contrasting differences in the parameters and types of ES application, which lead to an inability to generate sufficient data to support any one standard therapeutic approach. Although variations in the time of duration, types of current and dosing of ES,the majority of studies showed a serious improvement in wound area reduction, or also accelerate healing compared to standard of care or local perfusion improved by sham therapy.
Conclusion: More, better-designed clinical trials are needed to improve of our understanding of the optimal dosing, timing and type of ES to be used.
Electrical stimulation is defined as the application of electrical current through electrodes placed on the skin either near or directly on the wound. Electrical stimulation can reduce infection, improve cellular immunity, increase perfusion, and accelerate cutaneous wound healing. Various different applications of electricity have been defined including low-intensity direct current, high-voltage pulsed current and direct current. Electrical stimulation devices have varying currents, voltages, modes and length of time of application as different wounds need to be treated differently. Different electrical stimulation devices are used and methods of application are used such as electrode placement, dressing and practitioner-assisted. However in majority of the trials the electrodes are applied directly on the skin or on the wound. Most of the studies showed positive outcomes using electrical stimulation to accelerate wound healing.
The studies in different research papers showed that high voltage pulsed current is most beneficial for pressure ulcer treatment while a limited number of studies showed that high voltage pulsed current has positive results when used in ischemic, diabetic and chronic leg ulcers. However, that does not mean that other types of wounds such as acute wounds or venous ulcers would respond differently to this therapy. Additionally, high voltage pulsed current and direct current stimulation exhibit higher levels of evidence when compared to other electrical stimulation techniques.It is hard to identify which wound types respond better to treatment and the ideal anatomical location, frequency, duration and time to commence the application of Electrical stimulation for each wound type, however further trials are needed for better understanding of optimal dosing, timing and type of Electrical stimulation to be used.
When we initially searched on pubmed the wound healing by electrical methods it showed us 637 researches and then when we applied the first filter to get the researches 2 Tauqeer Hussain and Mustafa Sajjani, Human Machine Interface for the recent five years, it showed us 220 researches. We are only concerned for the recent five years researches as it includes the best and the latest methods used for wound healing by electrical methods. Furthermore we applied one more filter that was human just because our research is based on human species only and eventually the figure reduced to 141 researches. In the last we activated the review filter to further cut down our research and we got 25 researches ultimately. After going through the different researches, we only found 3 to 4 researches that really concerned our topic and quite related to electrical methods for wound healing.
Our main focus will be on the pulsed current and direct current that are used for wound healing. External electric current applied to a wound is believed to mimic the body’s natural bioelectricity. Different electrical stimulation devices are used and methods of application are used such as electrode placement, dressing and practitioner assisted. However in majority of the trials the electrodes are applied directly on the skin or on the wound. After going through several research papers we came to know that some of the studies have used continuous direct current while others used high voltage pulsed current to minimize the risk of skin burn and achieve greater current penetration.
Overall, the incidence of adverse effects was very low and showed positive results. Different types of current, including bidirectional currents have been used to promote healing but there is not sufficient summary about their effects nor consensus on best parameters to be used. In most of the studies the therapy was provided in a hospital or at the clinic while in one of the study the patients were provided with electrical stimulation device to use at home. The data was recorded by the number of hours the device was used and these data were downloaded from the device when the patients visited the clinic weekly.
Pulsed current is bidirectional or unidirectional flow of electrons, and has monophasic waveform or biphasic waveform. Monophasic pulsed current is also described as low-voltage and high-voltage. Biphasic pulsed current is bidirectional and it has two waveform symmetric or asymmetric. Low voltage pulsed current devices transfer continuous direct current, lower voltages (20-35V) and biphasic and monophasic waveforms of longer duration. The parameters used are a duration of 132 microseconds and 64 pulses per second. High-voltage pulsed current delivers a monophasic pulsed current in which the pulses are delivered in doubles. It has a high peak voltage (150-500V) and each pulse is of short duration (less than 200 microseconds). High voltage pulsed current is transferred by a device with both positive and negative electrodes placed on the skin or wound site.
A randomized controlled trial was conducted by Peter in which 40 patients were treated for 12 weeks with diabetic foot ulcers. Patients were randomly divided to receive high-voltage pulsed current or sham therapy. Patients were treated every hour for 8 hours each day over the 12 week study. Most patients healed in the electrical stimulation group( 65% compared to the sham group), however the difference was not significant. Patients who used the device at least three times a week were more likely to heal as compared to the patients who received sham therapy and who used the device 0,1 or 2 times a week. Another randomized controlled trial was conducted by Houghton which involved 27 patients with chronic leg ulcers. High voltage pulsed current was delivered at 150V,100 pps and 100 microsecond duration. Patients were treated 3 times a week for 4 weeks and the treatment lasted for 45 minutes. The treatment group wounds were significantly reduced in size. The unidirectional flow of charged particles is known as continuous direct current, which flows for 1 second or longer, and is produced by solar cells, thermo couplings and batteries. Pulsed direct current is a monophasic pulsed waveform that flows from 1ms to 1 second. In order to avoid damaging healthy tissue while treating wound a low intensity direct current (20-100 microamps) is used.
A study by Gault was conducted for 8 weeks using continuous low intensity direct current to treat 76 patients with ischaemic skin ulcers. The negative electrode was directly applied onto the wound for three days in order to debride necrotic tissue. Three times daily for two hours the current ranging from 200-800 microamps was used. Forty-eight of the hundred ulcers were completely healed. One of the recent study used a wireless micro current stimulation device for the treatment of leg and diabetic foot ulcers, this study was conducted on 47 patients. The treatment was applied 2 to 3 times a week for 60 minutes per session combined with standard wound care. The study demonstrated that within 3 months majority of the cases were successful as the wounds were healed completely. Different wounds can Tauqeer Hussain and Mustafa Sajjani, Human Machine Interface 3 be treated at the same times by this device, and the device is contactless and pain free.
Table 1: Pulsed Current Author Type of Wound Type of ES Parameters Outcome Feeder Chronic dermal ulcers Monophasic pulsed vs sham 29.2 V, 29.2 mA, 132 microseconds, polarity reversed every 3 days then daily reversal with 64 pps Reduction in wound size. Wound area reduction ES 66% vs. sham 33% (p < 0.02) Peter  Diabetic foot ulcers High Voltage pulsed vs sham 50V, 100 microseconds Enhanced wound healing when used with standard care Houghton  Chronic leg ulcers High Voltage pulsed vs sham 150V, 100 microseconds,100 Hz Accelerate wound closure. Wound area reduction ES 44% vs sham 16%.
Table 2: Direct Current Author Type of Wound Type of ES Parameters Outcome Gault Ischemic ulcers LIDC vs sham 200-800 microamps LIDC group healed twice as fast as control) Wirsing  Diabetic leg and foot ulcers Wireless LIDC 1.5 Microamps Significantly accelerated healing 4 Discussion After going through several research papers we came across few research papers that were quite related to our topic. These research papers focus only on the electrical methods that have been used for wound healing and how successful these treatments are. The recorded studies indicate reasonable variability in the parameters of Electrical Stimulation application that leads to difficulty in developing sufficient evidence to support any one standard therapeutic approach. Most of the studies stated successful positive outcomes using electrical simulation to accelerate wound healing. The studies in different research papers showed that high voltage pulsed current is most beneficial for pressure ulcer treatment while a limited number of studies showed that high voltage pulsed current has positive results when used in ischemic, diabetic and chronic leg ulcers. However, that does not mean that other types of wounds such as acute wounds or venous ulcers would respond differently to this therapy. Additionally, high voltage pulsed current and direct current stimulation exhibit higher levels of evidence when compared to other electrical stimulation techniques. Pressure ulcers, venous ulcers, vascular ulcers and diabetic foot wounds are mainly been evaluated by electrical stimulation.The variation in outcome measurements, type of electrical stimulation and how the therapy was dosed in the trials leads to difficulty in interpreting these data. Most of the studies were small and had short treatment period therefore many of the studies did not use complete wound healing as the final outcome.
Tauqeer Hussain and Mustafa Sajjani, Human Machine Interface Based on the studies and findings until now it is of note that not all applications and modalities of electrical stimulation have an effect on all phases of wound healing. Electrical stimulation induces the migration of keratinocytes, which adds to the skin’s first line of defense against pathogens, this is a key process in wound healing. In one of the study they showed that after one hour period the physiological electrical field enabled human dermal fibroblasts to begin migrating towards the anode, in a direction opposite to that of keratinocytes, which migrate towards the cathode.
This is also supported by another study, where they identified that applying the anode in the wound could enhance wound healing. Further studies were conducted to determine whether the anodal or cathodal micro amperage direct current electrical stimulation were more appropriate for wound repair. Anodal micro amperage direct current decreases the wound surface area faster, allowing for faster wound healing as compared to cathode micro amperage direct current therefore it concludes that anodal electrical stimulation is more effective than cathodal electrical stimulation. It is necessary to treat the wound as soon as it occurs and to treat with exact frequency. Different wounds are treated differently such as different voltages and currents are used and also the duration of treatment time varies. Unidirectional electrical stimulation is most beneficial for pressure ulcers whereas bidirectional electrical stimulation is beneficial for venous leg ulcers and diabetic foot ulcers. Compliance is a factor that affects wound healing in electrical stimulation studies. In most of the studies, therapy was provided in a hospital or at the clinic, so patients who kept their clinic appointment determined the main measure of compliance.
In one of the study performed the patients were provided with electrical stimulation device to use at home. The data was then recorded by the number of hours the electrical simulation device was used. These data were downloaded from the electrical stimulation device when the patients visited the clinic weekly. A higher proportion of wounds were healed in patients who were co-operative in the electrical stimulation treatment group – 71%, while the result of wound healing in patients who were non cooperative in the electrical stimulation treatment group were 50%. Electrical stimulation can be performed by a single experienced practitioner and there is often no pain associated with the treatments. It is hard to identify which wound types respond better to treatment and the ideal anatomical location, frequency, duration and time to commence the application of ES for each wound type.
Electrical stimulation therapy is considered safe and easy to use, as electrical stimulation decreases bacterial infection, increases local perfusion and accelerates wound healing. No device-related complications or negative effects have been reported till now. Electrical stimulation application is relatively cost effective as compared to other comparative treatments. Majority of the studies showed that electrical stimulation increased wound healing or improvement in wound area reduction, however further trials are needed for better understanding of optimal dosing, timing and type of Electrical stimulation to be used.
 Feedar J.A., Kloth L.C., Gentzkow G.D. Chronic dermal ulcer healing enhanced with monophasic pulsed electrical stimulation. Phys. Ther. 1991;71:639–649. [PubMed]
 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.
 Houghton P.E., Kincaid C.B., Lovell M., Campbell K.E., Keast D.H., Woodbury M.G., Harris K.A. Effect of electrical stimulation on chronic leg ulcer size and appearance. Phys. Ther. 2003;83:17–28.[PubMed] 457–472.
 Gault W.R., Gatens P.F., Jr. Use of low intensity direct current in management of ischemic skin ulcers. Phys. Ther. 1976;56:265–269. [PubMed]
 Wirsing P.G., Habrom A.D., Zehnder T.M., Friedli S., Blatti M. Wireless micro current stimulation—An innovative electrical stimulation method for the treatment of patients with leg and diabetic foot ulcers. Int. Wound J. 2013[PubMed] [Cross Ref ]
 Sara Ud-Din, Ardeshir Bayat, Electrical Stimulation and Cutaneous Wound Healing Healthcare 2014, 2(4), 445-467;
 Gaurav Thakral, Javier LaFontaine, Bijan Najafi, Talal K. Talal, , Paul Kim, and Lawrence A. Lavery, Electrical stimulation to accelerate wound healing. 2013 Sep 16.
 Alicia Martínez-Rodrí,Olalla bello,Manuel Fraiz,Sandra Martinez-Bustelo. The effect of alternating and biphasic currents on humans’ wound healing.
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