Journal of Community Nursing

January 2007

volume 21 issue 1









Journal of Community Nursing

the definitive peer-reviewed journal

promoting excellence in primary care practice

and nurse prescribing









Product Review



Electric stimulation for treatment of chronic wounds

by Keith Moore

W OUND M ANAGEMENT /P RODUCT R EVIEW





Electric stimulation for

treatment of chronic wounds

Electric stimulation (E-Stim) he diversity of management treatment of chronic wounds. This

to initiate healing of

recalcitrant wounds has been

T options available for chronic

wounds (Schultz et al., 2005) gives

some insight into the complexity of the

review will explore the evidence

describing how electric stimulation (E-

stim) of chronic wounds induces healing

defects that have to be reversed in order and the data available to support the use

discussed in the literature for for healing to be initiated and wound of POSiFECT®RD for treatment of chronic

many years and many closure achieved. Non-viable tissue wounds.

requires debridement, appropriate treat-

publications indicate its

ment needed to lower bacterial numbers What is the current of injury?

efficacy. This review by Keith to levels that will not retard healing, Possibly the most well known generation

Moore considers the clinical moisture balance has to be achieved to of electric currents by cells is in the

encourage moist wound healing and neuron where thermal, mechanical or

and laboratory evidence stimulation of epithelial migration. Even chemical stimuli trigger electrical signals

underpinning the use of when underlying factors, such as that can result in a sensation of pain.

diabetes, vascular insufficiency, or pres- However, all cells within the body

E-Stim for treatment of sure to the wound site, that contribute to generate ionic currents across their

chronic wounds. non-healing have been managed, it is membranes and this is where the current

often found that multiple wound treat- of injury originates.

ment interventions may be required. This Cell membranes possess a membrane

suggests that no single treatment potential which is the electrical potential

addresses the central cause of non- difference or voltage across the

Key words: healing in the chronic wound membrane. Cells within intact skin are

Chronic wound environment. negatively charged on the inside whereas

Current of injury Over the last decade our knowledge of the exterior of the cell, the extracellular

Electric stimulation (E-Stim) normal and chronic wound physiology space, is positively charged. The differ-

Galvanotaxis has grown so that a number of biologi- ence in charge arises because cell

Infection cally active treatments have been membranes possess ‘pumps’ that move

Treatment

developed for targets in the chronic sodium ions out of the cell in exchange

wound. In addition to a deluge of anti- for potassium ions which are pumped

bacterial dressings (Graham, 2005) there into the cell. For the skin this results in the

are growth factors (Robson et al., 2001), epidermis being negatively charged rela-

tissue engineered dermal replacements tive to the deeper tissues that carry a

(Marston et al., 2003) bioactive wound positive charge (Kloth & McCulloch,

dressings (Cullen, et al., 2002) and 1996). The transcutaneous potential of

specific agents such as protease intact skin can be measured at 40-80mV

inhibitors (Fray, 2003). These interven- but as soon as a full thickness incision is

tions tend to be specifically targeted and made this disappears so that a voltage

multiple interventions are often gradient forms between the wound and

required. Whilst these may be useful in surrounding intact skin (Jaffe & Vanable,

stimulating healing of some recalcitrant 1984). A micro-current will then flow

wounds there are obvious advantages to from the area of higher potential, the

alternative interventions that would intact skin, into the wound so that a

have wider applicability by treating core current of injury is generated (Figure 1).

defects that inhibit healing. The voltage peaks immediately after

Treatment modalities that reverse core injury and gradually decreases as the

defects are less well established although wound heals (McGinnis & Vanable, 1986)

knowledge of at least one potentially leading to the concept that current flows

modifiable central regulatory process has may be defective in chronic wounds and

been known for many years. This is the that applying electrical currents to

current of injury which has been well wounds may stimulate healing (Kloth,

documented in experimental studies 1995).

(Borgens et al., 1977) and clinical practice It is well established that wounds heal

(Ojingwa & Isseroff, 2003). The concept optimally under a moist environment

of a current of injury has underpinned (Winter, 1962) and it has been suggested

Keith Moore PhD, BSc is a Freelance

the development of a device, the (Cutting, 2006) that, at least in part, this

Scientist at WoundSci.

POSiFECT®RD bio-electric wound care may be a consequence of allowing an

Article accepted for publication: December 2006 dressing, which is currently available for optimum wound current flow. If wounds



Journal of Community Nursing January 2007, volume 21, issue 1

W OUND M ANAGEMENT



Epidermis E-stim with POSiFECT®RD

After injury The POSiFECT®RD bio-electric wound

current flows dressing (Biofisica, Hampshire, UK) has

(arrows) from recently been launched in the UK for the

negative skin to treatment of chronic wounds. This device

positive dermis. incorporates an E-stim system into a

single use wound dressing. The dressing

Dermis has a circular anode that contacts the

Fibroblasts and peri-wound skin and a central cathode

other cells that is placed in contact with the wound

generate a bed.A DC microcurrent generated by an

positive integral miniature circuit and battery

extracullular

charge. passes between the electrodes to replicate

the natural current of injury and stimu-

Figure 1: The current of injury. late healing.

Four pilot studies have demonstrated

are allowed to dry the wound current identify possible mechanisms of healing that POSiFECT®RD treatment exerted a

decreases, whereas there is a current stimulation. positive effect on healing of pressure

flow in moist wounds (Jaffe & Vanable, ulcers and venous leg ulcers. One of these

1984). Clinical evidence for efficacy (Feldman et al., 2005) indicated that pres-

Pressure ulcers: Pulsed low voltage DC sure ulcer healing was initiated during

Delivery of E-Stim to the wound treatment of stage II and III pressure weeks 1-3 of E-stim treatment and this

At its most basic E-stim of a wound ulcers evaluated in a double blind multi- observation has led to a treatment

requires applied current to be passed centre study resulted in 25 of 43 ulcers protocol where cycles of three weeks

from the periphery of a wound to the healing in the active treatment group active treatment are separated by one

wound bed in the same way that the within eight weeks compared to one in week of standard treatment.

current of injury flows as shown in the placebo group where the majority of Three further case studies have

Figure 1. The most common way of ulcers increased in size (Wood et al., reported using this treatment regime.

achieving this is to place one electrode in 1993). Higher pulsed voltages of 100- One (Hampton & Collins, 2006) docu-

contact with the peri-wound skin and 175v for 45 minutes/day, five days a ments the successful treatment of a large,

one contacting the wound bed. Both week appeared equal or greater in effec- necrotic, intractable grade III heel pres-

electrodes are connected to a battery tiveness in a smaller study (Kloth, & sure ulcer which measured 4.5 × 6cm.

driven power source with control Feedar, 1988). All the ulcers in the treat- After seven days POSiFECT®RD treat-

circuitry that applies the desired stimu- ment group of nine patients healed with a ment much of the fibrous slough had

lating electrical current. The E-stim mean time to healing of 7.3 weeks and a debrided and the ulcer reduced in size to

applied can either be of a high or low mean healing rate of 44.8 per cent. In 3 × 4cm. Only a small quantity of slough

voltage and is usually delivered as one contrast the sham treated placebo group remained by week four, size reduction

of three types of current: of seven patient’s ulcers increased in size continued and the wound margin was

by 29 per cent. surrounded by healthy epithelial tissue.

Direct Current (DC): The electric current

Healing continued so that by week seven

flows in one direction only from positive

Leg Ulcers: Low voltage DC E-stim is also the ulcer measured 1.5 × 1.5cm and was

to negative electrode. This type of current

effective in accelerating healing of leg completely closed by 13 weeks after initi-

is usually intended to mimic naturally

ulcers where a 2.5 times faster healing ation of E-stim.

occurring wound currents and is of low

rate was observed compared to standard The remaining studies suggest that E-

intensity.

wet-to-dry dressings and whirlpool stim with POSiFECT®RD may stimulate

Alternating Current (AC): The flow of therapy (Carley & Wainapel, 1985). The healing, at least in part, by exerting an

current is rapidly reversed many times E-stim treated ulcers also required less anti-bacterial effect. Treatment of a

per second. debridement, no infections occurred and painful ulcer with a green malodorous

the patients reported less pain at the discharge indicating colonisation with

Pulsed: Pulsed E-stim may be either DC or

wound site. As with pressure ulcers, leg .P aeruginosa eliminated evidence of

AC but is delivered in pulses so that there

ulcers will also respond to higher voltage Pseudomonas infection after four weeks

is an off cycle where no electricity is

pulsed currents. In a double blind with an accompanying decrease in rate of

delivered to the wound between pulses.

prospective study of 27 subjects 42 ulcers exudation (Hampton & King, 2005). By

Pulses may be in micro or milliseconds.

of venous, arterial or diabetic origin week eight, after another cycle of ‘three

With so many variables in terms of (Houghton et al., 2003) were randomised weeks on/one week off’ the wound was

delivery there are obviously a number of to two groups that received E-stim or granulating with islands of epithelial

different approaches possible for elec- sham treatment for 45 minutes three tissue and POSiFECT™RD was discon-

trical stimulation of chronic wounds. times a week for four weeks. The investi- tinued. By week 18 the ulcer was healed.

This makes it difficult to compare indi- gators concluded that ‘E-stim should be Another non-healing venous leg ulcer of

vidual studies. There is, however, a large used to accelerate healing for chronic vascular two years duration in which bacterial

body of clinical evidence (Ojingwa, 2003) ulcers’ as ulcers in the active treatment biofilm was judged to be delaying

to indicate that healing is improved by E- group reduced in area by approximately healing was also induced to initiate

stim regardless of the type of current 50 per cent over the four week treatment healing (White et al., 2006). The patient

applied and experimental evidence to period. could not tolerate compression therapy



Journal of Community Nursing January 2007, volume 21, issue 1

W OUND M ANAGEMENT



but after six days of treatment with The presence of bacteria in chronic (Goldman et al., 2004) possibly by stimu-

POSiFECT®RD the wound had reduced wound tissue often acts as a major factor lating angiogenic responses after

in size and slough reduced by 50 per cent. in delaying healing (Bowler, et al., 2001) interacting with endothelial cell growth

After a further 17 days the wound exhib- and stimulating chronic inflammation in factor receptors (Zhao et al., 2004).

ited 100 per cent granulation tissue. wound tissue. E-stim has been shown to Once a healthy and functional wound

A prospective, descriptive, evaluative, inhibit bacterial growth in vitro (Kincaid bed has formed keratinocytes have to

non-blinded clinical trial with a sample & Lavoie, 1989) and on intact human skin migrate over it to close the wound and

size of 18 patients with 21 recalcitrant (Bolton et al., 1980). Anti-bacterial effects form new epidermis. In the same way

wounds (nine pressure ulcers, 11 venous have been demonstrated in P. aeruginosa that macrophages will migrate towards

leg ulcers, one traumatic wound) has infected experimental incisional wounds the cathode in electrotherapy systems

recently been completed (Hampton et al., (Rowley et al., 1974) and similarly bacte- keratinocyte migration is also enhanced

2005; Biofisica UK Ltd, 2006, Data on file). rial proliferation within human pressure and directed in the same way. The effect

All the wounds were previously non- ulcers has been demonstrated to be inhib- of enhanced directional migration in an

healing for greater than six months. The ited after three days of E-stim treatment electrical field is called galvanotaxis or

wounds were treated with two cycles of (Wheeler et al., 1971). However, bacteria electrotaxis and plays an important role

three weeks with POSiFECT®RD bio- can grow as free organisms or as a biofilm in the healing process (Nishimura et al.,

electric therapy followed by one week of on the wound surface. Biofilms are 1996). A recent study (Zhao et al., 2006)

standard care. Patient’s wounds were formed by bacteria producing a carbohy- has elegantly characterised the intra-

assessed at eight weeks and again at 16 drate film (glycocalyx) that protects them cellular events that occur as cells

weeks. The total mean surface area of the from antimicrobial therapy. Bacteria are migrate within an electrical field. It

wounds was 18cm2 at commencement of released from the biofilm to produce demonstrated that exposure to an elec-

the study and 10.3 cm2 at the end of eight localised infections and wound break- tric field induced signals to be passed

weeks. This was an average healing of down (Sibbald, 2003). E-stim is known to across the cell membrane on the side of

7.65 cm2 wound area decrease demon- disrupt biofilms (Costerton et al., 1994) the cell that migrated towards the

strated in previously non-healing and the recent successful treatment of a anode. The same signals are generated

wounds over an eight week period. At 16 leg ulcer where healing was delayed by by migrating keratinocytes during

weeks, six wounds had healed com- biofilm suggests that this E-stim delivery wound healing. The importance of elec-

pletely, and a further six were almost by POSiFECT®RD acts to disrupt bacte- tric currents during healing was

healed. All the other wounds showed rial biofilms. demonstrated by the fact that healing

some improvement – even in patients Decreasing the number of bacteria could be inhibited by reversing the elec-

who discontinued/dropped out part within chronic wound tissue will assist in tric field.

way through the programme. The conversion of chronic inflammation to a The chronic wound exhibits many

authors concluded that the results of this resolving inflammatory response. This is cellular defects and the fact that E-stim

study were significant and demon- considered one of the key events in initi- may address many of these simultane-

strated the clinical effectiveness of ating healing of chronic wounds (Moore, ously goes some way to explaining how

POSiFECT®RD and its potential for 1999). The population of macrophages the positive clinical effects demonstrated

initiating wound healing. Also noted involved in chronic inflammation have to by POSiFECT®RD may be generated.

was that POSiFECT®RD did not cause be replaced with fresh monocytes

any pain or discomfort in any wounds. recruited from the blood and E-stim may Conclusion

The observation was made that treat- play a role here by accelerating their There is a long history of using E-stim to

ment possibly decreased pain in painful migration towards the anode placed in treat chronic wounds and many labora-

wounds although this requires further the wound bed (Orida & Feldman, 1982; tory investigations that provide a

investigation. At one year follow up Cho et al., 2000). rationale for its use. This large body of

10 wounds had healed, and none of Formation of healthy granulation published data allows one to draw the

the previously healed wounds had tissue depends on the proliferation of conclusion that E-stim is of benefit as an

recurred. fibroblasts and their ability to synthesise aid to healing chronic wounds. Despite

a functioning extracellular matrix. This is this the E-stim treatment modality is not

How E-stim aids healing an energy consuming process and widely understood. This may be because

The interaction of E-stim with the chronic requires angiogenesis to produce new the majority of publications report on the

wound to initiate the healing effects blood vessels to supply oxygen and use of experimental systems each using a

described earlier has recently been nutrients. There is considerable experi- delivery system favoured by the authors.

reviewedindetail(Cutting,2006)andonly mental evidence that E-stim interacts in The consequence is that each report is

key aspects will be described here. Many all aspects of granulation tissue unique and the reader cannot easily draw

functional cellular defects are known to synthesis. It increases fibroblast protein on the evidence to allow selection of a

be associated with the non-healing state synthesis and proliferation (Bourguig- readily available treatment option and

of chronic wounds such as bacterial bio- non & Bourguignon, 1987), increases evaluate it for themselves. Obviously this

burden, chronic inflammation, defective collagen production (Canseven & Atalay, will act as a barrier to adoption of the

granulation tissue and defective re- 1996) and improves collagen fibre organ- technology and further investigations of

epithelialisation that causes a slowing or isation (Brown et al., 1987) to give efficacy. In addition the technology for

cessation of healing (Moore, 2004). E-stim increased healed wound strength delivering E-stim has not been readily

has been demonstrated in experimental (Taskan et al., 1997). available or usable outside a research

systems to regulate cell functions that are Angiogenesis can be enhanced by setting.

potentially important to reverse these E-stim improving dermal capillary The recent introduction of the POSi-

defects and stimulate healing. formation in human ischaemic wounds FECT®RD bio-electric wound care



Journal of Community Nursing January 2007, volume 21, issue 1

W OUND M ANAGEMENT



dressing should change this situation. It Fray M.J., Dickinson R.P., Huggins J.P., Ojingwa, J.C., Isseroff R.R. (2003) ‘Electrical

provides an E-stim system in a single use A

Occleston N.L. (2003) ‘ Potent, Selective stimulation of wound healing’. J Invest

Inhibitor of Matrix Metalloproteinase-3 for Dermatol, 121: 1-12.

dressing that is applied directly to the

the Topical Treatment of Chronic Dermal

wound and may be used alone for pres- Ulcers’. J Med Chem, 46: 3514-25. Orida N., Feldman J.D. (1982) ‘Directional

sure ulcers or in conjunction with protrusive pseudopodial activity and

Gardner S.E., Frantz R.A., Schmidt F.L.

compression bandaging for treatment of motility in macrophages induced by

(1999) ‘Effect of electrical stimulation on

venous leg ulcers. The published POSi- extracellular electric fields’. Cell Motil, 2:

chronic wound healing: a meta-analysis’.

243-55.

FECT®RD clinical studies demonstrate Wound Repair Regen, 7: 495-503.

that it has proven efficacious in treating Goldman R., Rosen M., Brewley B., Golden Robson M.C., Phillips T.J., Falanga V.,

recalcitrant ulcers. In at least two case M. (2004) ‘Electrotherapy promotes Odenheimer D.J., Parish L.C., Jensen J.L.,

studies (Hampton & King, 2005; White healing and microcirculation of infra- Steed D.L. (2001) ‘Randomized trial of

popliteal ischemic wounds: a prospective topically applied repifermin (recombinant

et al., 2006) a clear anti-bacterial effect pilot study’. Adv Skin Wound Care, 17: 284- human keratinocyte growth factor-2) to

was observed prior to initiation of 94. accelerate wound healing in venous ulcers’.

healing. This indicates one valuable facet Wound Repair Regen, 9: 347-52.

Graham C. (2005) ‘The role of silver in

of POSiFECT®RD in healing chronic wound healing’. Br J Nurs, 14: S22, S24, S26 Rowley B.A., McKenna J.M. (1974) ‘The

wounds. Definition of a precise mode(s) passim. influence of electrical current on an

of action awaits further studies. Hampton S., King L. (2005) ‘Healing an infecting microrganism in wounds’. Ann N

intractable wound using bio-electric Y Acad Sci, 238: 543-51.

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Journal of Community Nursing January 2007, volume 21, issue 1

BIOFiSICA is introducing a unique

therapeutic modality that harnesses

the natural current of healing.1



Latest findings2,3 show that

POSiFECT® RD bio-electric wound

care dressing can heal non-healing

Grade 4 necrotic heel 14.3.05 Same heel with wound healed 16.6.05

wounds. non-healing for 18 months







POSiFECT® RD is an easy to use,

disposable dressing that is being

launched in Europe during 2006.









Leg ulcer of 12 months duration 25.2.05 The same ulcer healed 16.6.05









Biofisica UK Ltd

Old Bank House

59 High Street POSiFECT® RD

Odiham bio-electric wound

Hampshire RG29 1LF care dressing

U.K.

T +44 (0)1256 704555

F +44 (0)1256 704717



E info@biofisica.com

w w w.biofisica.com

®



References:

1. K.F. Cutting - Electric stimulation in the treatment of chronic wounds. Wounds UK,

February 2006 Vol 1 No3.

2. S. Hampton, A. Kerr and L. King - Bio-Electric stimulation of chronic wounds: POSiFECT“ RD

Bio-Electric wound care dressing. Wounds UK, Harrogate, 2005

3. S. Hampton and L. King - Healing an intractable wound using bio-electric stimulation therapy

British Journal of Nursing, (Tissue Viability Supplement), Vol 14 no15, pp s30-32, 2005

20060626/A