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High Volt Pulsed Current HVPC

Clinical Application. Use: Is the goal stimulation of the peripheral nerve OR some other tissue?For NMES PN stim is the goal; best for mild to moderate contractions and areas not covered with excess adipose.For TENS - PN stim is the goal; portable HVPC devices do exist*Wound healing - chronic,

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High Volt Pulsed Current HVPC

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    1. High Volt Pulsed Current (HVPC) Almost 60 yrs old, popular last 25 years with numerous uses. Review of the waveform: Twin-peak monophasic pulse phase duration: 25?s, sometimes adjustable comfortable but weak current; polarity present but electrochemical (net DC) effect not harmful. Typical stimulation time does not exceed 1 hour.

    2. Clinical Application Use: Is the goal stimulation of the peripheral nerve OR some other tissue? For NMES – PN stim is the goal; best for mild to moderate contractions and areas not covered with excess adipose. For TENS - PN stim is the goal; portable HVPC devices do exist *Wound healing - chronic, slow healing wounds Acute edema formation – based in animal research Iontophoresis - cutting edge; not widely supported PN stim is NOT the goal on the last 3, but it still happens

    3. Factors in using HVPC for NMES or TENS: Amplitude (based on desired excitatory response) Pulse Rate (related to pain control theory or motor response needed) Mode - Continuous, Ramp-Surge, Alternate Placement of Electrodes: nothing new

    4. Wound Healing: E-stim for Tissue Repair (ESTR) Robert Becker – 1962 Theory - “Current of Injury” normal bioelectric system, nonexcitable tissues have a charge skin ----- deeper tissues +++++ neuraxis ++++++ periphery ------- Wounds - system is disturbed & creates a “current of injury” that initiates tissue healing . . . inflammatory process, migration of cells, etc.. Use of E-stim magnifies the “current of injury” to initiate, maintain, or speed the process.

    5. “Current of Injury” cont... Further research established Wound tissue is (+) & skin around is (-); this difference is the “skin battery” or “current of injury” and must exist for proper healing; if it fails or is disrupted, then slow/no healing can occur. E -stim can help restore the “skin battery”. Further supported by evidence that many chronic wounds lost (+) polarity; e-stim w/ the anode (+) over the wound enhanced healing. (using DC) If healing plateaued, switching polarity = good outcome Kloth & Feedar, Phys Ther, April 88

    6. Phys Ther 1988 method for e-stim of wounds Monophasic twin-pulse current (HVPC) 105 pps Amplitude: submotor Time - 45 min, 5 days a week Wound packed with soaked gauze and anode (+) placed over wound Cathode placed 15 cm away, proximal Rationale: Done to amplify the “current of injury”

    7. Contemporary Theory: Galvanotaxis A naturally occurring process whereby signaling/messenger systems work via bioelectrical mechanisms. (Does not contradict the chemical model of human physiology; “chemotaxis”).

    8. Contemporary Theory: Galvanotaxis Process can be corrected and/or enhanced by attraction of cells to the wound thru use of anode (+) or cathode (-) Leukocytes, fibroblasts, endothelial & epithelial cells, etc.. all have polarity and can be electrically attracted. Treatment polarity depends on stage of the wound READ THE ARTICLE: Kloth & McCulloch (1996)

    9. Kloth Advances in Wound Care 1996 method Monophasic twin-pulse current (HVPC) 100 pps, no mention of pulse width Amplitude - just below motor Time - 60 min, 5 days a week Wound packed with soaked gauze Polarity - based on wound state Other electrode placed 15 - 20 cm away (proximal) to complete the circuit Done to amplify the “injury potential” or “current of injury” and produce “galvanotaxic attraction”

    10. Electrode Placement Options Directly over the wound Directly in the wound * Straddle the wound More information FYI: http://medicaledu.com/estim.htm

    11. Some Hx of ESTR Why not use LIDC ??: Studies have shown it to be effective Much longer Rx time and greater frequency of Rx electrochemical changes more pronounced & potentially harmful (due to pH changes in tissue) HVPC has a shorter Rx time and less frequent, no harmful electrochemical changes in the tissue Mechanisms by which biphasic or AC may enhance healing are not well-understood.

    12. ESTR Treatment Tid-bits ESTR usually not used on well-healing wounds, more for chronic wounds DOES NOT replace typical wound care Suggest physician cooperation/agreement Patient tolerance or refusal a potential issue based on the way you describe it. Suggest continuing education to become more competent.

    13. Contraindications Osteomyelitis Malignancies / neoplasms Carotid sinus / laryngeal ms. Thru the thorax Demand-type pacemakers Over topical agents containing metal ions (iodine, mercurochrome) Others as previously learned; except for open tissue

    15. Reimbursement Issues Centers for Medicare & Medicaid Services (CMS) Electrical stimulation for the treatment of wounds will only be covered for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers. All other uses of electrical stimulation for the treatment of wounds are non-covered. Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence. Electrical stimulation will not be covered as an initial treatment modality.

    16. Reimbursement Issues . . . Electrical stimulation will be covered only after appropriate standard wound therapy has been tried for at least 30-days and there are no measurable signs of healing. This 30-day period can begin while the wound is acute. Measurable signs of improved healing include a decrease in wound size, either surface area or volume, decrease in amount of exudates and decrease in amount of necrotic tissue. Standard wound care includes: optimization of nutritional status; debridement by any means to remove devitalized tissue; maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; and necessary treatment to resolve any infection that may be present.

    17. Reimbursement Issues . . . Continued treatment with electrical stimulation is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Electrical stimulation must be discontinued when the wound demonstrates 100 per-cent epithelialzed wound bed. This service can only be covered when performed by a physician, physical therapist, or incident to a physician service.

    18. HVPC for Acute Edema control Based on the results from animal studies, HVPC may have an effect upon acute edema FORMATION but the effect is short-lived (several hours); therefore, treatment is recommended for 30 minutes every 4 hours for the period of time that bleeding/swelling is expected to occur. This treatment duration and frequency fits well with the RICE protocol but may often be too frequent for an individual needing/trying to function (work or school). A portable HVPC unit is essential (and available)

    19. This treatment is indicated for acute trauma (sprain, strain, contusion) or post-surgery. The situation must be an ACUTE TRAUMATIC CONDITION where bleeding, swelling & inflammation are actively developing. The underlying physiological effect is largely unknown but studies often point toward an effect upon capillary permeability - related to histamine release.

    20. ELECTROTHERAPY TREATMENT OF SWELLING I EDEMA

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