At WoundCon Fall, Jeanine Maguire, PhD, MPT, CWS introduced the use of electrical stimulation (e-stim) as a modality in wound healing. She discussed key terminology, current parameters for use in the United States, and important considerations for all clinicians.

Dr. Maguire began by pointing out that e-stim is best known as a modality in physical therapy to promote physiologic tissue healing in musculoskeletal injury. She said she approaches e-stim in wound management with a similar mindset. Many national and international organizations support electrical stimulation for wounds. Specifically, the Centers for Medicare and Medicaid Services cites its appropriateness for select types of wounds that have not responded to standard wound care over at least 30 days.¹

Dr. Maguire stressed that before choosing electrical stimulation, it is important to assure proper evaluation of the wound etiology and the reasons for nonhealing. She said this may include:

• Addressing nutritional status
• Appropriate moist dressings
• Treatment for infection
• Debridement

Exploration of the role of chronic disease and relevant social determinants of health is also wise, she noted.

E-Stim Basics

When used in wound management, Dr. Maguire shared that e-stim allows an electric current to pass through the wound. This current promotes angiogenesis, collagen production, and migration of epithelium.² It is applied via electrodes placed on the skin in close proximity to the wound. She related that this is usually just around the wound, allowing one to not disturb the dressing. There are multiple settings to consider, so she encouraged clinicians to consult with unit manufacturers to understand the nuances of each specific device.

Dr. Maguire then presented the concept of looking at the skin as a battery. Accordingly, when there is a break in the skin, this represents a “short circuiting” of the transepithelial voltage, causing a voltage difference between that wound and the surrounding skin.³ Electrical stimulation attempts to restore that break in current.

What Does the Evidence Reveal?

Research over the past several decades has shown multiple positive outcomes related to the use of e-stim in wounds, and Dr. Maguire presented several of these.

Antibacterial Impact. Multiple in vitro studies found that e-stim had an antibacterial effect, especially when using positive polarity, high-voltage pulsed current (HVPC), and silver anodes.^4-7

Improving Healing. A 2021 review of 30 randomized controlled trials (RCTs) on e-stim in wound care found acceleration of wound healing with potential for increased epithelialization, increased local vascularity, reduced pain, increased fibroblast migration, and less financial burden.³ Several other studies noted improvement in healing for venous wounds and pressure injuries.^8-10

Perfusion. Evaluation of 2 series of cases involving limb ischemia found improvements in the transcutaneous oxygen pressure (TcPO2) of the associated wounds with e-stim as part of treatment.¹¹

Phases of Wound Healing. Three RCTs of human punch biopsies using direct current electrical stimulation looked at the proliferative phase of healing and found increases in growth factors, angiogenesis, and granulation tissue while resulting in decreased wound size.¹² Additionally, case studies examining the remodeling phase found increased fibroblastic activity in wounds with electrical stimulation.¹³

Pain Management. A series of cases involving several wound etiologies found that 12 days using wearable microcurrent electrical stimulation resulted in 100% pain reduction over the treatment period, improving as the treatment period progressed.¹⁴

Impairment of the Skin “Battery”. The research also shows that age and diabetes are factors that impair the current of skin injury. E-stim therapy has the potential to initiate a “kick-start” of that battery.^15-17

Important Considerations and Precautions

Dr. Maguire shared that clinicians should be aware of the potential contraindications and precautions associated with electrical stimulation of wounds. Among these are:

• Malignancy
• Electronic implants that may impact or prohibit electrode placement
• Dressings with metal ions
• Untreated osteomyelitis
• Immature bone
• Pregnancy
• Epilepsy

Risks of electrical stimulation are low, with possible skin irritation being a consideration. However, she stressed the importance of reviewing potential contraindications for each patient use.

From a practice management perspective, Dr. Maguire noted that it is vital to be aware of your local practice act and any other relevant state or federal laws that could influence the ability to use e-stim. It is also important to investigate the reimbursement structure in your area and through your payors. It is important to note that TENS/microcurrent (transcutaneous electrical nerve stimulation) is different from e-stim as discussed in this presentation, and it may not be reimbursable for wounds.

Concluding Thoughts

Dr. Maguire conveyed that she hopes clinicians will remember the potential positive benefits in wound healing and pain management provided by e-stim. The relatively low risk, ease of use, and low cost make it an appealing option for the right patients. She noted that additional research could provide clearer treatment parameters and standardization of its use in wound management.

Overall, she advised addressing the cause of the wound, the cause of the non-healing, and to implement standard wound care before utilizing e-stim. Clinicians should assess if e-stim is possible for the patient, if one is competent and comfortable with its use, and any risks to the patient. Finally, she noted that wound care providers can look at e-stim as a possible “jump-start” adjunctive treatment for chronic, full-thickness wounds not progressing towards healing.

References

1. Centers for Medicaid and Medicare Services. Electrical stimulation for the treatment of wounds. Https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=131&ncdver=2… . Updated July 1, 2004. Accessed October 13, 2023.
2. Kloth LC. Electrical stimulation technologies for wound healing. Adv Wound Care (New Rochelle). 2014;3(2):81-90.
3. Rajendran SB, Challen K, Wright KL, Hardy JG. Electrical stimulation to enhance wound healing. J Funct Biomater. 2021;12(2):40.
4. Kincaid CB, Lavoie KH. Inhibition of bacterial growth in vitro following stimulation with high voltage, monophasic, pulsed current. Phys Ther. 1989;69(8):651–655.
5. Gomes RC, Brandino HE, de Sousa NT, Santos MF, Martinez R, Guirro RR. Polarized currents inhibit in vitro growth of bacteria colonizing cutaneous ulcers. Wound Repair Regen. 2015;23(3):403-411.
6. Daeschlein G, Assadian O, Kloth LC, Meinl C, Ney F, Kramer A. Antibacterial activity of positive and negative polarity low-voltage pulsed current (LVPC) on six typical Gram-positive and Gram-negative bacterial pathogens of chronic wounds. Wound Repair Regen. 2007;15(3):399-403.
7. Barranco SD, Spadaro JA, Berger TJ, Becker RO. In vitro effect of weak direct current on Staphylococcus aureus. Clin Orthop Relat Res. 1974;(100):250-255. PMID: 4838406.Falcone AE et al. Plast Reconstr Surf. 1986;77:455-459
8. Borges D, Pires R, Ferreira J, Dias-Neto M. The effect of wound electrical stimulation in venous leg ulcer healing – a systematic review. J Vasc Surg Venous Lymph Disorders. 2023;11(5):1070-1079.
9. Arora M, Harvey LA, Glinsky JV, et al. Electrical stimulation for treating pressure ulcers. Cochrane Database Syst Rev. 2020;1:CD012196.
10. Chen L, Ruan Y, Ma Y, Ge L, Han L. Effectiveness and safety of electrical stimulation for treating pressure ulcers: A systematic review and meta-analysis. Int J Nurs Pract. 2023;29(2):e13041.
11. Goldman RJ, Brewley BI, Golden MA. Electrotherapy reoxygenates inframalleolar ischemic wounds on diabetic patients: a case series. Adv Skin Wound Care. 2002;15(3):112-20.
12. Sebastian A, Syed F, Perry D, et al. Acceleration of cutaneous healing by electrical stimulation: degenerate electrical waveform down-regulates inflammation, up-regulates angiogenesis and advances remodeling in temporal punch biopsies in a human volunteer study. Wound Repair Regen. 2011;19(6):693-708.
13. Ud-Din S, Sebastian A, Giddings P, et al. Angiogenesis is induced and wound size is reduced by electrical stimulation in an acute wound healing model in human skin. PLoS One. 2015;10(4):e0124502.
14. Kurz P, Danner G, Lembelembe JP, Nair HKR, Martin R. Activation of healing and reduction of pain by single-use automated microcurrent electrical stimulation therapy in patients with hard-to-heal wounds. Int Wound J. 2023;20(6):2053-2061.
15. Nuccitelli R, Nuccitelli P, Li C, Narsing S, Pariser DM, Lui K. The electric field near human skin wounds declines with age and provides a noninvasive indicator of wound healing. Wound Repair Regen. 2011;19(5):645-55.
16. Tyler S. Nature's electric potential: A systematic review of the role of bioelectricity in wound healing and regenerative processes in animals, humans, and plants. Front Physiol 2017;8:627
17. Harding K, Gray D, Timmons J, Hurd T. Evolution or revolution? Adapting to complexity in wound management. Int Wound J. 2007;4 Suppl 2(Suppl 2):1-12.