Lucinda L. Baker

Effects of electrical stimulation on wound healing in patients with diabetic ulcers.

OBJECTIVE To evaluate the effects of two stimulation waveforms on healing rates in patients with diabetes and open ulcers. The hypothesis was that stimulus waveforms with minimal polar characteristics would provide significant healing for this patient sample. RESEARCH DESIGN AND METHODS This was a prospective study that enrolled 80 patients with open ulcers. Patients received stimulation with either an asymmetric biphasic (A) or symmetric biphasic (B) square-wave pulse. Amplitudes were set to activate intact peripheral nerves in the skin. Two other groups received either very low levels of stimulation current (MC), or no electrical stimulation (C). When combined these groups were referred to as the control group. Treatment was carried out daily until the wound healed, the patient withdrew from the study, or the physician changed the overall wound management program. Average healing rates were calculated from weekly measures of the wound perimeter and were used for statistical comparison through a one-way analysis of variance. RESULTS Stimulation with the A protocol significantly increased the healing rate, enhancing healing by nearly 60% over the control rate of healing. Stimulation with the B protocol did not increase the healing rate when compared with control subjects. CONCLUSIONS Electrical stimulation, given daily with a short pulsed, asymmetric biphasic waveform, was effective for enhancement of healing rates for patients with diabetes and open ulcers.

Effects of waveform parameters on comfort during transcutaneous neuromuscular electrical stimulation.

Twenty-three females between the ages of 19 and 35 were studied in order to compare the effects of variations in pulse duration, waveform symmetry, and source regulation on comfort during quadriceps surface stimulation at amplitudes necessary to produce 27 Nm torque. Stimulation parameters compared were: 1) 50 and 300 μs pulse durations, 2) asymmetrical and symmetrical biphasic waveforms, and 3) current and voltage source regulation. Subjects overwhelmingly preferred the 300 μs pulse duration regardless of waveform or source regulation, strongly preferred the symmetrical biphasic waveform, and had inconsistent preference for either regulated voltage or regulated current sources.

Effect of electrical stimulation waveform on healing of ulcers in human beings with spinal cord injury

Various electrical stimulation waveforms have been used to enhance wound healing, with little consideration for potential differences in their physiologic effect. The present study evaluated the effect of stimulation waveform and electrode placement on wound healing. Eighty patients with spinal cord injury and one or more pressure ulcers were treated. A total of 185 ulcers received 45 minutes of stimulation daily. Each ulcer was subjected to one of four treatment protocols: asymmetric biphasic waveform, symmetric biphasic waveform, microcurrent stim‐ulation, or a sham control protocol. Electrodes were placed outside the wounds, over intact skin and surrounding the area of the ulcer. Data were categorized by ulcers which healed during the protocol and those which did not. Analysis of the “good response” ulcers (n = 104) showed significantly better healing rates for those receiving stimulation with the asymmetric biphasic waveform, compared with the control and microcurrent groups. Mean healing rates from the present study were similar to previously reported measures. The waveforms studied possessed minimal polar capabilities, and the electrodes were placed outside the wound. These data show that electrical stimulation clearly enhanced healing of pressure ulcers in a significant number of individuals with spinal cord injury; the physiologic implications of these findings relative to the mechanism(s) by which electrical stimulation enhances wound healing are discussed. However, extrapolation of these results to patients with other types of wounds must await further study.

Effects of waveform on comfort during neuromuscular electrical stimulation

Electrical stimulation is a commonly used clinical tool, but subject and patient comfort is still a major problem retarding its widespread application. Stimulus waveform in combination with pulse duration can play a major part in subject comfort. An asymmetric balanced biphasic square waveform was perceived as comfortable and was clinically effective in stimulating wrist flexor and extensor muscles. Subjects preferred the square waveforms over a paired spike monophasic waveform. In the larger quadriceps muscle group, a symmetric biphasic square wave was perceived as more comfortable than either a monophasic paired spike or any of three medium frequency waveforms. There seemed to be, however, a small subpopulation of subjects who consistently preferred the medium frequency waveforms. Medium frequency stimulation should be tried for those patients who have considerable difficulty adapting to the sensory input inherent with the use of surface electrical stimulation.

Recruitment data for nerve cuff electrodes: implications for design of implantable stimulators

Recruitment characteristics of nerve cuff electrodes, implanted in four cats for five months, were measured. Monopolar, bipolar, and tripolar configurations were considered. Approximately twice the current was required to achieve a given response using the tripolar configuration as compared with monopolar stimulation. Bipolar stimulation also required more current than did monopolar stimulation. A number of strategies for modulating muscle tension were considered using the recruitment data. It was shown that both pulse amplitude and pulse duration should be software-selectable to achieve adequate control of muscle tension when using either pulse-amplitude modulation or pulse-duration modulation. The effects of pulse-amplitude and pulse-duration step size on the maximum step change in muscle tension and the linearity of the recruitment curves were examined. The use of logarithmic steps in the modulation parameter was examined and shown to result in improved controllability and linearity.<<ETX>>

Characterization of postsynaptic potentials evoked by sural nerve stimulation in hindlimg motoneurons from acute and chronic spinal cats

The purpose of this study was to characterize the changes in postsynaptic potentials recorded in ankle extensor motoneurons resulting from activation of the sural nerve after spinal cord transection in the adult cat. Eight acute and nine chronic animals were spinalized at T12. Intracellular recordings from motoneurons innervating the triceps surae were performed. Sural nerve stimulation evoked complex synaptic potentials consisting of early and late components in all motoneurons. Early excitatory and inhibitory postsynaptic potentials (PSPs), as well as long latency excitatory postsynaptic potentials were recorded and averaged for assessment of PSP amplitude and duration. Early PSPs, both excitatory and inhibitory, were significantly larger in the motoneurons of cats spinalized 4-6 months earlier. Central latency of excitatory potentials were similar in the two samples of motoneurons, but the central latency associated with the initial inhibitory PSP was significantly shorter in the recordings from motoneurons of chronic spinal cats. In most recordings, an additional inhibitory PSP followed the initial excitatory PSP in motoneurons, and this secondary inhibitory PSP was similar in peak amplitude and duration in both samples of motoneurons. Also, a long latency excitatory PSP was recorded in a large percentage of motoneurons from both samples. This potential was typically of greater amplitude and longer duration in the motoneurons from chronic animals, when compared to recordings from acute animals. Although changes in amplitude and duration of PSP activity could be documented, there was no marked alteration in the frequency of occurrence of each PSP pattern recorded from the two preparations. This suggests that the synaptic pathways mediating the sural nerve reflexes have not qualitatively changed in the chronic spinal animal. The changes in amplitudes and durations of the PSPs in the chronic spinal cat indicate, however, that quantitative changes have occurred. The quantitative changes have probably occurred in the interneuronal networks activated by cutaneous nerve (sural) stimulation, since it was shown that only minor changes in motoneuron membrane properties could be recorded in these same chronic spinal animals.

Effect of electrical stimulation on foot skin perfusion in persons with or at risk for diabetic foot ulcers.

The failure of foot wounds to heal results in 54,000 people with diabetes having to undergo extremity amputations annually. Therefore, treatment is needed to speed healing in people with diabetes in order to reduce the need for amputation. This study tested the effect of high‐voltage pulsed current on foot blood flow in human beings who are at risk for diabetic foot ulcers. Neuropathy, vascular disease, Wagner Class, glucose, gender, ethnicity, and age were measured. A sample of 132 subjects was tested using a repeated‐measures design. A baseline transcutaneous oxygen level was obtained; stimulation was applied, and transcutaneous oxygen measurements were recorded at 30‐ and 60‐minute time intervals. The grouped foot transcutaneous oxygen levels decreased ({ifF = 5.66, p = .0039}) following electrical stimulation. Analysis of variance (Scheffe, p < .05) showed that initial transcutaneous oxygen was significantly higher than subsequent readings. However, oxygen response was distributed bimodally: 35 (27%) subjects showed increased transcutaneous oxygen (mean 14.8 mm Hg), and 97 (73%) experienced a decreased transcutaneous oxygen reading (mean 12.2 mm Hg). Logistic regression analysis did not explain these differences. Although this treatment appears to increase blood flow in a subset of patients, further study is needed to identify probable mechanisms for this response.

Effects of joint angle, electrodes and waveform on electrical stimulation of the quadriceps and hamstrings

Isometric twitch moments of the quadriceps and hamstrings were recorded in 20 normal subjects at 40 cells of a superimposed grid. Results were compared at 15, 45, and 75° of knee flexion. Bipolar stimulation at 6 pairs of cells was performed to determine the effect of electrode size, waveform, and polarity on moments. The quadriceps had one region of excitability over the femoral nerve and a second broader region of excitability over the muscle mass. Neither location was significantly affected by knee flexion. Regions of excitability for the hamstrings demonstrated more individual variation and were affected by knee angle. Electrode size had little effect on moments produced with monopolar or bipolar stimulation. When monophasic waveforms were used, reversing polarity generally caused changes in moments of >20%, whereas polarity had no significant effect when using biphasic waveforms. Moments produced with biphasic waveforms were always greater (by 20–25%) when compared with monophasic waveforms. During monopolar, monophasic stimulation, the anode, often termed the “indifferent” electrode, produced nearly 70% of the moment produced by the cathode.

l-Dopa-induced locomotor-like activity in ankle flexor and extensor nerves of chronic and acute spinal cats

The ability of L-DOPA and nialamide to produce locomotor-like rhythmic discharges (fictive locomotion) in hind limb nerves of acute and chronically spinalized and paralyzed cats was examined. Ankle flexor and extensor nerves of chronic cats exhibited pharmacologically induced alternate bursts of activity that had significantly shorter cycle times and burst durations than those produced in ankle flexor and extensor nerves of acutely prepared cats. Furthermore, prior to pharmacologic activation, both ankle flexor and extensor nerves of chronic preparations frequently exhibited spontaneous alternate bursts of activity. Neuronal discharges from nerves of chronic preparations, both prior to and after pharmacologic activation, exhibited much greater variability in both cycle time and burst duration compared with those observed in acute preparations.

Spectral analysis of EMG using intramuscular electrodes reveals non-linear fatigability characteristics in persons with chronic low back pain.

Greater fatigability across lumbar extensors has been reported in persons with chronic low back pain (LBP), however, extensor atrophy tends to be local to the site of pain. Therefore, specific ultrasound guided local and remote intramuscular electromyographic recordings were undertaken during an isometric horizontal trunk hold in two carefully matched cohorts; persons with and without LBP. The test was performed to self-determined maximal hold time, and the control group held the horizontal position longer (P < 0.001). A power spectral analysis was performed to calculate the normalized median frequency (NMF) slope for both the first and last 30s of the fatigue test due to the group difference in hold times. There were no significant group differences in NMF slope at the first 30s of testing (P = 0.650). The NMF slope for the first and last 30s was not different in healthy subjects (P = 0.688), but was different in persons with LBP, illustrated by shallowing of the slope at the last 30s of the test (P = 0.008). A between muscle comparison in the LBP group showed greater non-linear behavior in the deep multifidus (painful region) in contrast to T10 longissimus thoracis (nonpainful region) (P = 0.013). Possible explanations for these findings are discussed.