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High-Volt Pulsed Stimulation As An

Effective Therapeutic Modality?


Fact or Fiction According to the Evidence
Lark Welch, MS, ATC, CSCS
Christine Lauber, EdD, ATC

Presentation Objectives
Review of HVPS parameters and uses
What current and past literature exists
Effects of this modality on swelling and pain
Identify protocols to use in clinical practice

What is High Voltage Pulsed


Stimulation?
Twin Peaked, Monophasic, Pulsed Current
Phase duration is relatively short
20-45 sec

Interpulse interval
Resulting in a short pulse duration up to 200 sec

Low total current


Known polarity under each electrode
Purported that little or no electrochemical
reaction occurs under the electrode

Belanger, 2010

Textbook Effects of HVPS

Edema Management
Pain Modulation
Muscle Re-education and Spasm Reduction
Wound Management

Knight & Draper , 2008

Textbook Protocols
Edema Management
Negative Polarity

120 pps

Pain Modulation
Negative/Positive
Polarity

1-150 pps

Under Water or
Large Surface

90% VMT

Sweep or Target
Specific Area

Sensory Tolerance/
No VMT

Muscle Spasm Reduction


Positive Polarity 1-50 pps

Target Specific
Area

Moderate Visible
Muscle Contract.

Wound Management
Negative/
Positive Polarity

100 pps

Active Electrode
Over Wound

Sensory

How HVPS is Studied


Animal Models
Hamster
Rat
Frog

Human Models
Healthy
Injured

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Poll: In the clinical setting, do you use HVPS...

Poll: In the clinical setting, do you use HVPS...

Poll: Can HVPS be used to treat edema?

Poll: Can HVPS be used to treat pain?

Questions?
Does HVPS Work?
If so.

What Parameters Are Most Effective?

Clinical Questions
Is HVPS Effective in the Treatment of Edema?
Is HVPS Effective in the Treatment of Pain?

HVPS and Edema


Theoretical Physiological Effects
HVPS will decrease plasma protein leakage from
microvasculature into the interstitial spaces
(Taylor et al, 1997; Reed, 1988)
Negative polarity repels plasma proteins

HVPS will aid thrombus formation at the injured


microvasculature (Voight, 1984)
Positive polarity enhances thrombus formation

HVPS and Edema


Theoretical Effects
HVPS will increase blood flow (Walker et al, 1988;
Heath et al, 1992)
HVPS will increase lymphatic flow (Cook et al,
1994)

HVPS and Edema


What the Evidence Says:
Plasma protein leakage - Hamsters
Significant positive effect of HVPS using a negative or a
positive polarity at 50% or 90% of VMT and 120 pps for
5 min. (Taylor et al, 1997)
Significant positive effect of HVPS using a negative
polarity at 50 V (VMT) and 30 V for 25 min. (Reed,
1988)

HVPS and Edema


What the Evidence Says:
Blood flow Humans
No significant increase in blood flow using a negative
polarity at 10% or 30% of MVC and 30 pps for 5 min.
(Walker et al, 1988)
Significant increase in blood flow using a negative
polarity at maximal tolerated intensity at 2 pps or 128
pps for 30 sec on and 30 sec off for 10 min. (Heath et al,
1992)

HVPS and Edema


What Does the Evidence Say:
Lymphatic flow Rats
Significant increase in lymphatic flow using a negative
polarity at submaximal contraction intensity and 100
pps for 1 hour. (Cook et al, 1994)

No evidence found to support theory that a


positive polarity aids thrombus formation.

Does HVPS Control Edema?


Systematic Review
Snyder et al. 2010
Animal Studies
Frogs 4 studies
Rats 7 studies

Human Studies - 2

Does HVPS Control Edema?


Frog Studies
Significant effect over the first 24 hours 2 studies
Negative polarity, 120 pps, 90% VMT, four 30 min
treatments over 4 hours (30 min treatment; 30 min
rest)
Large effect sizes

Significant effect during first 8 hours 1 study


Negative polarity, 120 pps, 90% VMT, one 30 min
treatment
Medium effect size over 8 hrs, small effect over 24 hrs

Does HVPS Control Edema?


Frog Studies
No significant effect over initial 2 hours 1 study
Positive polarity, 120 pps, 90% VMT, four 30 min
treatments over 4 hours (30 min treatment; 30 min
rest)
Small effect size

Discussion
Positive polarity study may not have been carried out
long enough to determine a treatment effect

Does HVPS Control Edema?


Rat Studies
Significant effect over initial 4 hours 3 studies
Negative polarity, 120 pps, 90% VMT, four 30 min
treatments over 4 hours (30 min treatment; 30 min
rest)
Small to large effect sizes
May be due to different rat strains

Significant effect over initial 4 hours 2 studies


Negative polarity, 120 pps, 90 % VMT, continuous 180
min treatment
Small to large effect sizes

Does HVPS Control Edema?


Rat Studies
No significant effect over initial 24 hours
Negative polarity, 100 pps, 90% VMT, three 60 min
treatments
Trace effect size

No significant effect over initial 24 hours


Negative polarity, 80 pps, 40 V (no VMC), three 20 min
treatments
Medium effect size

Does HVPS Control Edema?


Animal Studies Conclusions:
Begin treatment early
Deliver treatment often or for long duration
Four, 30 min treatments
One continuous 180 min treatment

Parameters
Negative Polarity
120 pps
90% VMT

Does HVPS Control Edema?


Human Studies Systematic Review
No significant effect over 3 days 1 study
Negative polarity at intensity just below muscle
contraction, 28 pps or 80 pps, for 30 min 1 treatment
for 3 days
Ice, compression, and elevation also included with the
treatment
Treatment initiated on average within 30 hours of injury

Discussion
Treatment not applied immediately
Longer rest time in between treatments

Does HVPS Control Edema?


Sandoval, et al. 2010
Humans Ankle Sprains
Compared HVPS (-), HVPS (+), and cryotherapy
HVPS (-) 120 pps, submotor intensity, 30 min
treatment, 1X/day for 5 days or until the end of
treatment or 8 weeks
HVPS (+) same as HVPS (-)
Cryotherapy 30 min treatment, 1X/day

Outcome measures: pain, limb girth, limb volume,


ROM, gait

Does HVPS Control Edema?


Summary of Results
No significant differences in limb girth and limb
volume between groups during treatment
HVPS (-) had clinical improvements in limb volume
and girth compared to HVPS (+)

Conclusions
Not long enough treatment time
Treatment not applied immediately post injury as
seen in animal models.

Does HVPS Control Edema?


Mendel et al. 2010

Humans Ankle Sprains


To determine if near continuous HVPS for first 3 days
post injury would affect rate of recovery
Compared stocking electrode to placebo, in addition to
normal care
Stocking electrode: negative polarity, subsensory intensity,
120 pps
Stimulation began up to 25 hours post injury
Average delay 7 hours, 40 min

Take off stocking for 20 minutes 4-5X/day

Outcome measure: recovery time

Does HVPS Control Edema?


Summary of Results

No significant differences between groups across grade of


injury
For Grade II ankle sprains, no significant differences
between groups
For Grade I ankle sprains, HVPS rate of recovery was
significantly longer than control

Conclusions

Subsensory intensity rather than submotor intensity


Lack of standardized return to play point
Treatment not applied immediately post injury as seen in
animal models.

Does HVPS Control Edema?


Griffin et al. 1990
Humans Hand Edema
Compared intermittent compression, HVPS, and
sham
IC One 30 minute treatment
HVPS One 30 minute treatment, Negative polarity, 8
pps reciprocal 5 sec over median nerve, 5 sec over
ulnar nerve motor intensity

Outcome measure: limb volume

Does HVPS Control Edema?


Summary of Results
No significant differences between HVPS and placebo
in limb volume, BUT researchers consider differences
to be clinically meaningful
HVPS decreased volume 6.3 mL
IC decreased volume 7.7 mL
Sham decreased volume 1.3 mL

Conclusions
Results different from other human studies because
frequency was lower, muscle contraction intensity muscle
pump contraction, electrodes were not over edema site

Does HVPS Control Edema?


Conclusions
Evidence indicates that HVPS controls edema
in animal studies
Four, 30 min treatments over 4 hours
One, 180 min treatment continuously
Negative polarity, 120 pps, 90% VMT

Does HVPS Control Edema?


Conclusions
Evidence is inconclusive of an effect in human
studies
HVPS not applied immediately after injury
HVPS not applied for 30 min treatment, 30 min rest
for 4 continuous hours OR HVPS not applied for
continuous 180 minutes
Treatment times may not be long enough

Ability for clinicians and patients to apply


treatment immediately and for long duration
treatment times

High-Volt Pulsed Stimulation As An


Effective Therapeutic Modality?
Fact or Fiction According to the Evidence

HVPS and Pain


Historical Review
Mendel and Fish state anecdotal evidence was

useful in treating decubiti, burns, sprains,


strains, and pain with HVPS in 1945 and 1953
(Mendel, 1993)

3 or fewer treatments of 5 mins on consecutive days


4-30 pps, vigorous muscle twitch,
Said to give deep massage and direct nervous effect

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HVPS and Pain The Physiology


Theoretical Effects
HVPS will effect acute pain - gate control theory
(Brown, 1981; Lamboni, 1983; Voight 1984)
Negative /positive polarity can elicit sensory/peripheral
nerve stimulation

HVPS will effect chronic pain- opiate release


(Mohr, 1985)
Positive polarity can elicit motor/muscle contraction
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Gate Control Theory (GCT)

Sensory information
coming from A fibers
is transmitted to higher
centers in brain
Pain message" carried
along A & C fibers is
not transmitted to
second-order neurons
and never reaches
sensory centers
(Prentice, 2003)

Endogenous Opiate Release (EOR)


Stimulation of A
and C afferents can
stimulate release of
endogenous opioid
-endorphin from
hypothalamus
Dynorphin released
from periaqueductal
grey

Dynorphin
released

Effects of HVPS on Pain On Soft Tissue


Injuries
Human studies that have been conducted
Muscle Soreness 3
Ankle Injuries 3
Myofascial Pain - 1
Lateral Epicondylitis 1 - RCT

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HVPS and Pain


Evidence summary regarding decreasing pain in
muscle injury
HVPS ineffective in providing lasting pn relief in DOMS
(Butterfield et al. 1997)
Positive polarity - EOR

Early and freq HVPS provides significant reduction in


DOMS
(McLoughlin et al. 2007)
Negative polarity - GCT

HVPS and Pain


HVPS was ineffective in reducing DOMS
(Tourville et al. 2006)
Positive polarity - EOR

HVPS and Pain


Evidence summary regarding decreasing pain
in ankle injury
HVPS seems to suppress pain
(Voight 1984)
Positive or negative polarity - GCT

HVPS has a tendency to decrease pain


(Michlovitz et al. 1988)
Negative polarity - EOR

HVPS and Pain


HVPS can accelerate the initial phase of recovery
from ankle injury/sprain
(Sandoval et al. 2010)
Negative polarity - EOR

HVPS and Pain


Evidence summary regarding decreasing pain
in myofascial pain
HVPS helps patients pain decrease
(Tanrikut et al. 2003)
Positive polarity - GCT

HVPS and Pain


Evidence summary regarding decreasing pain
in lateral epicondylitis
Pain intensity decreased in HVPS tx group, with
f/u data of patients showing 83% pn-free @ 6
month
(Nourbakhsh et al. 2010)
Positive polarity - EOR

HVPS and Pain


Muscle Injury/DOMS
Butterfield et al. 1997
28 college aged participants
Compared HVPS and Sham
3- 1x/day HVPS txs for 30 min over a 48 hour period
HVPS(+) 120 pps, visual muscle contraction, 30 min
Txs given @ 24 hrs, 48 hrs, 72 hrs post exercise

Outcome measures: Pain, ROM, and Strength


Significant pain reduction during tx, but diminished
after treatment

McLoughlin et al. 2004


Induced muscle soreness of 14 healthy males
Compared HVPS tx Ex Group and Controls
8- 5 multiple day 30 min txs over a 120 hr period
HVPS(-) 120 pps, patient tolerance, 30 min
Txs given @ 5 mins, 3,6,24,48,72,96, and 120 hrs post
exercise

Outcome measures: Pain, ROM, Strength, Edema


Early and freq. application has significant
reduction in DOMS at 24 hr and 48 hr time points

Tourville et al. 2006


20 healthy males and females
HVPS and placebo group comparison
3-1x/day- 20 min txs for 3 consecutive days
HVPS(+) 100 pps, 90% of VMC
Txs given @ 0, 24, 48, 72 hrs post DOMS induction

Outcome Measures: Pain, Strength, Flex


No significant difference in reported perceived
muscle soreness/pain.

HVPS and Pain


Ankle Injury/Sprain

Voight. 1984
HVPGS application s/p ankle injury
# of txs not given, 20 to 30 min tx times;
elevate limb, or place in cold H20 emersion
HVPS(+) or (-) 60 to 80 pps or varied
Sub motor contraction or pt tolerance
Author believes this to be effective in swelling and
pain reduction. 3 other references used that were
in this presentations literature review.

Michlovitz et al. 1988


30 healthy military recruit with Grade I/II ankle
sprains
Ice, Ice & HVPS @28pps, Ice & HVPS @80pps
Tx given 1x/day-30 min for 3 days
Pn assessed prior to 1st tx and following 1st tx
HVPS(-) with palpable contraction

Outcome Measures: Pain, Volume, Flex


Ice only showed slight pn improvements. Ice &
HVPS txs moderate improvements for pn.

Sandoval, et al. 2010


Ankle Sprains of 28 male and female participants
Compared HVPS (-), HVPS (+), and cryotherapy
HVPS (-) 120 pps, submotor intensity, 30 min
treatment, 1X/day for 5 days or until the end of
treatment or 8 weeks
HVPS (+) same as HVPS (-)
Cryotherapy 30 min treatment, 1X/day

Outcome measures: Pain, Limb Girth, Limb


Volume, ROM, Gait
No significant pain reduction during tx, but
clinical improvements in all OM in the HVPS(-) gr

HVPS and Pain


Myofascial Pain

Tanrikut, et al. 2003


45 male/female pts with dx myofascial pn
Exercise only, HVPS & exc, Placebo HVPS & exc
10-20 min txs over 2 weeks

HVPS(+), 80-120 pps, pt tolerance of sensory stim and


slight muscle contract; Placebo group was sub-sensory
and no muscle response

Outcome measures: Pain, PPT, Anagesic use, Global


Assessment
Pn levels decreased in all groups, but significant
decrease in HVPS group.

HVPS and Pain


Lateral Epicondylitis

Nourbakhsh et al. 2008


18 pts with chronic epicondylitis
Randomly assigned to tx or placebo groups
6-3/30 second tx over a 2 week period

HVPS(+) and (-)/varied polarity and Hz applied to pt


tolerance for the 30 second point

Outcome Measures: Pain, Strength, Activity Level, Six


mon f/u results also
Significant pain intensity decrease between the tx
group and placebo group. 83% remained pain free @
six mon f/u.

Does HVPS Control Pain?


In DOMS
Inconclusive according to the literature
Of the 3 human studies
2 ineffective
1 effective
Now What?

Does HVPS Control Pain?


In Ankle Injuries
Decreases pain, especially in initial injury
phase
Of 3 Human studies
2 decreased pain
1 improved initial recovery phase post ankle
injury
So What?

Does HVPS Control Pain?


In Myofascial Pain & Elbow Pain
Strong current studies
Significant in decreasing pain in both
conditions
Of these 2 Human Studies
Myofascial pain decreased with HVPS & exc
Lat Epicondylitis HVPS tx group significant pain
decrease

Does HVPS Control Pain In Soft Tissue


Injuries?
Conclusions
Begin treatment early
Deliver treatment often or for duration of >8 txs
Both GCT and EOR can be effective with proper
protocol usage

How Can HVPS Control Pain?


Conclusions on Protocols
Clinicians and patients will have decreased pain with this
modality in 20-30 min treatments as well as direct probe
of area.
Evidence indicates that HVPS decreases pain

8, 30 min treatments over 120 hours


One, 180 min treatment continuously/3- 30 second direct tx
Positive or Negative polarity
Choose GCT or EOE goal of treatment and choose then polarity

Fact or Fiction to Edema or Pain?

Knight & Draper, 2008

IN CLOSING..
What we have presented: The Evidence/Facts
1 part of EBP

Evidence Based Practice is all three:


Evidence
Clinical Experience
Patient Values

Thank You for your time!


The Facts According to the Evidence on
HVPS.
Lark Welch Lewis University
Dr. Christine Lauber University of Indianapolis

References
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practice. Philidelphia, PA. Lippincott Williams and Wilkins. 2010.
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References
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