Case report

High-voltage electrical stimulation for the
management of Stage III and IV pressure
ulcers among adults with spinal cord injury:
Demonstration of its utility for recalcitrant
wounds below the level of injury
Albert C. Recio 1,2 , Cara E. Felter 1, Anna Corrine Schneider 1, John W. McDonald 1,2,3
1

The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore,
MD, USA, 2Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore,
MD, USA, 3Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
Context: Patients with spinal cord injury (SCI) have many factors that are associated with pressure ulcer
formation, including paralysis, loss of sensation, poor nutrition, anemia, and skin maceration related toincontinence. Treatment of these ulcers involves relieving pressure, improving nutrition and skin hygiene,
treating infections, removing necrotic tissues, and applying the appropriate dressings. However, some cases
are not responsive to the above treatment. Electrical stimulation (ES) is thought to enhance soft tissue healing
through promotion of protein synthesis, inhibition of bacterial growth, facilitation of epithelial tissue migration,
improvement of blood flow, and tensile strength. This data is mainly based on evidence from animal studies
and very few rigorously controlled studies conducted in humans.
Objective: To demonstrate the effectiveness of ES in the treatment of recalcitrant pressure ulcers.
Methods: Retrospective case series describing the care of adults with SCI and recalcitrant pressure ulcers. ES
was applied directly into the wound bed: 60 minutes per session, 3–5 times per week; with an intensity of 100
milliamperes and a frequency of 100 pulses per second. Polarity was negative initially and was switched weekly.
The amplitude and wave form were maintained throughout.
Results: The long-standing (11–14 months) pressure ulcers were completely healed after 7 to 22 weeks oftreatment with high-voltage ES.
Conclusion/clinical relevance: This case series demonstrates the effectiveness of ES for enhanced healing ofStage III–IV ulcers otherwise unresponsive to standard wound care. Further study is needed to identify themost effective protocol for ES therapy in the treatment of recalcitrant pressure ulcers.

Keywords: Electrical stimulation, Spinal cord injuries, Pressure ulcer, Wound healing

Introduction
Pressure ulcers are a significant health care problem inall patient care settings. They are a lifelong, serious complication of spinal cord injury (SCI) that has the potential to interfere with physical, psychological and social
well-being, and overall quality of life. According to theInstitute of Medicine, SCI research should prioritize
the elimination of SCI-related complications, such as
Correspondence to: Albert Recio, Kennedy Krieger Institute, Johns Hopkins
School of Medicine, 801 N. Broadway, Suite 560, Baltimore, MD 21205, USA.
Email: Recio@kennedykrieger.org

58© The Academy of Spinal Cord Injury Professionals, Inc. 2012
DOI 10.1179/2045772311Y.0000000044

pressure ulcers.1 Pressure ulcers are wounds caused byunrelieved pressure from forces perpendicular (compression) or tangential (shear) to the tissue surface.1
This constant force can interfere with the pressure incapillaries and therefore, affect the exchange and elimination of nutrients and metabolites. Prolonged circulatory interference ultimately leads to cell death and insevere cases individuals can develop septic shock andultimately organ failure.1
Pressure ulcers rank as the second highest cause of
re-hospitalization after traumatic SCI.2 It is estimated

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Recio et al.

that approximately 25–40% of patients with SCI willdevelop a pressure ulcer in their lifetime and that at 2year follow-up the prevalence of pressure ulcers is
8.9%.1,3
Patients with SCI may have many factors that areassociated with pressure ulcer formation, including
paralysis, loss of sensation to pain and pressure, poor
nutrition, anemia, and skin maceration related to incontinence. Healing time for pressure ulcers can vary
greatly.
As Gardner et al. 4 point out, there are several moderating variables that impact healing, including tissue perfusion, bacterial burden, and nutritional status, but few
studies have provided data regarding these variables.
Poor nutritional status has been correlated with thehealing of pressure ulcers.5,6 Biochemical parameters
useful in assessing nutritional status include prealbumin,
total protein, albumin, hemoglobin, and hematocrit.
According to the Consortium for Spinal Medicine,
specific nutritional factors associated with woundhealing include micronutrients such as zinc, vitamin C,
vitamin A, and vitamin E.7
Treatment of these ulcers involves relieving pressure,improving nutrition and skin hygiene, treating infections, removing necrotic tissues, and applying the appropriate dressings. However, some cases are not responsive
to the above treatment.
Electrical stimulation (ES) is thought to enhance soft
tissue healing, but this is based chiefly on evidence fromanimal studies and very few rigorously controlled
studies conducted in humans.
While the mechanisms that explain how ES promotes
wound healing are poorly understood, some believe that
ES imitates the natural electrical current that occurs inskin when it is injured.4 It has been shown that ES
induces cellular actions in almost every phase of thewound healing cascade, including the stimulation ofseveral fibroblast activities, such as enhanced collagenand deoxyribonucleic acid synthesis, adenosine triphosphate production and calcium influx, and an increased
number of growth factor receptor sites.8 In vitro studies

HVES for the management of Stage III and IV pressure ulcers among adults with SCI

on macrophages, epithelial cells, and fibroblasts havedemonstrated that ES promotes the migration and activation of key cells within the wound site. Additionally,in vivo studies involving animal models have shownthat ES results in more collagen deposition, enhanced
angiogenesis, greater wound tensile strength, and afaster wound contraction rate.8 ES has also beenshown to improve tissue perfusion and reduce edema
formation, indirectly stimulating healing by improving
oxygen delivery to the tissue.9
There have been relatively few controlled studies conducted regarding the use of ES specifically for thehealing of recalcitrant pressure ulcers. In Regan et al.’s9
review of therapeutic interventions for pressure ulcers,
the ES studies focus on comparing the rate of healing
with ES to either sham/placebo groups or to standard
wound care groups. There is no discussion on the useof ES for recalcitrant wounds that have failed torespond to standard wound care and have persisted for
longer than 11 months. Houghton et al. 8 provide a
recent single-blind randomly assigned study that compares healing rates for standard wound care versus ES
plus standard wound care for pressure ulcers, but theirstudy includes Stage II and non-recalcitrant wounds. In
addition, their standard wound care group had a disproportionate amount of Stage II versus Stage III and IV
wounds when compared to the Standard Wound Care
(SWC) + Electrical Stimulation Treatment (EST) group.
When you consider that all Stage II wounds were fully
healed within 3 months for both groups, the comparison
between both groups becomes skewed.

Case series
We report a retrospective case series describing the careof three adults with SCI and recalcitrant pressure ulcers.
Patient A is a 49-year-old man with T4 AIS B paraplegia following a fall. He presented for outpatient physical therapy with a 14-month-old pressure ulcer thatpersisted despite conventional wound care management.
He was noted to have a Stage IV pressure ulcer on his
left heel measuring at 4.45 × 2.54 cm with moderate

Figure 1 Patient A’s recalcitrant pressure ulcer at initial evaluation and the progression of wound healing after application of highvoltage electrical stimulation (HVES). Source: Kennedy Krieger Institute.

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HVES for the management of Stage III and IV pressure ulcers among adults with SCI

serosanguineous yellowish, non-foul smelling discharge,
and a well-defined flat margin (Fig. 1). No tunnelingwas noted and the calculated wound surface area
(WSA) was 11.30 cm2.
Case B is a 29-year-old man with T12 paraplegia AIS
A due to a gun-shot wound. He presented with an
11-month-old Stage IV left ischial wound, despite conventional wound care, which measured 4 × 4 × 1 cm
(16 cm2 WSA) (Fig. 2). The wound included no necrotic
tissue, minimal non-foul smelling serosanguineous discharge, and no tunneling. The margin was flat and welldefined with an area of maceration and scant granulation.
Patient C is a 51-year-old man with a C7 AIS A following a bicycle accident. He presented with an 11month-old Stage III pressure ulcer over the right ischial
tuberosity. Standard wound care management at awound care clinic had yielded no significant improvement. The ulcer measured 3.6 × 2.0 cm (7.20 cm2
WSA), had minimal non-foul smelling serosanguineous
drainage, no necrotic tissue, no induration, no tunneling,
well-defined flat margins, and scant granulation.
All three patients were checked for specific biochemical parameters associated with the development andprolonged healing of pressure ulcers. Anemia, asassessed by hemoglobin levels below 12.0–14.0 g/dl, isassociated with an increased incidence of pressure
ulcers and serum total protein levels less than 6.4 g/dl
have been associated with the development of pressure
ulcers.10–12 Serum albumin levels lower than 3.5 g/dl
have a higher incidence of pressure ulcers and low testosterone levels are associated with impaired healing of
long-standing pressure ulcers.12–14
The patients’ blood work tests included hemoglobin,
total protein, albumin, zinc, total testosterone, and freetestosterone. Their results were all within normal limits.

ES wound treatment protocol
The patients’ wound care protocol included highvoltage electrical stimulation (HVES) treatments tothe wound bed for 60-minute sessions 3–5 times per
week. The following guidelines were used for initialwound healing: the wound cavity was filled with
Hydrogel, a 2-inch round electrode was placed into
the wound bed, and a dispersive electrode was placed
over an area proximal to the wound (avoiding bonyprominences). High voltage pre-programmed settings
were used (twin peaked, monophasic, 10 microsecond
pulse width) on the Empi 300 PV unit to administer
the ES to the wound. These parameters were chosen
based on information available in the users’ manual
for this device.15
Negative and positive polarities were alternated once
weekly.8,16,17 As past literature has shown that different
cell types are attracted to either a positive or negative
polarity, alternating polarities produce improved
results in both chemotaxis and wound closure
times.17–29 Preset parameters included a 2 second
ramp-up time, continuous on cycle; pulse rate of
100 Hz, and user chosen negative pre-programmed regimens (PPR 1) or positive (PPR 2) polarity. Following
the ES treatment, the wound was dressed with a sterile
Telfa pad and sterile gauze and was then secured inplace with Hypafix tape. Treatment was administered
3–5 times per week and re-assessment was performed
on a weekly basis by a physical therapist and physician.

Post-initiation
Periodically, each patient’s wound was measured and
WSA and percent decrease in wound surface area (%WSA↓) was calculated.
For Patient A, approximately 10 weeks after the
initiation of HVES, there was significant reduction indrainage and WSA (62.82%) of the left heel decubitus
ulcer (Graph 1, Table 1). There was granulation tissue
within the wound bed and minimal drainage (Fig. 1).
After 16 weeks, the WSA had decreased by 95.58%
and ES to the wound bed was discontinued (Table 1).
During this re-evaluation the wound demonstrated
clean and dry edges, granulation, and epithelial tissues
filled the wound bed without drainage. Wound care
was continued and consisted of cleansing the woundwith a saline solution and dressing it with a Telfa

Figure 2 Patient B’s recalcitrant pressure ulcer at initial evaluation and the progression of wound healing after application of HVES.
Source: Kennedy Krieger Institute.

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Recio et al.

Graph 1

Patient A, B, and C’s measured WSA pre- and post-application of HVES for recalcitrant pressure ulcers.

Table 1 WSA and percent decrease in wound surface area (%WSA↓) for Patient A after application of HVES
Duration of HVES
treatment (weeks)
0
8
10
12
16

Table 2
HVES

Wound surface
area (cm2)% WSA ↓

11.30
8.75
3.75
1.50
0.50

22.59%
66.82%
86.73%
95.58%

WSA and % WSA↓ for Patient B after application of

Duration of HVES
treatment (weeks)
0
5
9
13
18
22

HVES for the management of Stage III and IV pressure ulcers among adults with SCIWSA (cm2)% WSA ↓

16.00
14.00
6.75
3.50
0.75
0.60

12.50%
57.81%
78.13%
95.31%
96.25%

padding secured with Hypafix (Fig. 1). During a
12-month follow-up over the telephone, the patientreported that he no longer had a pressure ulcer.
For Patient B, approximately 9 weeks after initiationof HVES, there was significant reduction in woundsize (57.81% WSA↓) and drainage of the wound(Graph 1). Upon discharge 22 weeks later, the wound
was clean without macerated edges or undermining(Fig. 2, Graph 1). At that point, the WSA had decreased
by 96.25% (Table 2) and ES was discontinued. Woundcare consisted of cleansing the wound with a saline solution and dressing it with a Telfa padding secured with

Hypafix (Fig. 2). During a 12-month follow-up, thepatient reported that he no longer had a pressure ulcer.
For Patient C, after 6 and a half weeks of HVES treatment, the 11-month-old wound was completely healed(100% decrease in WSA – Table 3) and HVES treatment
was discontinued (Graph 1, Fig. 3). A 6-month followup with the patient revealed no pressure ulcers.
As Graph 1 demonstrates, despite conservative
wound care management all three patients had
wounds that had persisted for at least 11 months. For
all three patients HVES initiation resulted in significant
healing and a substantial decrease in wound surface(Graph 1).

Discussion
As a consequence of altered autonomic nervous system
function, SCI patients whose neurological level isabove T6 often lose the ability to perform reflexive
sweating. For these patients, the functional propertiesof their skin are altered and they are unable to maintaina constant body temperature. Neurologically impaired
skin undergoes a number of metabolic changes thatusually do not stabilize for 3–5 years after the injury.
Multiple reports describe a significant and rapid
Table 3HVES

WSA and % WSA↓ for Patient C after application of

Duration of HVES
treatment (weeks)
0
2
4
5
6.5

WSA (cm2)% WSA ↓

7.20
6.00
2.25
1.50
0.00

16.67%
68.75%
79.17%
100.00%

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HVES for the management of Stage III and IV pressure ulcers among adults with SCI

Figure 3 Patient C’s recalcitrant pressure ulcer at initial evaluation and the progression of wound healing after application of HVES.
Source: Kennedy Krieger Institute.

increase in the overall rate of collagen catabolism
immediately after the trauma resulting in abnormal concentration of collagen metabolites.30,31 Rodriguez andMarkowski32 report a decrease in the proportion oftype I–type III collagen in the skin below the level of
injury. The increased degradation of collagen affects
the integrity of the skin.
The delivery of electrical current into refractorywounds for the purpose of enhancing tissue healing
dates back to the seventeenth and twentieth centuries,
when several reports described the use of electrostatically charged gold leaves in the treatment of skinlesions associated with small pox and wounds ofvarious etiologies, including ischemic and venous insufficiency ulcers of the lower extremity.17 Since the mid1960s, more research has been aimed at evaluating theeffects of ES on healing of chronic wounds.17,33 ES asa wound healing modality is sometimes used to help
heal Stage II and III ulcers in cases where surgery orother treatment methods are not indicated. For StageIV ulcers, surgery is often the best method for covering
chronically exposed bone with excellent results. In 2002,
ES was approved for payment by the Centers for
Medicare and Medicaid Services for the treatment ofpressure ulcers and wounds that have not responded tostandard wound treatment.17,34
Laboratory and clinical studies have shown evidence
that ES promotes chemotaxis, helps reduce edema, inhibits bacterial growth, promotes protein and DNA synthesis in human fibroblasts, facilitates epithelial tissue
migration, increases the migration of neutrophils andmacrophages, and improves blood flow and tensile
strength.4,17,35

Conclusion
This case series demonstrates the efficacy of HVES forthe enhancement of Stage III–IV wound healing thathas otherwise not responded to standard wound care.
Recalcitrant pressure ulcers, for which the duration
ranged from 8 to 14 months, were completely healed
after 7–22 weeks of three times a week treatment with

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HVES. Further study is needed to identify the mosteffective protocol for HVES therapy in the treatmentof long-standing pressure ulcers.

Acknowledgements
We acknowledge Cristina Sadowsky, MD and Varsha
Gandhi, DPT for their invaluable support.

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