Effects of High Voltage Pulsed Electrical Stimulation on Blood Flow

DONNA CARLSON WALKER, DEAN P. CURRIER, and A. JOSEPH THRELKELD The purpose of this study was to determine whether high voltage electrical stimulation would increase blood flow to skeletal muscle in healthy subjects. Subjects were assigned to one of three groups: 1) an Electrical Stimulation (ES) Group (n = 16), 2) an Exercise (EX) Group (n = 14), or 3) a Control Group (n = 8). Isometric contractions were induced electrically at 30 Hz in the ES Group and performed volitionally in the EX Group for five minutes at intensities of 10% and 30% of predetermined maximal voluntary isometric contraction (MVC) efforts. Blood flow, heart rate, and blood pressure were unaffected in the ES Group, but blood flow and systolic blood pressure increased and decreased, respectively, for the EX Group at 30% of MVC. High voltage stimulation at a pulse rate of 30 Hz and at intensities needed to evoke contractions at 10% and 30% of MVC for plantar flexion did not increase blood flow at the popliteal artery. Key Words: Blood circulation; Cardiac, general; Electrotherapy, electrical stimulation.

Direct current is classically described as a continuous current of constant intensity and uniform polarity.1 Because of its unidirectional property, a net charge transfer occurs, causing electrochemical alterations in tissues underlying the electrodes. Direct current is used clinically for administering drugs percutaneously (iontophoresis)2 and for healing of wounds.3 A relatively recent modality in physical therapy is high voltage pulsed electrical stimulation, which is characterized by generators having more than 150 V and producing a monophasic twinpeaked waveform with effective phase durations of 20 to 45 sec.4 Because this current has extremely short pulse durations (5-100 sec) and a low total current (1.5 mA), little or no electrochemical reaction occurs beneath the stimulating electrodes.4 To include the
D. Walker, MSEd, is Director, Department of Physical Therapy, Central Baptist Hospital, 1740 S Lime St, Lexington, KY 40503. She was a graduate student, University of Kentucky, Lexington, KY 40536, at the time of this study. D. Currier, PhD, is Professor and Chairman, Department of Physical Therapy, University of Kentucky Medical Center, Annex 1, Lexington, KY 40536-0079 (USA). A. Threlkeld, PhD, is Assistant Professor, Department of Physical Therapy, University of Kentucky Medical Center. Address all correspondence to Dr. Currier. This article was submitted January 28,1987; was with the authors for revision eight weeks; and was accepted June 25, 1987. Potential Conflict of Interest: 4.

term "galvanic" with this high voltage stimulation (HVS) would be a misnomer because the classic definition of galvanic current1 states it is continuous, not pulsed. Manufacturers of HVS devices claim that the benefits of this form of electrical stimulation include increasing blood flow to stimulated muscles. Local metabolism influences blood flow to skeletal muscle both during and after volitional exercise.5 Because muscle metabolism increases as a function of the magnitude and frequency of voluntary contractions, blood flow to the contracting muscle also increases.6,7 Because HVS induces muscle contractions, blood flow and muscle metabolism should increase in response to the electrical stimulus applied to the muscle. We could find no reports supporting the claim that HVS increases blood flow to muscles in humans. Alon et al reported that no significant changes in blood flow at the posterior tibial artery, as measured by a Doppler device, occurred in 20 subjects after HVS at intensities below the threshold for observable muscle contraction.8 In unpublished studies at the University of Kentucky in 1981 that also measured bloodflowwith a Doppler unit, Loze was unable to find an increase in bloodflowin the femoral artery offivehealthy subjects after stimulating their right gastrocnemius muscle. He used stimulus rates of 4 and 80 Hz and switched the stimuli between

two cathodes every 2.5 seconds. The stimulus was maintained for two minutes of rhythmic muscular contractions with an intensity adjusted to the subjects' level of tolerance (G. Loze, unpublished data, 1981). In 1982, Fields applied HVS to the right gastrocnemius muscle of 14 healthy subjects using stimulus rates of 15 and 30 Hz at the highest tolerated intensity levels. The switching rate between the two cathodes was 2.5 seconds. No increase in blood flow at the popliteal artery was found immediately after 10 minutes of HVS of the subjects' calf muscle (S. A. Fields, unpublished data, 1982). Various intensities, waveforms, and pulse rates of electrical stimulation (other than HVS) have been used on animals to study effects on blood flow. Wakim found significant increases in blood flow when he applied stimuli at 8 to 32 Hz directly to muscles of dogs and smaller increases in blood flow at pulse rates higher than 32 Hz and lower than 8 Hz. Pulse rates higher than 32 Hz produced tetanic muscle contractions that interfered with the flow of blood during contractions.9 Randall et al found a greater increase in blood flow in dogs immediately after the cessation of electrical stimulation than during muscle stimulation.10 Folkow and Halicka found that blood flow to the gastrocnemius muscle of the cat progressively increased when they increased 481

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frequencies of the continuously pulsed electrical stimulation from 1 to 2 to 4 Hz.11 Petrofsky, using various stimulus frequencies and levels of induced muscle force, found that blood flow increased during graded levels of contractions induced by pulsed electrical stimulation and that blood flow was greatest immediately after the contractions, regardless of the level of contractile force produced.12 Because HVS has achieved widespread clinical acceptance and because increased blood flow may be important in treating many clinical conditions, investigation was needed to determine the effectiveness of HVS in augmenting blood flow during and after electrically induced muscle contractions. The purpose of this study, therefore, was to determine the effect of HVS on blood flow to skeletal muscle in healthy subjects when producing isometric contractions equivalent to either 10% or 30% of the subjects' maximal voluntary isometric contraction (MVC). Because of earlier findings of HVS on humans in the studies of Alon et al,8 Loze (unpublished data, 1981), and Fields (unpublished data, 1982), we did not expect an increase of blood flow to skeletal muscle using this modality. METHOD Subjects Thirty-eight healthy volunteers (15 men, 23 women), ranging in age from 20 to 30 years, participated in the study. All subjects had normal resting heart rates and blood pressures and gave their informed consent. Subjects were randomly assigned to one of three groups: 1) an Electrical Stimulation (ES) Group (n = 16), 2) an Exercise (EX) Group (n = 14), or 3) a Control Group (n = 8). The subjects' demographic data are shown in Table 1. Measurement of Torque The two experimental groups (ES and EX) were pretested for MVC of their right plantar flexor muscles using a Cybex II isokinetic dynamometer system.* During testing, the ES and EX Group subjects lay prone on a test table with their upper limbs at their sides to minimize assistance of other body musculature during exertion. For testing of the plantar flexor muscles, we secured

TABLE 1 Demographic Data of Subjects (N = 38) Group Electrical Stimulation s Control s Exercise s
a

Age Weight Height Torque (cm) (N-m)a (yr) (kg)

22.4 60.3 2.5 9.3 25.4 2.9 24.1 3.1 65.0 8.2 66.8 13.1

168.7 8.6 168.4 8.4

95.7 33.9

174.2 114.2 9.7 65.6

Value for maximal voluntary isometric contraction during plantar flexion.

the right foot of the subject's test leg to the dynamometer in the neutral position (0 dorsiflexion) and the subject's calf to the test table with webbed straps. The highest torque value of three MVCs was recorded (chart recorder damping set at 2) and used as the subject's MVC for testing of the plantar flexor muscles. Each muscle contraction was maintained for 3 to 5 seconds. While the ES Group subjects were still stabilized in the prone position, their right gastrocnemius muscle was electrically stimulated alternately with two surface electrodes (cathodes). The skin over the targeted locations was cleaned with alcohol. The 10- 10-cm metal cathodes were secured with webbed straps to the skin over the motor points of the medial and lateral heads of the muscle. A 23- 28.5-cm anode was placed over the low back area and secured by a 5-kg weighted bag. Sponges moistened with tap water and inserted between the skin and the electrodes served as conductive couplings. Stimulus intensities were adjusted to produce torque values equivalent to 10% ( = 238.8 V, range = 150-350 V) and then 30% ( = 270.8 V, range = 190-415 V) of the measured MVC of the subjects' right plantar flexor muscles. Measurement of Blood Flow, Heart Rate, and Blood Pressure All subjects remained in the prone position for about 15 minutes after each muscle contraction, and then heart rate and blood pressure measurements were obtained from their right upper limbs. Heart rate was measured by palpation of the radial artery. Blood pressure was measured with a sphygmomanometer while auscultating the brachial artery. We measured arterial blood flow to the calf muscle using a 5.3-MHz, dual-

frequency, continuous wave, ultrasonic, directional Doppler device. Measurements were made at the beginning, midpoint, and end of the five-minute intervention period of the experimental phase of the study (t = 0, 2.5, and 5). The transmitted ultrasonic beam intercepts the blood moving in an artery, and the reflected vibrations are received and displayed by the Doppler device at a higher frequency than that of the reflected vibrations. The velocity of the blood particles is added to the frequency of the transmitted ultrasonic beam increasing the number of waves per unit over time that arrive at the receiving crystal of the Doppler probe. The faster the blood velocity, the greater the volume of blood flowing per unit of time. The pencil probe of the Doppler unit was hand-held and positioned on the skin over the popliteal artery of the prone subjects so that an angle of about 45 degrees was formed with respect to the horizontal plane. The probe position was adjusted empirically by the primary author for each measurement to yield a maximum signal. This technique of Doppler probe placement has been shown to be a reliable measure of blood flow changes over time.13 Twenty consecutive signals, each representing a complete cardiac (pulse) cycle, were transcribed from the Doppler device to a strip chart recorder, and the resultant tracings were analyzed. Procedure Subjects rested for 15 minutes preceding measurement of the circulatory variables (heart rate, blood pressure, blood flow). During this rest period, surface electrodes were attached to therightgastrocnemius muscle of each subject in the ES Group as described previously. We used a Sentry Mark IV high voltage stimulator (twin-peaked, monophasic waves of 75-sec duration) to provide the desired muscle contractions (10% of MVC) at a stimulus rate of 30 Hz. The anode was placed over the skin of the lumbosacral area. Muscle contractions were induced continuously for a total of five minutes except when interrupted briefly at t = 2.5 for circulatory measurements. Immediately on cessation of the electrical stimulation (t = 5), measurements were obtained for bloodflow,heart rate,
Model 909, Parks Medical Electronics, Inc, Beaverton, OR 97075. Sentry Systems, Inc, 309B Pineview Dr, Kernersville, NC 27284.

*Cybex, Div of Lumex, Inc, 2100 Smithtown Ave, Ronkonkoma, NY 11779.

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RESEARCH and blood pressure. After a five-minute rest period, these circulatory measurements were repeated and constituted pretest values for the second phase of the study in which we investigated the effect of electrical stimulation at intensities sufficient to induce muscle contractions at 30% of MVC. The procedure for measuring responses associated with these stronger contractions was identical to that described for the 10% of MVC level. Volitional Exercise The EX Group subjects voluntarily plantar flexed their right foot isometrically against the footplate of the dynamometer's stationary lever arm to develop the designated 10% of the predetermined MVC torque, then relaxed their muscles. This procedure was repeated rhythmically (about 30 contractions per minute) for 2.5 minutes at which time (t = 2.5) blood flow, heart rate, and blood pressure measurements were recorded. Muscle contractions were monitored with the dynamometer to ensure that the appropriate percentage of MVC intensity was produced. After these circulatory measurements, the subjects rhythmically contracted and relaxed their plantar flexor muscle for an additional 2.5 minutes. Posttest measurements of blood flow, heart rate, and blood pressure were obtained immediately after the second 2.5 minutes of volitional isometric contraction of the plantar flexor muscles (t = 5). A similar sequence of exercise and measurement was then followed for the EX Group during the second phase of the experiment using a stimulus rate of 30% of MVC. The Control Group received the same sequence of blood flow, heart rate, and blood pressure measurement as did the ES and EX Groups. Control Group subjects, however, did not engage in volitional resistive exercise or receive electrically induced exercise preceding any of the circulatory measurements. Data Analysis Velocity (in centimeters per second), determined from the signal amplitude of the blood flow pulses recorded by the Doppler device, was used to analyze blood flow through the popliteal artery. We used the mean peak amplitude of the centermost 15 cycles of 20 consecutive signals for each measurement (t = 0, 2.5, and 5) of each subject in our analysis. Each velocity value used in the
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Figure. Means and standard deviations of blood flow velocities at the popliteal artery showing effects of time (pretest, midtest, and posttest) and force of muscle contraction (10% and 30% of maximal voluntary isometric contraction [MVC]) for all three groups. (CG = Control Group, ES = Electrical Stimulation Group, EX = Exercise Group.)

TABLE 2 Analysis of Variance Results of Effect of Graded Muscle Contractions on Blood Flow Source Between Group (EX,a ESb Control) Error Within Intensity (10% and 30% MVCC) Intensity group Error Time (pretest, midtest, posttest) Time group Error Intensity time Intensity time group Error
a b c

df 2 35 1 2 35 2 4 70 2 4 70

SS 31.84 107.84 0.05 0.68 15.52 8.89 7.29 23.64 0.26 0.71 14.97

MS 15.92 3.08 0.05 0.34 0.44 4.45 1.82 0.34 0.13 0.18 0.21

F 5.17

P .01

0.11 0.77 13.09 5.35 0.62 0.86

NS NS .0003 .0003 NS NS

EX = Exercise. ES = Electrical Stimulation. MVC = maximal voluntary isometric contraction.

blood flow analysis represents the mean of 15 analog signals recorded in each group of recorded signal tracings. We used a 2 3 38 factorial (10% and 30% of MVC subject groups number of subjects) analysis of variance procedure for repeated measures over intervals of time for measuring popliteal artery blood flow (t = 0, 2.5, and 5) to assess the mean blood flow values. A multivariate analysis of variance" was performed across heart rate and systolic and diastolic blood pressure data obtained from the three groups of subjects. A 5% probability level for significance
BMDP-4V, University of California, Los Angeles, Los Angeles, CA 90024. || SAS Computer Program, SAS Institute, Inc, Cary, NC 27511.

(p < .05) was applied for all statistical tests. When significant differences were found, a Duncan's post hoc test was applied to discern which means of a treatment array were significantly different. RESULTS Descriptive data for the blood flow values are shown in the Figure. Duncan's post hoc analysis revealed that the EX Group had a significantly greater mean popliteal artery blood flow with muscle contractions than either the ES or Control Groups. Both the midtest (t = 2.5) and posttest (t = 5) mean blood flow measurements of the EX Group were significantly greater than the mean pretest (t = 0) value recorded for these
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TABLE 3 Means and Standard Deviations of Physical Characteristics of Subjects Heart Rate (bpm) Source Pretreatment Electrical Stimulation (n = 16) 10%MVC s 30% MVC s Exercise (n = 14) 10% MVC s 30% MVC s Control (n = 8) 10% MVC s 30% MVC s
a

Blood Pressure (mm Hg)a Posttreatment Pretreatment Midtreatment Posttreatment

Midtreatment

72.8 10.9 71.9 9.9

72.3 10.2 72.2 10.2

74.8 11.7 70.8 9.8

114.9/65.0 109.3/67.3 108.5/65.5 14.1/9.3 14.0/8.7 15.2/7.3 111.3/66.4 109.5/66.6 107.9/66.1 12.4/6.3 12.7/5.8 12.9/8.1

69.5 9.6 66.1 10.3

68.4 14.4 68.6 13.7

67.2 12.8 71.9 10.1

113.8/67.9 113.4/68.5 111.1/69.2 12.7/9.7 17.2/13.1 15.1/10.5 111.6/67.4 110.8/67.4 111.0/67.6 16.1/9.6 16.2/11.5 18.2/9.0

increases induced by electrical stimulation of the gastrocnemius muscle were not dependent on stimulus intensity (10% MVC effects = 30% MVC effects). The interaction of time and intensity and of time, intensity, and group had no significantly different effect on blood flow of subjects tested in this study (Tab. 2). Means and standard deviations of heart rate and blood pressure are given in Table 3. Duncan's post hoc analysis revealed significant among-group differences in mean heart rates for the EX and Control Groups, but the only mean difference occurring within subject groups was between the pretreatment and posttreatment measurements of the EX Group at 30% of MVC. Significant systolic blood pressure changes occurred in the ES and Control Groups. No statistical difference in mean diastolic blood pressure occurred in the study (Tab. 4). DISCUSSION The results of this study revealed that blood flow to the calf muscle was not influenced by HVS. Neither the 10% nor the 30% of MVC intensity of HVS resulted in changes in blood flow from pretest measurements. These findings are in agreement with those of Loze (unpublished data, 1981) and Fields (unpublished data, 1982), who studied the effects of HVS on healthy subjects. Small myelinated (Group III, A-delta) and nonmyelinated (Group IV, C) nerve fibers arising from afferent muscle receptors produce reflex cardiopulmonary responses. Accumulation of metabolites and mechanical events (pressure, stretch) from contractions of the gastrocnemius muscle have been linked to activation of these reflex responses.1415 The strength of HVS used in this study may not have been sufficient to produce this reflex cardiovascular change. High voltage stimulation has high peak voltages, but its pulse durations are extremely short (<75 sec), resulting in small total currents (current flow per second) that may have been insufficient to cause metabolite accumulation in the stimulated muscle. Studies reporting increased bloodflowto muscles in animals used electrical stimulators having pulse durations of 0.1 msec or longer.5,9,11 The amount of metabolic change in the tissue produced by the stimulation used in this study may have been less than that produced by stimulators using pulsed waveforms of longer duration because HVS produces small total currents and
PHYSICAL THERAPY

77.3 10.4 76.1 9.6

72.0 9.1 76.8 13.0

76.0 10.5 75.0 10.8

112.5/67.8 113.6/70.5 106.8/67.5 19.0/9.5 11.8/7.5 13.6/9.6 117.0/64.8 113.1/65.5 107.5/64.8 14.0/8.2 16.0/11.4 11.6/9.4

Systolic/diastolic value.

TABLE 4 Multivariate and Univariate Analyses of Variance Results Main Effect and Dependent Variable Group effects at 10%MVC a Time effects at 10%MVC Group x time effects at10%MVC HRb SBPC DBPd Group effects at 30% MVC Time effects at 30% MVC Group x time effects at 30% MVC HR SBP DBP
a b

Multivariate df F 8,50 16,14 38,26 4,26 4,26 4,26 8,50 8,22 16,42 4,54 4,54 4,54 0.43 2.37 4.90 P NS NS .038 F

Univariate P

0.63 8.57 1.20 0.30 2.62 2.53 NS .035 .008 5.74 3.90 1.75

NS .003 NS

.001 .007 NS

MVC = maximal voluntary isometric contraction. HR = heart rate. c SBP = systolic blood pressure. d DBP = diastolic blood pressure.

subjects, as revealed by the post hoc analysis (Tab. 2). Increasing the intensity of the electrical stimulation or the isometric exercise
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from 10% to 30% of MVC had no additive effect on the mean blood flow measured from the subjects of the two experimental groups. That is, blood flow

RESEARCH

generates little (if any) heat in the tissues.16 This aspect of HVS needs further investigation. Our finding of increased blood flow in the popliteal arteries of subjects performing volitional isometric exercises of 10% and 30% of MVC is in agreement with the findings of others.7,12 Previous studies involving graded exercise intensities have shown increases in blood flow to the exercising muscles to be dependent on exercise intensity.6,7,12 That is, as the exercise intensity increased, so did the blood flow. Blood flow to skeletal muscle during volitional exercise is largely controlled by local metabolism.12 As the magnitude of the muscle contractions increased, the local metabolism and thus the blood flow also increased proportionally as a result of the graded active exercise intensities of 10% and 30% of MVC. Heart rate and blood pressure were unaffected when the gastrocnemius muscle was stimulated electrically. In contrast, the voluntary exercise in our study was sufficient to produce systemic changes, causing the heart rate of the EX Group subjects to increase from pretest to posttest. In another study in which experimental conditions were similar to those of the ES Group in our study, the results revealed no heart rate or blood pressure changes related to the electrical stimulation of the calf muscle.17 Electrical stimulation of large muscles does not seem to influence the heart rate or blood pressure, whereas voluntary exercise of similar intensity does cause these changes.18 The mean heart rate and diastolic blood pressure of the Control Group remained unchanged throughout the

study, whereas the mean systolic blood pressure decreased significantly over time. Inactivity, coupled with prone subject positioning, probably caused the systolic blood pressure to decrease. Our results indicate that there appears to be little clinical benefit in using HVS to obtain increased blood flow to stimulated muscles. Further research is indicated to determine the reliability of these findings. A different pulse rate may perhaps be more effective than the 30-Hz pulse rate used in this study. Pilot studies by Alon et al,8 Loze (unpublished data, 1981), and Fields (unpublished data, 1982) on HVS using various stimulus rates, however, were not encouraging.
CONCLUSION

Results of this study enable us to conclude that HVS at 30 Hz and at intensities needed to evoke contractions at 10% or 30% of MVC does not increase bloodflowto the stimulated region. This finding applies to healthy calf muscles in which contractions are induced by HVS at stimulation characteristics similar to those used clinically by physical therapists. Our findings, therefore, do not support the clinical use of HVS for augmenting blood flow in human subjects.
REFERENCES
1. Karselis TC: Descriptive Medical Electronics and Instrumentation. Thorofare, NJ, Slack Inc, 1973, p 8 2. Harris PR: Iontophoresis: Clinical research in musculoskeletal inflammatory conditions. Journal of Orthopaedic and Sports Physical Therapy 4:109-112,1982 3. Gault WR, Gatens PF Jr: Use of low intensity direct current in management of ischemic skin ulcers. Phys Ther 56:265-269,1976 4. Alon G, De Domenico G: High Voltage Stimu-

lation: An Integrated Approach to Clinical Electrotherapy. Chattanooga, TN, Chattanooga Corp, 1987, pp 64-65 5. Petrofsky JS, Phillips CA, Sawka MN, et al: Blood flow and metabolism during isometric contractions in cat skeletal muscle. J Appl Physiol: Respirat Environ Exercise Physiol 50:493-502, 1981 6. Richardson D, Shewchuk R: Effects of contraction force and frequency on postexercise hyperemia in human calf muscles. J Appl Physiol: Respirat Environ Exercise Physiol 49:649654,1980 7. Richardson D: Blood flow response of human calf muscles to static contractions at various percentages of MVC. J Appl Physiol: Respirat Environ Exercise Physiol 51:929-933,1981 8. Alon G, Bainbridge J, Croson G, et al: Highvoltage pulsed direct current effects on peripheral blood flow. Abstract. Phys Ther 61:734, 1981 9. Wakim KG: Influence of frequency of muscle stimulation on circulation in the stimulated extremity. Arch Phys Med 34:291-295, 1953 10. Randall BF, Imig CJ, Hines HM: Effect of electrical stimulation upon blood flow and temperature of skeletal muscle. Am J Phys Med 32:22-26,1953 11. Folkow B, Halicka HD: A comparison between "red" and "white" muscle with respect to blood supply, capillary surface area and oxygen uptake during rest and exercise. Microvasc Res 1:1-14,1968 12. Petrofsky JS: Isometric Exercise and Its Clinical Implications. Springfield, IL, Charles C Thomas, Publisher, 1982, pp 96-97 13. Fronek A, Coel M, Bernstein EF: Quantitative ultrasonographic studies of lower extremity flow velocities in health and disease. Circulation 53:957-960,1976 14. Kniffki KD, Mense S, Schmidt RF: Muscle receptors with fine afferent fibers which may evoke circulatory reflexes. Circ Res 48(Suppl 1):25-21,1981 15. Kalia M, Mei SS, Kao FK: Central projections from ergoreceptors (C-fibers) in muscle involved in cardiopulmonary response to static exercise. Circ Res 48(Suppl 1):48-62, 1981 16. Alon G: Principles of electrical stimulation. In Nelson RM, Currier DP (eds): Clinical Electrotherapy. East Norwalk, CT, Appleton & Lange, 1987, pp 62-64 17. Currier DP, Petrilli CR, Threlkeld AJ: Effect of graded electrical stimulation on blood flow to healthy muscle. Phys Ther 66:937-943,1986 18. Buck JA, Amundsen LR, Nielsen DH: Systolic blood pressure responses during isometric contractions of large and small muscle groups. Med Sci Sports Exerc 12:145-147,1980

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