CLINICAL CONCEPT
Electroacupuncture: Applications in the Treatment of Chronic Nonhealing Wounds Edward W. Walton, DHSc, APN-C, NP-C
ABSTRACT Maximizing the effectiveness of any wound treatment requires that normal wound-healing dynamics are appreciated. In considering adjuvant wound therapies, the clinical evidence supporting a therapy must be fully understood. The biological changes associated with electroacupuncture can have a positive effect on wound healing, although limited clinical data are available. KEYWORDS: electroacupuncture, acupuncture, wound healing ADV SKIN WOUND CARE 2013;26:495Y7
INTRODUCTION Background and Significance In an acute injury to the skin and skin structures, most acute wounds will go on to heal without issue. Unfortunately, as we grow older, the aging process diminishes our body’s capacity to effectively heal a wound in which poor circulation, diminished inflammatory response (which is the important first step in the healing process), and the development of chronic diseases, such as diabetes mellitus, are common impediments to the healing process. All of the these physiological changes associated with the aging process can lead to slower healing and the development of a chronic wound.1 Optimizing wound-healing potential remains a key challenge to the wound care clinician in which various strategies to accelerate the wound-healing process continue to be explored. Currently, there is a paucity of data supporting the use of complementary and alternative medicine in wound healing, although alternative treatment modalities, such as acupuncture, yoga, biofeedback, massage, therapeutic touch, and aromatherapy, have been used with varying degrees of success in specifically treating wound pain.2 One strategy that has shown promise in enhancing woundhealing potential is the application of an electrical stimulus to a wound surface. Electrical stimulation has been shown to stimulate cellular migration in various wound models, in particular, keratinocyte migration.3,4 The actual biological effects of electric stimulation remain somewhat of a mystery and poorly understood.5 Recent studies profiling the biochemical effects of electrical stim-
ulation have reported that the exogenous electrical currents introduced during therapy may stimulate various intracellular signaling pathways, which ultimately leads to enhanced cellular migration.5 Along with the effects of electrical stimulation on cellular migration, Young et al6 reported that electrical stimulation can be used to decrease periwound edema. By combining both acupuncture and electrical stimulation, electroacupuncture has the potential to offer the beneficial effects of both modalities; however, there is a paucity of data in the literature to support acupuncture as a healing modality. The literature offers conflicting evidence regarding the potential benefits of acupuncture, particularly when used in isolation without concurrent electrical stimulation.7,8 The biological effects of electroacupuncture on wound healing have been described through small-scale mechanistic and animal model studies.9 A sound understanding of the physiological changes that occur during electroacupuncture therapy will help the clinician to understand the potential benefit, yet fully appreciate the limitations of this modality. The astute clinician needs to consider all potential variables that could be influencing healing outcomes and develop a clinical decision-making process that allows the clinician to make informed and logical decisions. With increased knowledge regarding the physiological effects of electroacupuncture, the clinician may consider the deployment of electroacupuncture as adjunctive therapy.
REVIEW OF THE LITERATURE Wound Healing Komarcevic10 describes wound healing as a complex cascade of cellular and biochemical events that occur among various cell types. The normal wound-healing process includes 3 predictable phases or stagesVinflammation, proliferation, and remodeling or maturation.10 During the wounding process, injury that occurs to adjacent blood vessels will eventually lead to the formation of a blood clot. Clark11 cited that the blood clot serves several key roles in the initiation of the healing process, including the provision of key components necessary in the initial formation of the extracellular matrix, creating a barrier against invading microorganisms and acting as a reservoir of growth factors.
Edward W. Walton, DHSc, APN-C, NP-C, is Assistant Professor of Nursing, School of Health Sciences, The Richard Stockton College of New Jersey School of Health Sciences, Galloway, New Jersey. Dr Walton has disclosed that he has no financial relationships related to this article. Submitted June 4, 2012; accepted in revised form January 3, 2013. WWW.WOUNDCAREJOURNAL.COM
495
ADVANCES IN SKIN & WOUND CARE & NOVEMBER 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CLINICAL CONCEPT
In the acute wound, regardless of the etiology, a sequential cascade of cellular and biochemical events occurs that guide the healing process. As previously described, the stages of wound healing are sequential and predictable in nature and often characteristic of the acute wound. It is a lack of progression, and/or stagnation through these fundamental stages, which promote abnormal healing processes. A smooth progression through the 3 stages of healing will ultimately lead to wound closure and complete healing in a timely manner. Chronic wounds remain a major problem for healthcare providers; billions of dollars are spent each year in the United States caring for these complex patients.12 Currently, there are multiple descriptors used when defining a chronic wound, although in the literature, it appears to be analogous with a wound in which healing is impaired. Many factors have been associated with impaired wound healing, including maceration, ischemia, and infection. Gasbarro13 stated that underlying systemic factors also needed to be considered in which chronological age, diabetes mellitus, poor nutrition, and renal impairment have all been implicated in negatively affecting wound healing. Chronic wounds are often the resultant effects of an underlying disease state, or display impaired healing due to coexisting disease.14 Examples of chronic wounds would include diabetic foot ulcers, arterial/ischemic lower-extremity ulcers, pressure ulcers, and venous leg ulcers. Despite different etiological factors, chronic wounds all share a common characteristic in which they lack progression through normal stages of healing. The lack of progression through the normal healing processes, combined with the heterogeneous nature of chronic wounds, is what makes the selection of wound treatment modalities quite complex.14
Electroacupuncture Overview Electroacupuncture has been shown to stimulate tissue repair in various tissues including osseous structures in which enhanced callus formation and bone mineralization were noted.15 In addition, the healing effects of electroacupuncture have been documented in chronic wounds that have become resistant to conventional forms of treatment. Data suggest that histochemical changes that occur in periwound tissues appear to be consistent with healing tissues. Electroacupuncture appears to improve blood supply, periwound biochemistry, and overall tissue repair processes.9 In addition to electroacupuncture’s effects on the periwound environment, Lewis et al16 demonstrated that electroacupuncture can be an effective intervention for controlling periwound pain. Their findings suggest that patients with burn injuries experienced significant reductions in pain levels immediately following wound debridement and dressing changes.
ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 11
Electroacupuncture Use in Chronic Wounds Electroacupuncture has been shown to have a positive influence on wound healing and tissue regeneration.17 Clinical studies have demonstrated that acupuncture provokes vasodilation in the skin and muscle, which promotes increased blood flow to injured or wounded tissue. Electroacupuncture’s effects are most likely due to direct effects on nerve fiber axons, although other undocumented mechanisms are also suspected.18 In addition to electroacupuncture’s effects on increasing cutaneous blood flow, reductions in the expression and/or activation of proYnerve growth factor, tumor necrosis factor >, interleukin 1A, interleukin 6, nitric oxide synthase, cyclooxygenase 2, and matrix metalloproteinase 9 have been reported.19,20 Sumano and Mateos21 published healing data on chronic wounds that were treated with 2 different electrical delivery methods: (1) via subcutaneously inserted needles placed around the wound edge or (2) saline-soaked gauze placed in the wound and connected to an electrical source. The findings of this study demonstrated that regardless of the delivery method, electrical stimulation appeared to facilitate healing in a timely and organized manner. There are several published studies that describe the use of electroacupuncture in the treatment of chronic venous leg ulcers in which considerable heterogeneity in the electroacupuncture technique and/or approach was noted. Variability was mostly noted in the timing of individual sessions, number of treatments, length or duration of treatment cycle, and optimal treatment amplitude in which the electrical current amplitude was often titrated to patient tolerance. Despite the lack of consensus in electroacupuncture technique, chronic venous leg ulcers appeared to respond favorably to electroacupuncture treatment and display evidence of enhanced wound healing.9,22,23 More recent evidence even suggests that ultralow microcurrent (in the mA to nA range) facilitated accelerated healing and appeared to offset the effect of a person’s age on wound healing.24
Adjunctive Therapy Another form of wound stimulation that can be used as adjunctive therapy with electroacupuncture is moxibustion. Moxibustion consists of burning the herb, Artemisia vulgaris, on or above the skin at specific acupuncture points to use thermal energy as a source of stimulation. The literature suggests that moxibustion can enhance regional blood flow and immune function in which published studies using infrared-spectrum technology demonstrate that moxibustion may be bimodal in its local stimulatory effect. It has been reported that moxibustion may not only produce its therapeutic effect by way of thermal energy, but may also involve sympathetic nerve stimulation, causing a vibratory effect at the skin surface.25 Moxibustion’s effects on local and regional
496
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CLINICAL CONCEPT
blood flow, in combination with data supporting enhanced immune function, highlight the main reasons why moxibustion has been considered a key adjunctive therapy to electroacupuncture in clinical practice. Moxibustion has recently been shown to produce a localized tissue warming effect in chronic skin ulcers in which an increase in periwound microcirculation and enhanced wound healing dynamics were noted.26 It is believed that moxibustion’s effects mimic the stimulation of acupuncture and electrical stimulation, whereby increasing blood flow to the wound and up-regulating growth factors need to promote healing processes.26 Even though this trend is based primarily on evidence provided by way of case studies and retrospective analyses, the potential for a differential response cannot be excluded. It should be noted, as with any treatment modality, that moxibustion is not without risk. Park et al27 published the results of a systemic review that reported moxibustion possesses the potential for various adverse events, such as contact allergies, thermal injuries, and local infections. Currently, the incidence of adverse events associated with moxibustion is unknown. Largescale safety studies would be warranted before widespread use of this modality is adopted in clinical practice.27
DISCUSSION Wounds are multidimensional; thus, their presenting features and characteristics may differ dramatically depending on the type, location, and classification. This variability provides a significant challenge to the wound-healing clinician and will greatly influence treatment options. Unless the clinician is acutely aware of the potential benefit and limitations of adjuvant therapies, clinical treatment decisions are based on arbitrary selection processes and not on clinical merit. A clinician who is aware of the limitations of electroacupuncture therapy can make an informed decision that will be in the patient’s best interest. Despite the documented biological effects of electroacupuncture, little research has been carried out in well-conducted clinical trials. In addition, there appear to be few data comparing electroacupuncture’s effects in various wound models. Therefore, a differential effect may be present, depending on the particular wound type that is being treated.
CONCLUSIONS Despite the lack of well-constructed, randomized controlled trials supporting the use of electroacupuncture, mechanistic studies appear to suggest that electrical stimulation may offer some benefit regarding wound healing. In considering the overall cost of a chronic wound, more research is needed regarding the costeffectiveness of electroacupuncture therapy. If electroacupuncture can initiate biochemical changes within a chronic wound and ‘‘kickstart’’ the healing process, electroacupuncture may prove to be a cost-effective option when considering adjuvant therapy. If WWW.WOUNDCAREJOURNAL.COM
electroacupuncture is going to be an accepted wound treatment option, more robust clinical data are needed to support its widespread use.
&
REFERENCES 1. Becker DL, Thrasivoulou C, Phillips AR. Connexins in wound healing; perspectives in diabetic patients. Biochim Biophys Acta 2012;1818:2068-75. 2. Rosenbaum C. An overview of integrative care options for patients with chronic wounds. Ostomy Wound Manage 2012;58(5):44-51. 3. Kucerova R, Walczysko P, Reid B, et al. The role of electrical signals in murine corneal wound re-epithelialization. J Cell Physiol 2011;226(6):1544-53. 4. Guo A, Song B, Reid B, et al. Effects of physiological electric fields on migration of human dermal fibroblasts. J Invest Dermatol 2010;130(9):2320-7. 5. Zhao M, Penninger J, Isseroff RR. Electrical activation of wound-healing pathways. Adv Skin Wound Care 2010;1:567-73. 6. Young S, Hampton S, Tadej M. Study to evaluate the effect of low-intensity pulsed electrical currents on levels of oedema in chronic non-healing wounds. J Wound Care 2011;20:368, 370-3. 7. Saarto EE, Hielm-Bjorkman AK, Hette K, Kuusela EK, Brandao CV, Luna SP. Effect of a single acupuncture treatment on surgical wound healing in dogs: a randomized, single blinded, controlled pilot study. Acta Vet Scand 2010;52:57. 8. Lee JA, Jeong HJ, Park HJ, Jeon S, Hong SU. Acupuncture accelerates wound healing in burn-injured mice. Burns 2011;37(1):117-25. 9. Di Bernardo N, Crisafulli A, Gemelli F, Ferlazzo F, Cucinotta E, Foti A. Experimental research on the effect of electro-acupuncture on reparative processes [in Italian]. Minerva Med 1980;71:3709-13. 10. Komarcevic A. The modern approach to wound treatment [article in Croatian]. Med Pregle 2000;53(7-8):363-8. 11. Clark RA. Basics of cutaneous wound repair. J Dermatol Surg Oncol 1993;19:693-706. 12. Fonder MA, Lazarus GS, Cowan DA, Aronson-Cook B, Kohli A, Mamelak J. Treating the chronic wound: a practical approach to the care of nonhealing wounds and wound care dressings. J Am Acad Dermatol 2008;58:185-206. 13. Gasbarro R. Negative pressure wound therapy: a clinical review. Wounds 2007; 19(12 Suppl):2-7. 14. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med 1999;341:738-46. 15. Nakajima M, Inoue M, Hojo T. Effect of electroacupuncture on the healing process of tibia fracture in a rat model: a randomised controlled trial. Acupunct Med 2010;28:140-3. 16. Lewis SM, Clelland JA, Knowles CJ, Jackson JR Dimick AR. Effects of auricular acupuncture-like transcutaneous electric nerve stimulation on pain levels following wound care in patients with burns: a pilot study. J Burn Care Rehabil 1990;11:322-9. 17. Foell J. Acupuncture as add-on treatment in the management of a patient with ecthyma gangrenosum. Acupunct Med 2012;20(1):60-2. 18. Vas J, Modesto M, Mendez C, et al. Effectiveness of acupuncture, special dressings and simple low adherence dressings for healing venous leg ulcers in primary healthcare. BMC Complement Altern Med 2008;8:29. 19. Jansen G, Lundeberg T, Kjartansson J, Samuelson UE. Acupuncture and sensory neuropeptides increase cutaneous blood flow in rats. Neurosci Lett 1989;97:305-9. 20. Choi DC, Lee JY, Moon YJ, Kim SW, Oh TH, Yune TY. Acupuncture-mediated inhibition of inflammation facilitates significant functional recovery after spinal cord injury. Neurobiol Dis 2010;39:272-82. 21. Sumano H, Mateos G. The use of acupuncture-like electrical stimulation for wound healing of lesions unresponsive to conventional treatment. Am J Acupunct 1999;27(1-2):5-14. 22. Mears T. Acupuncture for chronic venous ulceration. Acupunct Med 2003;21:150-2. 23. Bacchini M, Conci F, Roccia L, Carrossino R. Circulatory disorders and acupuncture. Minerva Med 1979;70:1755-7. 24. Lee BY, Wendell K, Al-Waili N, Butler G. Ultra-low microcurrent therapy: a novel approach for treatment of chronic resistant wounds. Adv Ther 2007;24:1202-9. 25. Shen X, Ding G, Wei J, et al. An infrared radiation study of the biophysical characteristics of traditional moxibustion. Complement Ther Med 2006;14:213-9. 26. Sun YH, Sun LH, Liang YL, et al. Effect of mildwarm moxibustion on microcirculation in the raw surface tissue of chronic refractory wound in skin ulcer rats [in Chinese]. Zhen Ci Yan Jiu 2011;36:321-6. 27. Park JE, Lee SS, Lee MS, Choi SM, Ernst E. Adverse events of moxibustion: a systematic review. Complement Ther Med 2010;18:215-23.
497
ADVANCES IN SKIN & WOUND CARE & NOVEMBER 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Electroacupuncture: Applications in the Treatment of Chronic Nonhealing Wounds Edward W. Walton, DHSc, APN-C, NP-C
ABSTRACT Maximizing the effectiveness of any wound treatment requires that normal wound-healing dynamics are appreciated. In considering adjuvant wound therapies, the clinical evidence supporting a therapy must be fully understood. The biological changes associated with electroacupuncture can have a positive effect on wound healing, although limited clinical data are available. KEYWORDS: electroacupuncture, acupuncture, wound healing ADV SKIN WOUND CARE 2013;26:495Y7
INTRODUCTION Background and Significance In an acute injury to the skin and skin structures, most acute wounds will go on to heal without issue. Unfortunately, as we grow older, the aging process diminishes our body’s capacity to effectively heal a wound in which poor circulation, diminished inflammatory response (which is the important first step in the healing process), and the development of chronic diseases, such as diabetes mellitus, are common impediments to the healing process. All of the these physiological changes associated with the aging process can lead to slower healing and the development of a chronic wound.1 Optimizing wound-healing potential remains a key challenge to the wound care clinician in which various strategies to accelerate the wound-healing process continue to be explored. Currently, there is a paucity of data supporting the use of complementary and alternative medicine in wound healing, although alternative treatment modalities, such as acupuncture, yoga, biofeedback, massage, therapeutic touch, and aromatherapy, have been used with varying degrees of success in specifically treating wound pain.2 One strategy that has shown promise in enhancing woundhealing potential is the application of an electrical stimulus to a wound surface. Electrical stimulation has been shown to stimulate cellular migration in various wound models, in particular, keratinocyte migration.3,4 The actual biological effects of electric stimulation remain somewhat of a mystery and poorly understood.5 Recent studies profiling the biochemical effects of electrical stim-
ulation have reported that the exogenous electrical currents introduced during therapy may stimulate various intracellular signaling pathways, which ultimately leads to enhanced cellular migration.5 Along with the effects of electrical stimulation on cellular migration, Young et al6 reported that electrical stimulation can be used to decrease periwound edema. By combining both acupuncture and electrical stimulation, electroacupuncture has the potential to offer the beneficial effects of both modalities; however, there is a paucity of data in the literature to support acupuncture as a healing modality. The literature offers conflicting evidence regarding the potential benefits of acupuncture, particularly when used in isolation without concurrent electrical stimulation.7,8 The biological effects of electroacupuncture on wound healing have been described through small-scale mechanistic and animal model studies.9 A sound understanding of the physiological changes that occur during electroacupuncture therapy will help the clinician to understand the potential benefit, yet fully appreciate the limitations of this modality. The astute clinician needs to consider all potential variables that could be influencing healing outcomes and develop a clinical decision-making process that allows the clinician to make informed and logical decisions. With increased knowledge regarding the physiological effects of electroacupuncture, the clinician may consider the deployment of electroacupuncture as adjunctive therapy.
REVIEW OF THE LITERATURE Wound Healing Komarcevic10 describes wound healing as a complex cascade of cellular and biochemical events that occur among various cell types. The normal wound-healing process includes 3 predictable phases or stagesVinflammation, proliferation, and remodeling or maturation.10 During the wounding process, injury that occurs to adjacent blood vessels will eventually lead to the formation of a blood clot. Clark11 cited that the blood clot serves several key roles in the initiation of the healing process, including the provision of key components necessary in the initial formation of the extracellular matrix, creating a barrier against invading microorganisms and acting as a reservoir of growth factors.
Edward W. Walton, DHSc, APN-C, NP-C, is Assistant Professor of Nursing, School of Health Sciences, The Richard Stockton College of New Jersey School of Health Sciences, Galloway, New Jersey. Dr Walton has disclosed that he has no financial relationships related to this article. Submitted June 4, 2012; accepted in revised form January 3, 2013. WWW.WOUNDCAREJOURNAL.COM
495
ADVANCES IN SKIN & WOUND CARE & NOVEMBER 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CLINICAL CONCEPT
In the acute wound, regardless of the etiology, a sequential cascade of cellular and biochemical events occurs that guide the healing process. As previously described, the stages of wound healing are sequential and predictable in nature and often characteristic of the acute wound. It is a lack of progression, and/or stagnation through these fundamental stages, which promote abnormal healing processes. A smooth progression through the 3 stages of healing will ultimately lead to wound closure and complete healing in a timely manner. Chronic wounds remain a major problem for healthcare providers; billions of dollars are spent each year in the United States caring for these complex patients.12 Currently, there are multiple descriptors used when defining a chronic wound, although in the literature, it appears to be analogous with a wound in which healing is impaired. Many factors have been associated with impaired wound healing, including maceration, ischemia, and infection. Gasbarro13 stated that underlying systemic factors also needed to be considered in which chronological age, diabetes mellitus, poor nutrition, and renal impairment have all been implicated in negatively affecting wound healing. Chronic wounds are often the resultant effects of an underlying disease state, or display impaired healing due to coexisting disease.14 Examples of chronic wounds would include diabetic foot ulcers, arterial/ischemic lower-extremity ulcers, pressure ulcers, and venous leg ulcers. Despite different etiological factors, chronic wounds all share a common characteristic in which they lack progression through normal stages of healing. The lack of progression through the normal healing processes, combined with the heterogeneous nature of chronic wounds, is what makes the selection of wound treatment modalities quite complex.14
Electroacupuncture Overview Electroacupuncture has been shown to stimulate tissue repair in various tissues including osseous structures in which enhanced callus formation and bone mineralization were noted.15 In addition, the healing effects of electroacupuncture have been documented in chronic wounds that have become resistant to conventional forms of treatment. Data suggest that histochemical changes that occur in periwound tissues appear to be consistent with healing tissues. Electroacupuncture appears to improve blood supply, periwound biochemistry, and overall tissue repair processes.9 In addition to electroacupuncture’s effects on the periwound environment, Lewis et al16 demonstrated that electroacupuncture can be an effective intervention for controlling periwound pain. Their findings suggest that patients with burn injuries experienced significant reductions in pain levels immediately following wound debridement and dressing changes.
ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 11
Electroacupuncture Use in Chronic Wounds Electroacupuncture has been shown to have a positive influence on wound healing and tissue regeneration.17 Clinical studies have demonstrated that acupuncture provokes vasodilation in the skin and muscle, which promotes increased blood flow to injured or wounded tissue. Electroacupuncture’s effects are most likely due to direct effects on nerve fiber axons, although other undocumented mechanisms are also suspected.18 In addition to electroacupuncture’s effects on increasing cutaneous blood flow, reductions in the expression and/or activation of proYnerve growth factor, tumor necrosis factor >, interleukin 1A, interleukin 6, nitric oxide synthase, cyclooxygenase 2, and matrix metalloproteinase 9 have been reported.19,20 Sumano and Mateos21 published healing data on chronic wounds that were treated with 2 different electrical delivery methods: (1) via subcutaneously inserted needles placed around the wound edge or (2) saline-soaked gauze placed in the wound and connected to an electrical source. The findings of this study demonstrated that regardless of the delivery method, electrical stimulation appeared to facilitate healing in a timely and organized manner. There are several published studies that describe the use of electroacupuncture in the treatment of chronic venous leg ulcers in which considerable heterogeneity in the electroacupuncture technique and/or approach was noted. Variability was mostly noted in the timing of individual sessions, number of treatments, length or duration of treatment cycle, and optimal treatment amplitude in which the electrical current amplitude was often titrated to patient tolerance. Despite the lack of consensus in electroacupuncture technique, chronic venous leg ulcers appeared to respond favorably to electroacupuncture treatment and display evidence of enhanced wound healing.9,22,23 More recent evidence even suggests that ultralow microcurrent (in the mA to nA range) facilitated accelerated healing and appeared to offset the effect of a person’s age on wound healing.24
Adjunctive Therapy Another form of wound stimulation that can be used as adjunctive therapy with electroacupuncture is moxibustion. Moxibustion consists of burning the herb, Artemisia vulgaris, on or above the skin at specific acupuncture points to use thermal energy as a source of stimulation. The literature suggests that moxibustion can enhance regional blood flow and immune function in which published studies using infrared-spectrum technology demonstrate that moxibustion may be bimodal in its local stimulatory effect. It has been reported that moxibustion may not only produce its therapeutic effect by way of thermal energy, but may also involve sympathetic nerve stimulation, causing a vibratory effect at the skin surface.25 Moxibustion’s effects on local and regional
496
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CLINICAL CONCEPT
blood flow, in combination with data supporting enhanced immune function, highlight the main reasons why moxibustion has been considered a key adjunctive therapy to electroacupuncture in clinical practice. Moxibustion has recently been shown to produce a localized tissue warming effect in chronic skin ulcers in which an increase in periwound microcirculation and enhanced wound healing dynamics were noted.26 It is believed that moxibustion’s effects mimic the stimulation of acupuncture and electrical stimulation, whereby increasing blood flow to the wound and up-regulating growth factors need to promote healing processes.26 Even though this trend is based primarily on evidence provided by way of case studies and retrospective analyses, the potential for a differential response cannot be excluded. It should be noted, as with any treatment modality, that moxibustion is not without risk. Park et al27 published the results of a systemic review that reported moxibustion possesses the potential for various adverse events, such as contact allergies, thermal injuries, and local infections. Currently, the incidence of adverse events associated with moxibustion is unknown. Largescale safety studies would be warranted before widespread use of this modality is adopted in clinical practice.27
DISCUSSION Wounds are multidimensional; thus, their presenting features and characteristics may differ dramatically depending on the type, location, and classification. This variability provides a significant challenge to the wound-healing clinician and will greatly influence treatment options. Unless the clinician is acutely aware of the potential benefit and limitations of adjuvant therapies, clinical treatment decisions are based on arbitrary selection processes and not on clinical merit. A clinician who is aware of the limitations of electroacupuncture therapy can make an informed decision that will be in the patient’s best interest. Despite the documented biological effects of electroacupuncture, little research has been carried out in well-conducted clinical trials. In addition, there appear to be few data comparing electroacupuncture’s effects in various wound models. Therefore, a differential effect may be present, depending on the particular wound type that is being treated.
CONCLUSIONS Despite the lack of well-constructed, randomized controlled trials supporting the use of electroacupuncture, mechanistic studies appear to suggest that electrical stimulation may offer some benefit regarding wound healing. In considering the overall cost of a chronic wound, more research is needed regarding the costeffectiveness of electroacupuncture therapy. If electroacupuncture can initiate biochemical changes within a chronic wound and ‘‘kickstart’’ the healing process, electroacupuncture may prove to be a cost-effective option when considering adjuvant therapy. If WWW.WOUNDCAREJOURNAL.COM
electroacupuncture is going to be an accepted wound treatment option, more robust clinical data are needed to support its widespread use.
&
REFERENCES 1. Becker DL, Thrasivoulou C, Phillips AR. Connexins in wound healing; perspectives in diabetic patients. Biochim Biophys Acta 2012;1818:2068-75. 2. Rosenbaum C. An overview of integrative care options for patients with chronic wounds. Ostomy Wound Manage 2012;58(5):44-51. 3. Kucerova R, Walczysko P, Reid B, et al. The role of electrical signals in murine corneal wound re-epithelialization. J Cell Physiol 2011;226(6):1544-53. 4. Guo A, Song B, Reid B, et al. Effects of physiological electric fields on migration of human dermal fibroblasts. J Invest Dermatol 2010;130(9):2320-7. 5. Zhao M, Penninger J, Isseroff RR. Electrical activation of wound-healing pathways. Adv Skin Wound Care 2010;1:567-73. 6. Young S, Hampton S, Tadej M. Study to evaluate the effect of low-intensity pulsed electrical currents on levels of oedema in chronic non-healing wounds. J Wound Care 2011;20:368, 370-3. 7. Saarto EE, Hielm-Bjorkman AK, Hette K, Kuusela EK, Brandao CV, Luna SP. Effect of a single acupuncture treatment on surgical wound healing in dogs: a randomized, single blinded, controlled pilot study. Acta Vet Scand 2010;52:57. 8. Lee JA, Jeong HJ, Park HJ, Jeon S, Hong SU. Acupuncture accelerates wound healing in burn-injured mice. Burns 2011;37(1):117-25. 9. Di Bernardo N, Crisafulli A, Gemelli F, Ferlazzo F, Cucinotta E, Foti A. Experimental research on the effect of electro-acupuncture on reparative processes [in Italian]. Minerva Med 1980;71:3709-13. 10. Komarcevic A. The modern approach to wound treatment [article in Croatian]. Med Pregle 2000;53(7-8):363-8. 11. Clark RA. Basics of cutaneous wound repair. J Dermatol Surg Oncol 1993;19:693-706. 12. Fonder MA, Lazarus GS, Cowan DA, Aronson-Cook B, Kohli A, Mamelak J. Treating the chronic wound: a practical approach to the care of nonhealing wounds and wound care dressings. J Am Acad Dermatol 2008;58:185-206. 13. Gasbarro R. Negative pressure wound therapy: a clinical review. Wounds 2007; 19(12 Suppl):2-7. 14. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med 1999;341:738-46. 15. Nakajima M, Inoue M, Hojo T. Effect of electroacupuncture on the healing process of tibia fracture in a rat model: a randomised controlled trial. Acupunct Med 2010;28:140-3. 16. Lewis SM, Clelland JA, Knowles CJ, Jackson JR Dimick AR. Effects of auricular acupuncture-like transcutaneous electric nerve stimulation on pain levels following wound care in patients with burns: a pilot study. J Burn Care Rehabil 1990;11:322-9. 17. Foell J. Acupuncture as add-on treatment in the management of a patient with ecthyma gangrenosum. Acupunct Med 2012;20(1):60-2. 18. Vas J, Modesto M, Mendez C, et al. Effectiveness of acupuncture, special dressings and simple low adherence dressings for healing venous leg ulcers in primary healthcare. BMC Complement Altern Med 2008;8:29. 19. Jansen G, Lundeberg T, Kjartansson J, Samuelson UE. Acupuncture and sensory neuropeptides increase cutaneous blood flow in rats. Neurosci Lett 1989;97:305-9. 20. Choi DC, Lee JY, Moon YJ, Kim SW, Oh TH, Yune TY. Acupuncture-mediated inhibition of inflammation facilitates significant functional recovery after spinal cord injury. Neurobiol Dis 2010;39:272-82. 21. Sumano H, Mateos G. The use of acupuncture-like electrical stimulation for wound healing of lesions unresponsive to conventional treatment. Am J Acupunct 1999;27(1-2):5-14. 22. Mears T. Acupuncture for chronic venous ulceration. Acupunct Med 2003;21:150-2. 23. Bacchini M, Conci F, Roccia L, Carrossino R. Circulatory disorders and acupuncture. Minerva Med 1979;70:1755-7. 24. Lee BY, Wendell K, Al-Waili N, Butler G. Ultra-low microcurrent therapy: a novel approach for treatment of chronic resistant wounds. Adv Ther 2007;24:1202-9. 25. Shen X, Ding G, Wei J, et al. An infrared radiation study of the biophysical characteristics of traditional moxibustion. Complement Ther Med 2006;14:213-9. 26. Sun YH, Sun LH, Liang YL, et al. Effect of mildwarm moxibustion on microcirculation in the raw surface tissue of chronic refractory wound in skin ulcer rats [in Chinese]. Zhen Ci Yan Jiu 2011;36:321-6. 27. Park JE, Lee SS, Lee MS, Choi SM, Ernst E. Adverse events of moxibustion: a systematic review. Complement Ther Med 2010;18:215-23.
497
ADVANCES IN SKIN & WOUND CARE & NOVEMBER 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
