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PEMF fractured wrist

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BL

I know someone who acquired a fractured distal radius. They are using a MagnaWave Semi -10. I always favored the Faraday’s Law of Induction for how PEMF works. A person may feel “things moving” for minor injuries, and more so for the fracture. I thought it appropriate to go over some nuances of the movement of charged particle explanations. Some studies of PEMF devices to treat fractures of the wrist and had are presented. Some electrochemistry mechanisms are presented first. The reader is invited to decide if they studies support electrochemical mechanisms.

Table of Contents
  1. Some electrochemical mechanisms
    1. Piezo-electric
    2. streaming potentials, aka electro osmosis
  2. The ASTAR ABR device (Bielsko-Biała, Poland)
    1. Lazović 2020, Abstract plus more
      1. Introduction: 
      2. objective
      3. Methods: 
      4. results
      5. Conclusions: 
    2. Krzyżańska 2020
      1. Introduction
      2. Objective
      3. Methods
      4. Results
  3. The Fracture Healing Patch (FHP) (Pulsar Medtech Ltd)
    1. Introduction
    2. objectives
    3. methods
    4. results
  4. Electrochemistry for broken hand bones
    1. Orthopulse III® PEMF bone growth stimulator, Ossatec®
      1. Introduction
      2. objectives
      3. Methods
      4. results
    2. Osteobit® and Biostim®
      1. introduction
      2. objectives
      3. methods
      4. results
  5. Electrochemistry for bone healing health?
  6. References

Some electrochemical mechanisms

 Figueiredo 2024 Magnetism is very much interwoven into the Wikipedia discussion of electrochemistry: chemical changes in response to electric field potential differences. The Figueirdo review goes over the usual reactive oxygen species from the mitochondria and Ca2+ signaling. Bone structure possesses electromechanical properties that are activated by mechanical loading through compression and/or tension. These mechanical tensions spur bone growth. A good walk is good for our bones. Electric or magnetic fields can cause similar chemical changes as do mechanical stimuli. This section will explore how the two categories of bone growth therapy devices overlap with natural mechanical stimuli:

  • Capacitively Coupled stimulation devices require two electrodes placed on opposite sides of the target tissue to deliver sinusoidal EFs. This would be the Osteobit of De Francesco 2022
  • Inductively Coupled stimulation is mostly achieved through the delivery of pulsed electromagnetic fields (PEMF) or combined magnetic fields (CMF) This would be the Biostim of De Francesco 2022

The first author in this publication is a PhD student. Everything is reviewed including frequency/magnetic field combinations of hundreds of publications. This post will skip the Ca2+ signaling mechanisms.

Piezo-electric

The piezoelectric effect (mainly on dry bone, and attributed to the crystalline structure of collagen molecules) “The word piezoelectricity means electricity resulting from pressure. It is derived from Ancient Greek πιέζω (piézō) ‘to squeeze or press’ and ἤλεκτρον (ḗlektron) ‘amber’ (an ancient source of static electricity)” Biological molecules have dipole moments, uneven distribution of charges, that can be reorientated by mechanical forces. Such reorientation can create currents. Age, mineral, and organic content can influence the dielectric properties of bone. This particular effect is generally associated with dry bone. Bone contains a lot of collagen. Collagen is composed of triple alpha-helices. Triple helices are held together by hydrogen bonds between negatively charged oxygens and positively charged hydrogens on N-terminal nitrogen.

This one relates to the CCEF (capacitive coupling electric fields) and the Osteobit in with electrodes are placed directly on the Sink (Francesco 2022)

“Schematic of a parallel plate capacitor with a dielectric spacer. Two plates with area A are separated by a distance d. When a charge Q is moved between the plates, an electric field E exists in the region between the plates. The dielectric material becomes polarized due to the charge displacement, reducing the total internal field, and increasing the capacitance.” Now imagine that the -/+ orange oval is the hydrogen bonding in collagen. The mineral component of bone, hydroxyapatite, might be another dielectric.

Collagen is the organic component of bone as well as the extracellular matrix to which all cells attach. Perhaps gently reorientating these dipole moments of the collagen H-bonds has the same effect has actual mechanical strains that come with the use of the limb.

streaming potentials, aka electro osmosis

The streaming potential ( electroosmosis), as the name suggest, is the flow of water that follows the flow of ions. A quote from Figueiredo 2024, “that explain the smaller potentials on hydrated bone, which in vivo few piezoelectric responses given its water content. The bioelectrical signals in wet bone are attributed to the electrokinetic behavior of the ionic movement after changes in spatial charge density caused by bone bending or extracellular fluid movement in the bone matrix.” Just pressing down on wrist bones might cause fluid and solutes to move around. Using PEMF to move the charged particles will move water via osmosis.

This one relates back to the PEMF and the Biostim (Francesco 2022) An inductive coupled mechanism

This image is a fusion of the indicated Wikimedia Commons source and an image of a charged particle moving in a magnetic field on PhilSchatz.com. “When a charged particle moves along a magnetic field line into a region where the field becomes stronger, the particle experiences a force that reduces the component of velocity parallel to the field. This force slows the motion along the field line and here reverses it, forming a ‘magnetic mirror.’ ” What does this mean for charged particles in a broken wrist? One would predict, more than anything, PEMF simply stirs things up, just like walking or pressing down with the wrist.

So is PEMF just a nice massage that gently gets charged junk moving in the absence of the usual mechanical stimuli? Let’s explore a Polish PEMF device that seems to preserve function of immobilized fractured wrists as they heal.

The ASTAR ABR device (Bielsko-Biała, Poland)

The patient’s hand, wrist, and distal forearm were placed inside a concentric coil applicator 345 mm in diameter and 440 mm in height generating a magnetic field intensity of 6–10 mT and a frequency of 25–30 Hz.

Lazović 2020, Abstract plus more

Introduction: 

Colles’ fracture is a common dorsally displaced break of the distal radius. Rehabilitation strategies were lacking at the time of publication.

objective

To assess whether the use of pulsed electromagnetic field (PEMF) therapy during cast immobilization of DRF provides beneficial effects on pain, edema, wrist range of motion and function, as well as on the frequency of complications immediately after cast removal.

Methods: 

The prospective randomized controlled study included 60 women over the age of 55 years with extra-articular displaced DRF treated with reduction and cast immobilization. The patients were alternately allocated to either a PEMF group (n = 30, received 10 days of PEMF therapy during immobilization), or a control group (n = 30, without PEMF therapy). Pain, function, hand circumference, wrist and forearm range of motion and frequency of complications for each patient was evaluated within two to three days of cast removal.

results

Hand edema was 18 mm in the control group and 10 mm, on average in the PEMF group (p<0.001) Pain and activity scores were statistically the same. Edema was measured as the difference in the circumference between the injured and uninjured hand.

Better mean values for the majority of examined parameters were recorded in the PEMF group than in the control group, but the difference was statistically significant just for edema (p < 0.001), flexion, extension and supination range (p < 0.01).

parameterPEMF group (n=30)Control group (n=30)
Mean±SD Median(Min–Max)Mean±SDMedian (Min–Max)p
Flexion (degrees)6.50±10.4247.50 (22-62)37.33±12.5336.00 (18-62)<0.01
Extension (degrees)41.43±10.9542.00 (21-65)33.27±12.7133.50 (12-65)<0.01
Radial deviation (degrees)10.00±4.509.50 (3-20) ns11.00±5.6310.00 (0-27)ns
Ulnar deviation (degrees)18.00±6.3917.50 (5-30)17.10±4.6218.00 (5-25)ns
Pronation (degrees)63.57±16.4167.50 (30-85)61.03±17.5064.50 (30-82)ns
Supination (degrees)54.00±11.6153.00 (33-75)45.40±10.9743.00 (30-72)<0.01

Also, there was no complex regional pain syndrome type 1 in the PEMF group but 7% in the control group, not statistically significant.

Conclusions: 

During immobilization PEMF therapy in DRF patients gave better results immediately after cast removal in terms of edema and wrist range of motion (ROM). Some of the potential mechanisms cited include release of fibroblast growth factor and increased blood flow.

The authors obviously do not favor the electrochemical movement hypotheses but more so the Ca2+ signaling mechanisms that may include nitric oxide synthesis.

Krzyżańska 2020

Introduction

Colle’s fractures of the distal radius (DRF) are very common in those over 40. Part of the recovery once the cast removed involves physical therapy to restore strength and range of motion. PEMF is used to reduce inflammation and increase bone healing.

Objective

 this study aimed to determine the effect of PEMF therapy, started a day after injury and cast immobilization, on pain, edema, limb range of motion, exteroceptive sensation, and daily functioning in patients with DRFs.

Methods

To assess whether pulsed electromagnetic field therapy during cast immobilization of distal radius fractures has beneficial effects on pain and limb function, the study included 52 patients (mean age 60.8 ± 15.0 years) with distal radius fractures treated with cast immobilization. Patients were allocated to a pulsed electromagnetic field group (n = 27) or a control group (n = 25). The patients received 22 treatments over the period of six weeks. Pain, limb circumference (swelling), touch sensation, grip strength, and range of joint motion were outcome measures. These measures were taken the day of the cast removal and three and six weeks after.

Results

  • At the start pain scores were statistically the same. Pain subsided iwth time in both groups as well. By three and six weeks, the PEMF group was reporting much less pain. Pain scores started out around 6-7. By six weeks: 0.2 ± 0.42 (PEMF) 2.7 ± 2.15 (control ), p<0.0001. According to the methods, the pain scale ranged from 0 to 100. Something is not right about a broken wrist having very mild pain.
  • PEMF did not influence the circumference of the shoulder or forearm.
  • The PEMF group experienced better shoulder and forearm mobility.
  • dorsal wrist flexation, (o) 26 ± 10.60 (PEMF) 15 ± 6.85 (control) p<0.0001 PEMF still half the uninjured limb
  • palmar flexation, (o)29.5 ± 9.17 (PEMF) 19.8 ± 5.79 (control) p<0.0003
  • grip strength (kg)4.5 ± 3.14 (PEMF) 2.2 ± 1.52 (control) p< 0.0012 PEMF score at six weeks still 1/4th uninjured limb.
  • improvement in exteroceptive sensation, and reduction in disability of the upper limb (disabilities of the arm, shoulder, and hand) (p=0.0003; p < 0.0001, respectively).
  • 6 week DASH score 29.1 ± 13.97 (PEMF) 60.1 ± 20.29 (control) p<0.0001 Disability of Arm Shoulder Hand

The authors acknowledged the limitations of their small study size. The goal was not do much to speed healing but rather to limit the disability once the cast was removed. Reduction of edema was closest to a mechanism of how PEMF achieved favorable results. Movement of inflammatory small molecules might work with electrochemical mechanism of PEMF.

The Fracture Healing Patch (FHP) (Pulsar Medtech Ltd)

This section is a quick summary of Factor 2023. The FHP model used in this trial is comprised of 2 units which are placed on the contralateral sides of the arm (volar and dorsal) (Figure 1). The units communicate with each other and are able to adjust the intensity of the PEMF to conform to different arm dimensions, thus creating a uniform PEMF through the arm. The PEMF generated by the FHP is characterized by a pulse frequency of 20 KHz, cycle frequency of 10 Hz and pulse intensity at fracture site of between 0.05 mT and 0.5 mT.

Introduction

 PEMF is claimed to increase bone healing by opening voltage-gated ion channels, increasing cytosolic calcium, enhancing early angiogenesis, and promoting osteoblast differentiation and maturation. Increased cell proliferation, adhesion, and the osteogenic commitment of Mesenchymal stem cells (MSCs) was also cited as a mechanism. What was not mentioned was why the authors chose to use a radio frequency device rather than an extremely low frequency device.

objectives

  1. As an adjuvant to immobilization for acute DRF, treated non-operatively, does it accelerate bone healing?
  2. Does it improve functional outcome?
  3. Long term adverse events?

methods

Patients were recruited with a closed unilateral dorsally angulated DRF (Colles’) visible by X-ray; indication for non-operative treatment by means of cast immobilization with or without closed reduction; age > 18.  Half of the devices were inactivated in this double blind study. Fig 2 is a flow chart of the study design.

results

  • Fractures treated with active PEMF demonstrated significantly higher extent of union at 4 weeks as assessed by CT (76% vs. 58%, p = 0.02) By six weeks, there was no difference according to most of the raters.
  • Flexion was significantly better in the PEMF treated patients at 12 and 24 weeks. (B–D) All other parameters were slightly better in PEMF treated group, however not statistically significant.
  • Pain sub-score was better in the PEMF group at week 12 (p = 0.06). Total PRWE score was better in PEMF treated patients at 12 weeks, however not statistically significant (p = 0.07). 
  • Better physical well being at 12 weeks

The discussion did not explore potential mechanisms. The comment was made that the distal radius includes both trabecular and cortical bone. Since FHP uses radio frequency of PEMF, perhaps some sort of Ca2+ binding to calmodulin is part of the mechanism.

Electrochemistry for broken hand bones

Electrochemistry will refer to PEMF and alternating currents applied directly to the skin. In order to avoid confusion in the presentation of these two techniques, lets get a mental image of what is going on.

While the bones of the hand are connected to the distal radius, it is often less obvious when they are broken. De Francesco 2022 is all about non union of finger bone fractures. These authors examined two biophysical techniques. Hannemann 2015 was focused on delay union and mal-union of the scaphoid bone.

Orthopulse III® PEMF bone growth stimulator, Ossatec®

Hannemann 2015 scaphoid bone… Electromagnetic stimulation was administered continuously for 24 hours a day using a PEMF bone growth stimulator incorporated into the cast (learn more). The signal characteristics of the PEMF device used in our study were:

  • pulse amplitude 50 mV,
  • pulse width 5 μs, burst width 5 ms, burst refractory period 62 ms, There are 15 of these burst/wait events per second.
  • repetition rate 15 Hz. Half of the PEMF-devices were randomly disabled in the factory. Identical devices and the same follow-up protocol were used for both control and PEMF cases. Neither the investigators nor the patients were aware of the device’s functionality.

Introduction

The scaphoid, resting on the radius, has an essential role in proper functionality of the wrist. The challenges and benefits of early detection were discussed. As these injuries tend to occur in the young, the economic costs of prolonged immobilization were discussed. Low intensity pulsed ultrasound and PEMF were claimed to accelerate fracture repair and delayed union. Reduction of osteoclast resorption were cited as a mechanism. Inducing the formation of the osteoid and angiogenesis were cited as mechanisms. Osteoids, collagens and other fibrous proteins, are secreted by osteoblasts. Bone formation occurs as minerals enter this matrix.

Implementation of PEMF to the conservative treatment protocol of scaphoid fractures is more costly compared to standard care. However, it might lead to cost-savings due to a reduction of the total amount of working days lost. Therefore it is necessary to assess whether PEMF stimulation is a cost-effective treatment for acute scaphoid fractures.

objectives

The authors ( Hannemann 2015) performed an economic evaluation alongside a double-blind, randomized, placebo-controlled, multicenter trial involving five centers in the Netherlands, to establish the cost-effectiveness of pulsed electromagnetic fields (PEMF) in the treatment of acute scaphoid fractures.

Methods

This placebo controlled double blind study is summarized in fig 1. CT scans were collected at 6, 9, 12, 24 and 52 weeks after the start of treatment. In patients with complete clinical and radiological union, the cast was removed at six, 9 or 12 weeks, depending on the time of union.

results

The average total number of working days lost was lower in the active PEMF group (9.82 days) compared to the placebo group (12.91 days) (p = 0.651). Total medical costs of the intervention group (€1594) were significantly higher compared to the standard health care (€875). The total amount of mean QALY’s (quality-adjusted life year) for the active PEMF group was 0.84 and 0.85 for the control group. The cost-effectiveness plane shows that the majority of all cost-effectiveness ratios fall into the quadrant where PEMF is not only less effective in terms of QALY’s but also more costly.

Osteobit® and Biostim®

Francesco 2020, finger bones...  The authors are members of a hand surgery clinic in Acona, Italy. The reader must remember that “stimlated refers to one or two techniques: CCEF (capacitive coupling electric fields) or PEMF (pulsed electromagnetic fields.

  • Osteobit®: 2 5 µA/cm2 in the relevant site. The standard electric signal developed contains electrical pulses of 12.5 Hz with a duty cycle of 50%. The electric pulse is part of an active process containing a sinusoidal wave of 60 kHz. The electrodes are placed on exposed skin is available.
  • Biostim® IGEA Spa, Carpi, Italy)The PEMF generator delivers a pulsed signal containing a peak magnetic field intensity of 2.5 ± 0.1 mT and a frequency of 75 Hz. This is the method of choice in patients in a splint or cast,

introduction

 Hand bone fractures seem to go undetected until it is too late. The percentage of delayed union has never been estimated, but a non-union represents 9% and a mal-union up to 28% of fractures. Electrical stimulation requires direct skin contact. PEMF can be used with a cast. The authors sought data to convince patients who might be reluctant to wear devices to give them a try. Do they promote healing? The two different devices were lumped together in this study.

objectives

 Most phalangeal fractures present favorable union within 3 to 6 weeks. The objective was to test two biophysical techniques to promote proper healing with minimal inconvenience to the patient.

methods

The patient was required to wear the battery-operated device (Biostim® or Osteobit®) 8 h/day for 60 days during the daytime or night-time and to be alert to any undesirable events or symptoms including burning sensation or signs of skin rash, which would indicate immediate interruption of the treatment. The device was to be worn for a minimal 8 h/day interval for 60 days. The patients who agreed to comply with the biophysical stimulation (PEMF or CCEF) regimen were included in the stimulated group and retrospectively compared with the control group of untreated patients who refused the postoperative biophysical application. Healing was evaluated with radiographic images.

results

Biophysical techniques improved outcomes.

Electrochemistry for bone healing health?

Radio or extremely low frequency PEMF? Both seem to have benefit it terms of bone repair as well as return to normal function. It would seem that the elusive mechanism(s) might be more electrochemical than simply opening voltage gated Ca2+ channels.

References

  • De Francesco F, Gravina P, Varagona S, Setti S, Gigante A, Riccio M. Biophysical Stimulation in Delayed Fracture Healing of Hand Phalanx: A Radiographic Evaluation. Biomedicines. 2022 Oct 9;10(10):2519.. PMC free paper
  • Factor S, Druckmann I, Atlan F, Rosenblatt Y, Tordjman D, Krespi R, Kazum E, Pritsch T, Eisenberg G. The Effects of Novel Pulsed Electromagnetic Field Therapy Device on Acute Distal Radius Fractures: A Prospective, Double-Blind, Sham-Controlled, Randomized Pilot Study. J Clin Med. 2023 Feb 27;12(5):1866. PMC free paper
  • Figueiredo JGS, de Sousa BM, Soares Dos Santos MP, Vieira SI. (2023) Gathering Evidence to Leverage Musculoskeletal Magnetic Stimulation Towards Clinical Applicability. Small Sci. 2024 Feb 26;4(5):2300303. PMC free paper
  • Hannemann PF, Essers BA, Schots JP, Dullaert K, Poeze M, Brink PR. (2015) Functional outcome and cost-effectiveness of pulsed electromagnetic fields in the treatment of acute scaphoid fractures: a cost-utility analysis. BMC Musculoskelet Disord. 2015 Apr 11;16:84. PMC free paper
  • Krzyżańska L, Straburzyńska-Lupa A, Rąglewska P, Romanowski L. (2020) Beneficial Effects of Pulsed Electromagnetic Field during Cast Immobilization in Patients with Distal Radius Fracture. Biomed Res Int. 2020 Feb 25;2020:6849352. PMC free paper
  • Lazović M., Kocić M., Dimitrijević L., Stanković I., Spalević M., Cirić T. (2020) Pulsed electromagnetic field during cast immobilization in postmenopausal women with Colles’ fracture. Srpski Arhiv Za Celokupno Lekarstvo. 2012;140(9-10):619–624.
     [free paper] [PubMed] 

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