Fundamental and practical aspects of therapeutic uses of pulsed electromagnetic fields (PEMFs).
The beneficial therapeutic effects of selected low-energy, time-varying magnetic fields, called PEMFs, have been documented with increasing frequency since 1973. Initially, this form of athermal energy was used mainly as a salvage for patients with long-standing juvenile and adult nonunions. Many of these individuals were candidates for amputation. Their clearly documented resistance to the usual forms of surgical treatment, including bone grafting, served as a reasonable control in judging the efficacy of this new therapeutic method, particularly when PEMFs were the sole change in patient management. More recently, the biological effectiveness of this approach in augmenting bone healing has been confirmed by several highly significant double-blind and controlled prospective studies in less challenging clinical circumstances. Furthermore, double-blind evidence of therapeutic effects in other clinical disorders has emerged. These data, coupled with well-controlled laboratory findings on pertinent mechanisms of action, have begun to place PEMFs on a therapeutic par with surgically invasive methods but at considerably less risk and cost. As a result of these clinical observations and concerns about electromagnetic "pollution", interactions of nonionizing electromagnetic fields with biological processes have been the subject of increasing investigational activity. Over the past decade, the number of publications on these topics has risen exponentially. They now include textbooks, speciality journals, regular reviews by government agencies, in addition to individual articles, appearing in the wide spectrum of peer-reviewed, scientific sources. In a recent editorial in Current Contents, the editor reviews the frontiers of biomedical engineering focusing on Science Citation Index methods for identifying core research endeavors. Dr. Garfield chose PEMFs from among other biomedical engineering efforts as an example of a rapidly emerging discipline. Three new societies in the bioelectromagnetics, bioelectrochemistry, and bioelectrical growth and repair have been organized during this time, along with a number of national and international committees and conferences. These activities augment a continuing interest by the IEEE in the U.S. and the IEE in the U.K. This review focuses on the principles and practice behind the therapeutic use of "PEMFs". This term is restricted to time-varying magnetic field characteristics that induce voltage waveform patterns in bone similar to those resulting from mechanical deformation. These asymmetric, broad-band pulses affect a number of biologic processes athermally. Many of these processes appear to have the ability to modify selected pathologic states in the musculoskeletal and other systems. Bassett C. Dep. Orthopedic Surgery, Columbia University, New York. Crit Rev Biomed Eng
Pulsed electromagnetic fields promote collagen production in bone marrow fibroblasts via athermal mechanisms.
Primary and passaged cultures of fibroblasts (RBMFs) raised from the bone marrow stroma of young rabbits were treated with pulsed electromagnetic fields (PEMFs) from the start of each culture until 1 week after they became confluent. The PEMF treatment had no effect on cell proliferation, estimated by phase contrast microscopy, by 3H-thymidine incorporation into DNA, or by total DNA assay. Collagen production, estimated by conversion of 3H-proline to 3H-hydroxyproline in nondialyzable material was markedly elevated in postconfluent cultures, but not in cultures that had only just reached confluence. About 65 of 3H-hydroxyproline was in low molecular weight form, and a correlation between collagen breakdown and cyclic AMP (cAMP) levels in RBMFs was demonstrated by adding dibutyryl cAMP or prostaglandin E3 (PGE2) to the culture medium concurrently with 3H-proline. The PEMF apparatus caused an insufficient temperature rise (less than 0.1 degree C) to account for these results. We propose that the rise in collagen production is consistent with the hypothesis that PEMFs act by reducing cAMP levels in RBMFs, and that thermal effects are insignificant. Farndale R. et.al Calcif Tissue Int
Modulation of collagen production in cultured fibroblasts by a low-frequency pulsed magnetic field.
Primary cultures of chicken tendon fibroblasts have been exposed for various periods to a low-frequency, pulsed magnetic field, and the effects on protein and collagen synthesis have been examined by radioisotopic incorporation. Total protein synthesis was increased in confluent cells treated with a pulsed magnetic field for the last 24 h of culture as well as in cells treated for a total of 6 days. However, in 6 day-treated cultures, collagen accumulation was specifically enhanced as compared to total protein, whereas after short-term exposure, collagen production was increased only to the same extent as total protein. Levels of cyclic AMP were significantly decreased after 6-day pulsed magnetic field treatment, probably as a consequence of diminished adenylate cyclase activity. Exposure to pulsed magnetic field had no effect on cell proliferation or collagen phenotype. These results indicate that a pulsed magnetic field can specifically increase production of collagen, the major differentiated function of fibroblasts, possibly by altering cyclic-AMP metabolism. Murray J. et.al. Biochim Biophys Acta
Results of pulsed electromagnetic fields (PEMFs) in ununited fractures after external skeletal fixation.
Of 147 patients with fractures of the tibia, femur and humerus, in whom an average of 3.3 operations had failed to produce union, all were treated with external skeletal fixation in situ and pulsed electromagnetic fields (PEMFs). Of the 147, 107 patients united for an overall success rate of 73%. Union of the femur occurred in 81% and the tibia in 75%. Only five of 13 humeri united. Failure to achieve union with PEMFs was most closely associated with very wide fracture gaps and insecure skeletal fixation devices. Marcer M. et.al. Clin Orthop
Osteonecrosis of the femoral head treated by pulsed electromagnetic fields (PEMFs): a preliminary report.
This has been a preliminary report with a short-term follow-up of a small number of observations (28 hips of 24 patients). The follow-ups ranged from 6 to 36 months, with an average of 17.8 months. Only eleven hips (in eleven patients) were followed an average of 8 months after cessation of the treatment. It should be emphasized that this was a "pilot" study, in which no control series was used to determine the natural course of the disease in a comparable clinical setting. Of note was the pain relief, in 19 of 23 patients with moderate to severe pretreatment pain. Also there was an improved function, which suggests that at least in approximately two thirds of the patients there was some clinical benefit from this mode of treatment. In eight hips, clinical conditions did not change; and in two they worsened, requiring further treatment. Eighteen remaining hips were thought to have benefited by the treatment. Six femoral heads that had already developed varying degrees of collapse (Ficat Type III) collapsed further (1 to 2 mm), and two round heads (Ficat II) progressed to off-round (Ficat III). This preliminary study suggests that further exploration of pulsed electromagnetic fields (PEMFs) is warranted in the treatment of osteonecrosis of the femoral head. Eftekhar N. et.al. Hip
Treatment of therapeutically resistant non-unions with bone grafts and pulsing electromagnetic fields.
This study reviews the cases of eighty-three adults with ununited fractures who were treated concomitantly with bone-grafting and pulsed electromagnetic fields. An average of 1.5 years had elapsed since fracture and the use of this combined approach. Nearly one-third of the patients had a history of infection, and an average of 2.4 prior operations had failed to produce bone union. Thirty-eight patients who were initially treated with grafts and pulsed electromagnetic fields for ununited fractures with wide gaps, synovial pseudarthrosis, and malalignment achieved a rate of successful healing of 87 per cent. Forty-five patients who had initially been treated unsuccessfully with pulsing electromagnetic fields alone had bone-grafting and were re-treated with pulsing electromagnetic fields. Ninety-three per cent of these fractures healed. The residual failure rate after two therapeutic attempts, one of which was operative, was 1.5 per cent. The median time to union for both groups of patients was four months. Bassett C. Et.al. J Bone Joint Surg Am
Effects of a pulsed electromagnetic field on a mixed chondroblastic tissue culture.
A mixed tissue culture predominantly composed of chondroblastic tissue was perturbed by a pulsed electromagnetic field (PEMF). Some cultures were nonconfluent, and purposely retarded in growth to resemble an atrophic nonunion, while others were grown to confluence in about one-half the time as a model for a hypertrophic nonunion. These two groups tested the effect of growth rate upon the products of cell proliferation and differentiation. The slowly growing cultures were stimulated to synthesize hydroxyproline. The rapidly growing cultures showed a large increase in lysozyme activity, and increase in hyaluronate and DNA, and a decrease in glycosaminoglycan. Exogenous lysozyme further decreased the glycosaminoglycan synthesis in the presence of PEMF. Chitotriose, a specific lysozyme inhibitor abolished this effect. Cycloheximide, a protein synthesis inhibitor, did not abolish the activation of lysozyme found in the matrix. Thus lysozyme appears to be activated by PEMF. These observations of the rapidly growing confluent cultures are consistent with events described in the normal healing of a bone fracture or endochrondral growth. Thus, PEMF appears to promote normal healing, probably by altering cartilaginous lysozyme activity in the matrix, and possibly the sequence of events leading to calcification. Norton LA Clin Orthop
Biological effects of magnetic fields: studies with microorganisms.
Five bacteria and one yeast were grown in magnetic fields of 50-900 gauss with frequencies of 0-0.3 HZ and square, triangular, or sine waveform. Growth of these microorganisms could be stimulated or inhibited depending upon the field strength and frequency of the pulsed magnetic field. Spore germination and mutation frequency were unaffected by the magnetic fields used in this study. Moore R. Can J Microbiol
Influence of magnetic fields on calcium salts crystal formation: an explanation of the 'pulsed electromagnetic field' technique for bone healing.
In the search for a mechanism by means of which a magnetic field deparalyses non-unions and enhances bone tissue formation, the influence of continuous magnetic fields on the formation of calcium phosphate crystal seeds has been investigated. From this perspective, an explanation is given of a working mode in conventional equipment for pulsed electromagnetic field treatment; this is compared with multifunction equipment. Madronero A J Biomed Eng
