Research Report

Effects of Electrical Stimulation on Lymphatic Flow and Limb Volume in the Rat

Background and Purpose. The mechanism by which electrical stimulation affects edemu has not been elucidated The purpose of this study was to determine whether subcontraction high-voltage stimulation (SC-FNS) (ie,electrical stimulation that did not elicit a visible contraction) applied to the right hind limbs of rats would (1) alter the rate of lymphatic uptake of injected albumin labeled with Evans blue dye (AL-EBD)and (2)affect experimentally induced edema. Subjects and Metbods. The paws of 28 anesthetized Sprague-Dawlq rats (mean weight-263 g,SD =48 @ were injected with AL-EBD. The experimentalgroup (n=13) received I hour of SC-HVS, and the control group (n=15) received sham treatment conskting of the same treatment administered to the experimental group but without the SC-HVS. Blood samples and volume measurements were obtained at intervals over a 7-hourperiod. Results. Analysis of variance and post hoc testing indicated that higher amounts of AL-EBD were taken up by the lymph of the e.xperimenta1group animals as compared with the control group animals at each time period following the treatment. The experimental group's AL-EBD reached signzjicance immediately after treatment, whereas the control group required an additional 4 hours. There was no signzjicant reduction in limb volume in either group. Conclusion and Discusdon. The SC-HVS signzjicantly increased the uptake of AL-EBD by lymphatic vessels, but it did not cause a signijicant decrease in the induced edemu. The results of this study indicate that SC-HVS has the potential to reduce edemu by increasing lymphatic uptake of proteins. [Cook Morales M, La Rosa EM, et al. E$cts of electrical stimulation on lymphaticjlow and limb volume in the rat. Phys Ther. 1994;74:1040-1046.1

Heather A Cook Monlca Morales Ellsabeth M La Rosa Jalmi Dean M Kelly Donnelly Patti McHugh Abby Otradovec Kimberly S Wrlght Theodore Kula Steven H Tepper

ta

Key Words: E d m , Electrical stimulation, Evans blue dye, Lymphatics, Rats.

HA Cook, FT, M Morales, FT,EM L a Rosa, FT,J Dean, PT, M K Donnelly, PT, P McHugh, FT, A Otradovec, PT, and KS Wright, FT,were senior physical therapy students at the University of Maryland

at Baltimore when this research was conducted in partial fulfillment of their degree requirements. T Kula, PhD, is Visiting Research Assistant Professor, Department of Diagnostic Sciences, School of Dentistry, The University of North Carolina, Chapel Hill, NC 27514. He was Assistant Professor, Department of Medical and Research Technology, University of Maryland at Baltimore, Baltimore, MD 21201, when this research was conducted. SH Tepper, PhD, FT, is Associate Professor, Program in Physical Therapy, Shenandoah UniversityWinches~.er Medical Center, 333 West Cork St, Winchester, V A 22601 (USA). He was Assistant Professor, Department of Physical Therapy, University of Maryland at Baltimore, when this research was conducted. Address all correspondence to Dr Tepper. The study protocol was approved by the Institutional Animal Care and Use Committee of the University of Maryland. This work was supported by CONMED Corp; Chattanooga Corp; and the Department of Physical Therapy, University of Maryland. This article was submitred July 6 1993, and was accepted June 23, 1994.

Subcontraction high-voltage stimulation (SC-HVS) (ie, electrical stimulation below the level needed to elicit a visible contraction) has been widely used in clinical settings for the purpose of reducing edema. Edema reduction is important because edema results in poor oxygenation of the affected tissue,l an impaired ability to function, and a decreased healing rate.2 Acute edema results from tissue trauma or infection as a result of the inflammatory process. Acute edema occurs as pan of the inflammatory response as chemical mediators lead to endothelial leakage of plasma proteins, primarily albumin,

Physical Therapy/Volume 74, Number 11/November 1994

and increased capillary hydrostatic pressure. The resulting increased capillary hydrostatic and interstitial oncotic forces draw fluid from the blood vessels into the interstitium.3 Because albumin is too large to be reabsorbed by blood vessels, it is returned to the bloodstream from the interstitium almost exclusively by the lymphatic system.G7 Consequently, when albumin is taken up by the lymph channels, fluid follows and edema decreases. The importance of the oncotic mechanism is readily apparent in cases of lymphatic obstruction, in which protein uptake is inhibited and edema occurs." The use of SC-HVS could theoretically affect edema either by preventing edema formationS1O or by reducing edema that has already been produced." The first hypothesis is that SC-HVS restricts leakage from the microvasculature by decreasing permeability to proteins.8 This mechanism addresses the prevention of edema and is supported by the research of Reeds and Bettany et al.9 ReedHfound reduced leakage of flourescein-labeled dextran from the microvasculature of the golden hamster cheek pouch receiving highvoltage stimulation as compared with control animals. Bettany et a19 found that following trauma, formation of edema was significantly less in frogs' limbs immersed in water and treated with SC-HVS (four 30-minute treatments at 1.5-hour intervals of continuous twin pulses at 75 microseconds, 120 Hz, with negative polarity) as compared with the control limbs. Experimental limb volume also continued to be less than that of the control limb throughout 17 hours of subsequent treatment and measurement intervals. Because there was no further reduction of edema with the subsequent SC-HVS treatments, this result cannot be differentiated from prevention of edema versus reduction of edema. In a follow-up study, Taylor et a1,lO using variables similar to those described (except with a single 30minute treatment), found a reduction

in edema for 4.5 hours following treatment. No difference between the control and the experimental limbs was measured during subsequent time periods. The second hypothesis addresses the reduction of edema. Alon and De Domenicoll hypothesized that SC-HVS enhances the movement of charged proteins into the lymphatic channels. When an electric field is introduced into an area, charged proteins are put into motion and migration into the lymphatic channels is accelerated. The lymphatic channels' osmotic pressure is thereby increased, hastening the absorption of fluid from the interstitial space.
A study on reduction of edema

right hind limbs of rats would (1) modify the rate of lymphatic uptake of albumin labeled with Evans blue dye (AL-EBD) and (2) influence limb volume.

Method

Subjects
A total of 30 male Sprague-Dawley

rats (mean weight=263 g, SD=48 g) were housed in a lighudark (12 hours each) and temperature-controlled (72F) environment. They were provided food and water ad libitum.

Procedure
The animals were divided into two groups: a control group (n= 15) and an experimental group (n= 15). All animals were initially anesthetized with an intraperitoneal injection of sodium pentobarbital (50 mg per kilogram of body weight) and were given subsequent doses as needed. Sodium pentobarbital has been shown not to influence the contraction rate of lymph vessels.l3 Initial paw volume measurements and blood samples were taken from each rat. All of the animals' right hind paws were then injected with AI-EBD, utilizing sterile techniques, between the second and third metatarsals, which created the experimentally induced edema. Over the course of the experiment, the AI-EBD was absorbed from the interstitium into the lymphatics, entered the bloodstream via the thoracic duct, and was monitored through blood samples. Postinjection blood samples and paw volumes were taken. The experimental group received 1 hour of SC-HVS. The control group received a 1-hour sham treatment. Sham treatment consisted of the same procedure used for the experimental group but without the SC-HVS. Volume measurements and blood samples were then taken from both groups as follows: 1 hour postinjection (corresponding to the termination of the sham or SC-HVS treatment), 3 hours postinjection, 5 hours postinjection, and 7 hours postinjection (Tab. 1).

yielded results that are seemingly contradictory to Alon and De Dominico's theory." Mohr et all2 applied one daily 20-minute treatment of SC-HVS (continuous mode, pulse rate=80 pulses per second, average current flow=35 PA, with the positive electrode placed over the right hip and the negative electrode over the right edematous hind paws of 20 rats) on 3 consecutive days after traumatization by weight drop (50 g, 0.5 cm in diameter, from a height of 50 cm). Volumes of the traumatized limbs were assessed by a plethysmograph. Both the control and experimental groups revealed a volume reduction over the testing days. The reduction of edema in the experimental group, however, did not reach statistically significant levels as compared with the control group animals. A possible flaw in the study by Mohr et a1 was their failure to establish reliability for their volume measurements. No studies have been found that examined the effects of SC-HVS on protein uptake and lymphatic flow. In view of the scarcity of research on this subject, the goal of our experiment was to determine whether SCHVS alters the flow of interstitial substances into the lymphatic system, thereby decting edema. The twofold purpose was to determine whether SC-HVS applied to the edematous

Physical Therapy / Volume 74, Number 1l/November 1994

Table 1. Basic Design of the Experimental Protocol

Blood Sample Llmb Volume

Anesthetization Preinjectis~n Injection of EBD~ Postinjection Treatment-1 Sham SC-HV!SC h

XXXa

XXX

XXX

XXX

1 h postinjection

XXX XXX XXX XXX

XXX XXX XXX XXX

3 h postinjection
5 h postinjection

7 h postinjection

"XXX=point at which blood sample and limb volume were taken. b ~ ~ ~ = ~blue v a dye. n s 'SC-HVS= high-voltage electrical stimulation that did not elicit a visible contraction.

with waterproof ink. The rat was suspended in a rat restrainer from a rod clamped to a camera tripod. Each rat's Daw was dampened prior to being lowered into the immersion vessel of the plethysmograph to the level of the paw's ink mark. The immersion of the limb caused a displacement of fluid, which was drawn off by a calibrated microsyringe until the circuit was broken, as indicated on the oscilloscope. The amount of displaced fluid was taken to be equivalent to the animal's paw volume (in milliliters). The procedure was performed until two measurements were within 0.1 mL of each other. The average of the two immersions was used for statistical analysis. The volumetric measurements were performed by the same experimenter (HAC) throughout the study. The experimenter measured the volume of 10 animals' limbs three times, and intratester reliability was assessed by subjecting the data to an intraclass correlation coefficient (ICC[2,1])procedure.

blood was collected from the nicked tips of the rats' tails into heparinized capillary tubes." After 5 minutes of centrifugation, the plasma was removed and stored in a refrigerator. For analysis, 100 pL of each plasma sample was diluted with 3 mL of 0.9% saline. The concentration of EBD in the solution (absorbance value) was measured by a DW-2 UV, VIS spectrophotometer' using a wavelength of 620 nm, a band pass of 3 nm, and a cuvette path length of 1 cm.3 Reliability testing of the apparatus was performed.

Electrical Stimulation
The 1 hour of monophasic pulsed SC-HVS was applied to the experimental group animals, with the positive electrode on the plantar surface and the negative electrode on the shaved dorsal surface of the paw.l5 Self-adhesive electrodesg measuring 2.3X 1.5 cm were used and did not overlap each other. The voltage setting was determined for each rat by eliciting a visible contraction of the digital muscles and reducing the intensity until the contraction ceased.12 The setting was readjusted after 15 minutes to account for accommodation. The stimulatorll was set on continuous mode at a pulse rate of 100 pulses per second, with an average current of 251.54 p A (SD=96.96) and a voltage of 100.62 V (SD=38.78). The control group animals received 1 hour of sham treatment using the same electrode placement.

Volumetric Measurements
Volume measurements of the right hind paws were performed using a small-volume plethysmograph as described by Mohr and Akers,14with modifications as described by Cosgrove el. all5 The modifications included the addition of a biopolar needle electrode,* an oscilloscope, and a tripod, which increased the accuracy of the volume measurements. The microsyringe of the plethysmograph was set at zero, and water was added until the fluid level met the tip of the needle electrode. The circuit was thereby closed, as indicated on the oscilloscope. To measure the paw volumes, the lateral malleohs of each animal was marked

Blood Sampling and Measurement of Evans Blue Dye

A mixture was prepared using Evans

blue dye (EBD) and rat plasma (2 mg of EBD per milliliter of heparinized rat plasma). At this concentration, all of the EBD binds to albumin.16 The concentration of the solution was doubled by centrifuging the mixture through an Amicon CentrifloTM membrane cone,+which removed one half of the fluid volume. This concentration was found to be necessary in order to monitor the EBD in the plasma by the spectrophotometer. This concentrated solution (0.5 mL per kilogram of body weight) was injected into the rats' paws.
To assess the EBD concentration in the plasma of the rats, 2oo pL

Data Analysis
The data collected from this research, the amount of AL-EBD in the plasma (absorbance value) and the limb volume measurements (in milliliters), were evaluated by a two-way analysis of variance for repeated measures with an alpha level of .05. A Student-Neuman-Keuls post hoc test was used to determine where significant results had occurred.

'Bioelectronics, 5696 Park Rd SW, Ft Myers, F L 33908. +Amicon,72 Cherry Hill Dr, Beverly, MA 01915. $American Instruments, Silver Spring, MD 20902. $CONMET)Corp, 310 Broad St, Utica, NY 13501. II~hattanoo~a Group Inc, 4717 Adams Rd, Hixson, TN 37343.

Results
Although the study began with 30 rats, only data from 28 rats (15 control

Physical Therapy /Volume 74, Number 1l/November 1994

Evans Blue Dye Concentration

Table 2. Statistical Analysis of Evans Blue Dye in Rat Plasma
MSE df
F P

Main effect differences of the AL-EBD between g r o u ~ s and over time were significant. For this study, however, the interaction effect between groups and time was considered to be the
" 1

Table 3 . Statistical Analysis #Limb

Volume Measurements
MSE df
F P

Groups

125.6 25.2 25.2

24 120 120

0,7
40.5 4.4

,0035a
.OOOOa ,0013"

Time periods Interaction

most important comparison (Tab. 2). The following interaction effects were of greatest importance: 1. No differences were found between control and experimental groups in the AL-EBD concentration in the preinjection and postinjection blood samples (ie, before treatment began) (Fig. 1). 2. Increases in the amount of AL-EBD were found in the plasma of the experimental group as compared with the control group at the I-, 3-,

Groups

0.1 168

25

0.23 ,6406

Time periods 5 , 63 25 Interaction 5.1 163 125

33,25 ,OOOOa
1.54 ,1802

group animals and 13 experimental group animals) were included in the data analysis. One rat died as a result o f an overdose from the anesthesia. A second rat's data were discarded due to technical error (volume of blood from the tail was inadequate).

5-, and 7-hour postinjection blood samplings (Fig. 1).

3. The experimental group animals

exhibited increases of AL-EBD from the postinjection (ie, pretreatment) values at 1, 3, 5, and 7 hours postinjection, as opposed to 5 and 7 hours postinjection needed in the control group animals before an increase was noted (Fig. 1).The AL-EBD values remained above the postinjection values for both groups in the subsequent time intervals. 4. Successive increases of the AL-EBD occurred in the experimental group between the time periods of postinjection (ie, pretreatment) and 1 hour postinjection ([4.40-+0.62 to 5.77k 1.281X and between 1 and 3 hours postinjection ([5.77+1.28 to 6.95+ 1.521x (Fig. 1). In contrast, no increase was seen between successive time periods in the control group animals. The reliability (Y) of the spectrophotometric readings, as determined by ICC (3,1), was found to be .99.

10

T
51
X
0

6 Z 8

I 4

Preinjury Postinjury

1h

3h

5h

7h

Llmb Volume
Main effect differences of limb volume between the control and experimental groups were not significant throughout the study. A significant main effect alteration, however, was noted between time intervals with both groups combined (Tab. 3, Fig. 2). The interaction effect revealed no difference between groups and time periods (Tab. 3, Fig. 2). The reliability (Y)of

Time Period
Control Group Experimental Group

Flgure 1. Comparison of mean amounts of Evans blue dye in the plasma over the course of the experiment between control and experimental groups (a=P<.O5) (error bars represent standard deviation). Signifcant increases occurred between successive time periods (c=P<.05), and specificallyfrom postinjection values in the experimental group only (b=P<.05). Signifcant increases specfically from postinjection values occurred in the control group only (d=P<.05).
52 / 1043

Physical Therapy/Volume 74, Number ll/November 1994

experimental group animals, as opposed to 5 hours postinjection needed in the control group animals (Fig. 1). This finding substantiates the efficacy of SC-HVS for rapid removal of the AL-EBD from the interstitial area. Due to the enhancement of lymphatic flow inherent during an edematous situation, the control group eventually did exhibit an in~ r e a s e . l 9The . ~ ~continual rise in the subsequent AL-EBD values supports our methodology. The dramatic increases that were found between two successive time intervals in the experimental group (Fig. I), as compared with the gradual rise in the control group, are another illustration of the beneficial effect of SC-HVS. In addition, SC-HVS continued to exert its effect for 2 hours poststimulation, for the amount of AL-EBD at the 3-hour measurement was also higher in the experimental group than in the control group (Fig. 1). At the present time, we have no explanation for this phenomenon. We hypothesize that SC-HVS increases lymphatic uptake of AL-EBD by the following mechanisms: (1) The movement of charged proteins into the lymphatic channels is accentuated, and (2) the contraction of lymphatic smooth muscle is enhanced. Alon and De Domenico's theory," as previously discussed, states that the introduction of an electrical field into an area expedites the movement of charged proteins into the lymphatic channels. Hargens and Zweifach13 studied the contractility of bovine mesenteric lymphatics and showed that when lymph vessel volume was increased, the contractile rate of lymphatic smooth muscles spontaneously increased. Therefore, the hypothesized mechanism is that the SC-HVS facilitated lymph transport by augmenting the movement of AL-EBD into the rats' lymphatic vessels. The fluid drawn into the vessels by the oncotic force of the AL-EBD distended the lumen of the lymphatic vessel and caused a subsequent increase in the rate of lymphatic c ~ n t r a c t i o n . ~ ~

Preinjury Postlnjury 1 h Control Group

3h

5h

7h

Time Period
Experimental Group

Flgure 2. Comparison of mean limb volumes specifcally from preinjection values

(b=P<.05) and between successive time intervals with control and experimental groups combined (a=P< .05) (error bars represent standard deviation).

the limb volume measurements, as determined by ICC (2,1), was 92.

Discussion

Evans Blue Dye

In both .the control and experimental groups, preinjection values of AL-EBD were not significantly dflerent from postinjection values. This finding revealed that the AL-EBD was not inadvertently injected into the bloodstream. This finding was important for establishing the credibility of our methods. The level of AL-EBD was higher in the experimental group than in the control group at 1, 3, 5, and 7 hours postinjection. The SC-HVS apparently exerted a positive effect on movement of the AL,-EBD from the interstitium into the bloodstream. Because the albumin was removed from the interstitial space almost exclusively by the

lymphatics and entered the bloodstream via the thoracic duct, the amount of AL-EBD in the blood plasma was directly related to lymphatic uptake from the area.l6818 In addition, recent studies using radiolabeled albumin support the concept that tagged albumin returns to the bloodstream via the lymphatics.7J9 If the injected AL-EBD had gone directly into the bloodstream, it would have been detected in the postinjection blood samples. The AL-EBD in the plasma, however, did not increase until at least 1 hour postinjection, showing further support that the lymphatics are responsible for plasma uptake. Both the control and experimental groups showed an increase in AL-EBD concentration in the plasma over the course of the experiment (Fig. 1). A rise in the AL-EBD as compared with postinjection values, however, occurred at 1 hour postinjection in the

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The third mechanism by which lymphatic flow is thought to increase is that SC-HVS enhances the contraction of lymphatic smooth muscle indirectly via the autonomic nervous system. A previous study22 demonstrated that under certain conditions (frequency=48-96 Hz, voltage=50 V, 0.3 milliseconds, 10 seconds' duration), lymphatic nerves and smooth muscle could be directly stimulated to facilitate the contractile rate. These electrical stimulation settings are different from those used in our experiment. McGeown et a123found that stimulation of the sympathetic chain increased lymph flow and lymphatic contraction frequency in sheep hindlimb lymphatics. Transmural stimulation of the bovine mesenteric lymphatics directly excited the intramural nerves of lymphatic smooth muscle.22 In our study, however, we administered electrical stimulation through the skin, as utilized in physical therapy clinics. Electrical stimulation delivered in this manner cannot directly stimulate lymph smooth muscle and autonomic nervous system fibers without activating skeletal motoneurons.I1 In addition, autonomic nervous sytem fibers that innervate lymph smooth muscle share morphological characteristics with pain fibers (ie, small fiber diameter, unmyelinated, low conduction velocity). If stimulation were to elicit direct excitation of intramural lymphatic nerves, the pain would be intolerable to the subjects and there would be unwanted skeletal musde contractions. Consequently, a hypothesized mechanism by which AL-EBD uptake was increased in this study is through transcutaneous stimulation of sensory neurons, which may have caused the autonomic nervous system to be stimulated. This stimulation may have led to the release of adrenergic substances, which are excitatory to lymph smooth muscle cells and result in spontaneous propulsion of lymph.24

lead to any differences in limb volume between the control and experimental groups (Fig. 2). This discrepancy between the increased uptake of AL-EBD without a concurrent reduction in limb volume may be due to the fact that the amounts of AL-EBD taken up were measured with a spectrophotometer, which is approximately 10 times more sensitive than are plethysmographic measurements. In addition, although the 1 hour of SC-HVS enhanced lymphatic flow, the time may not have been sufficient to create a significant volume change. These results agree with those of Mohr et a1,12 who found no difference between control and SC-HVS-treated traumatized rat paws. Our results differed from those of other investigationsSl0 in which SC-HVS was initiated immediately following trauma o r histamine injection. As demonstrated by Reed,8 SC-HVS limits the permeability of capillaries to larger molecules, similar to albumin. In our study, labeled albumin was already in the interstitium prior to the electrical stimulation, which may have led to the difference in results. The fact that limb volume increased over the course of the experiment in both groups was possibly due to (1) an inadvertent inflammatory reaction to the sterile injection procedure or (2) the oncotic force created by the extremely high concentration of ALEBD mixture in the interstitial space. If the concentration of tagged albumin had been the same as in plasma (and therefore the oncotic force had been less), the SC-HVS may have led to a reduction in the limb volume values. Based on the results of this study, we believe that SC-HVS has the potential to reduce edema. A 1-hour treatment, however, may not be sufficient in this model. Because a typical treatment protocol using SC-HVS for edema reduction is approximately 20 to 30 minutes in duration, further clinical research on this modality is essential. Future studies should address (1) creating a situation in which the interstitial concentration of proteins would be the same as in plasma, (2) increas-

ing the time of stimulation, (3) continuing the data collection for a longer time period, and (4) using a more sensitive device for measuring limb volume.

Conclusion
This study demonstrated a physiological mechanism by which SC-HVS may exert its effects on edema, because lymphatic uptake of AL-EBD was greater in the experimental group animals than in the control group animals. A reduction in the rat limb volume was not achieved in either the experimental group or thc contrul group. Although SC-HVS may assist in edema reduction via the lymphatics, further studies are needed to show actual reductions in limb volume.
References
1 Heughan C, Niinikoski J, Hunt TIC Effect of excessive infusion of saline solution on tissue oxygen transport. Sulg Gynecol Obsfet. 1972; 135257-260. 2 Kline I, Miller A, Katz L. Cardiac lymph flow impairment and myocardial fibrosis. Arch Pathol. 1963;76:424433. 3 Harada S, Dannenberg A, Kajiki A, et al. Inflammatory mediators and modulators released in organ culture from rabbit skin lesions produced in vivo by suIfur mustard, 11: Evans blue dye experiments that determined the rates of entry and turnover of serum protein in developing and healing lesions. Am J Pathol. 1985;121:2%38. 4 Olszewski W. On the pathomechanism of development of postsurgical lymphedema. L ~ ~ P ~ 1973;6:35-51. O ~ O ~ . 5 Ganong W. Review of Medical Physiology. Los Altos, Calif: Lange Medical Publications; 1993. 6 Henze E, Schelbert HR, Collins JD, et al. Lymphoscintigraphy with Tc-99m-labeled dextran. J Nucl Med. 1982;23:923-929, 7 Ohtake E, Matsui K. Lymphoscintigraphy in patients with lymphedema: a new approach using intradermal injections of technetium99m human serum albumin. Clin Nuc Med 1986;11:4744478. 8 Reed B. Effect of high voltage pulsed electrical stimulation o n microvascular permeability to plasma proteins: a possible mechanism to minimizing edema. Phys T h m 1988;68:491495. 9 Bettany JA, Fish DR, Mendel FC. Influence of high voltage pulsed direct current on edema formation following impact injury. Phys T h e 1990;70:219-224. 10 Taylor K, Fish DR, Mendel FC, Burton HW. Effect of single 30-minute treatment of high voltage pulsed current on edema formation in frog hind limbs. Pbys Ther. 1992;72:6348.

Limb Volume
The enhanced lymphatic drainage, as indicated by the increase in AL-EBD concentration in the plasma, did not

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11 Alon G , De Domenico G. High Voltage Stimulation:An Integrated Approach to Clinical Electrotherapy. Chattanooga, Tenn: Chattanooga Corp; 1987. 12 Mohr T, Akers T, Landry R. Effect of high voltage stimulation o n edema reduction in the rat hind limb. Phys Ther. 1987;67:1703-1707. 13 Hargens A, Zweifach B. Contractile stimuli m J Physiol. 1977; in collectnng lymph vessels. A 233:H57-.H65. 14 Mohr T, Akers T. Simplified plethysmographic technique. Biomed Sci Instrum. 1985; 21:l-3. 15 Cosgrove K, Alon G, Bell S, et al. The electrical effect of two commonly used clinical stimulators on traumatic edema in rats. Phys Ther. 199:!;72:227-233. 16 Courtice F, Steinbeck A. The lymphatic drainage of plasma from the peritoneal cavity

of the cat. Aust J Exp Biol Med Sci. 1950;28: 161-169. 1 7 Stearns S, Lee P. A rapid method for repeated collection of blood from the tail vein of rats. Lab Anim Sci. 1984;34:395-396. 18 Courtice F, Simmonds W. Absorption of fluids from the pleural cavities of rabbits and cats.J Physiol (Lond). 1949;109:117-130. 1 9 Stewart G, Gaunt JI, Croft DN, Browse NL. Isotope lymphography: a new method of investigating the role of the lymphatics in chronic limb oedema. Br J Surg 1985;72:906 909. 20 Reddy NP. Lymph circulation: physiology, pharmacology, and biomechanics. Crit Rev Biomed Eng. 1988;14:45-89. 21 Ohhashi T, Azuma T, Sakaguchi M. Active and passive mechanical characteristics of bo-

vine mesenteric lymphatics. Am J Physiol, 1980;239:H8%H95. 22 Ohhashi T, McHale N, Roddie I, Thornbury K. Electrical field stimulation as a method of stimulating nerve o r smooth muscles in isolated bovine mesenteric lymphatics. PJIugers Arch. 1980;388:221-226. 23 McGeown JG, McHale NG, Thornbury KD. The effect of electrical stimulation of the sympathetic chain o n peripheral lymph flow in the anaesthetized sheep. J Physiol (Lond). 1987; 393:123-133. 24 McHale N, Roddie I, Thornbury K. Nervous modulation of spontaneous contractions in bovine mesenteric lymphatics. J Physiol (Lond). 1980;309:461472.

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Physical Therapy is currently seeking qualified individuaIs to serve as manuscript reviewers. Reviewers should have:

Extensive experience in area(s) of content expertise Experience as authors of articles published in peer-reviewed journals Familiarity with peer review is essential, If you are interested in becoming a reviewer for the Journal, please send a cover letter and a copy of your curriculum vitae to: Editor Physical Therapy 1 1 1 1 North Fairfax Street Alexandria, VA 22314-1488

Interested in becoming involved, but not sure you have the time to review manuscripts? The Journal is also looking for article sa abstracters and booWsoftwarelvideotape reviewers, Send u letter expressing your interest and stating your general areas of expertise, along with a copy of your curriculum vitae, We look forward to hearing from you,

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