Electrical stimulation therapy for the treatment of pressure ulcers in individuals with spinal cord injury: a systematic review and meta-analysis

Bacterial Cellulose-Based Bandages with Integrated Antibacteria and Electrical Stimulation for Advanced Wound Management

Bandages for daily wounds are the most common medical supplies, but there are still ingrained defects in their appearance, comfort, functions, as well as environmental pollution. Here, novel bandages based on bacterial cellulose (BC) membrane for wound monitoring and advanced wound management are developed. The BC membrane is combined with silver nanowires (AgNWs) by using vacuum filtration method to achieve transparent, ultrathin (≈7 µm), breathable (389.98-547.79 g m-2  d-1 ), and sandwich-structured BC/AgNWs bandages with superior mechanical properties (108.45-202.35 MPa), antibacterial activities against Escherichia coli and Staphylococcus aureus, biocompatibility, and conductivity (9.8 × 103 -2.0 × 105  S m-1 ). Significantly, the BC/AgNWs bandage is used in the electrical stimulation (direct current, 600  microamperes for 1 h every other day) treatment of full-thickness skin defect in rats, which obviously promotes wound healing by increasing the secretion of vascular endothelial growth factor (VEGF). The BC bandage is used for monitoring wounds and achieve a high accuracy of 94.7% in classifying wound healing stages of hemostasis, inflammation, proliferation, and remodeling, by using a convolutional neural network. The outcomes of this study not only provide two BC-based bandages as multifunctional wound management, but also demonstrate a new strategy for the development of the next generation of smart bandage.

Rational Design of Multifunctional Hydrogels for Wound Repair

The intricate microenvironment at the wound site, coupled with the multi-phase nature of the healing process, pose significant challenges to the development of wound repair treatments. In recent years, applying the distinctive benefits of hydrogels to the development of wound repair strategies has yielded some promising results. Multifunctional hydrogels, by meeting the different requirements of wound healing stages, have greatly improved the healing effectiveness of chronic wounds, offering immense potential in wound repair applications. This review summarized the recent research and applications of multifunctional hydrogels in wound repair. The focus was placed on the research progress of diverse multifunctional hydrogels, and their mechanisms of action at different stages of wound repair were discussed in detail. Through a comprehensive analysis, we found that multifunctional hydrogels play an indispensable role in the process of wound repair by providing a moist environment, controlling inflammation, promoting angiogenesis, and effectively preventing infection. However, further implementation of multifunctional hydrogel-based therapeutic strategies also faces various challenges, such as the contradiction between the complexity of multifunctionality and the simplicity required for clinical translation and application. In the future, we should work to address these challenges, further optimize the design and preparation of multifunctional hydrogels, enhance their effectiveness in wound repair, and promote their widespread application in clinical practice.

Electrical stimulation facilitates NADPH production in pentose phosphate pathway and exerts an anti-inflammatory effect in macrophages

Macrophages play an important role as effector cells in innate immune system. Meanwhile, macrophages activated in a pro-inflammatory direction alter intracellular metabolism and damage intact tissues by increasing reactive oxygen species (ROS). Electrical stimulation (ES), a predominant physical agent to control metabolism in cells and tissues, has been reported to exert anti-inflammatory effect on immune cells. However, the mechanism underlying the anti-inflammatory effects by ES is unknown. This study aimed to investigate the effect of ES on metabolism in glycolytic-tricarboxylic acid cycle (TCA) cycle and inflammatory responses in macrophages. ES was performed on bone marrow-derived macrophages and followed by a stimulation with LPS. The inflammatory cytokine expression levels were analyzed by real-time polymerase chain reaction and ELISA. ROS production was analyzed by CellRox Green Reagent and metabolites by capillary electrophoresis-mass spectrometry. As a result, ES significantly reduced proinflammatory cytokine expression levels and ROS generation compared to the LPS group and increased glucose-1-phosphate, a metabolite of glycogen. ES also increased intermediate metabolites of the pentose phosphate pathway (PPP); ribulose-5-phosphate, rebose-5 phosphate, and nicotinamide adenine dinucleotide phosphate, a key factor of cellular antioxidation systems, as well as α-Ketoglutarate, an anti-oxidative metabolite in the TCA cycle. Our findings imply that ES enhanced NADPH production with enhancement of PPP, and also decreased oxidative stress and inflammatory responses in macrophages.

Association between Patients' Body Mass Index and the Effect of Monophasic Pulsed Microcurrent Stimulation on Pressure Injury Healing

This secondary analysis study aimed to detect individual variables that influence the efficacy of monophasic pulsed microcurrent on pressure injury healing. Eleven patients with pressure injuries showing delayed healing underwent a microcurrent stimulation period and a placebo period. We analyzed the correlation between the individual variables and the following three outcomes using monophasic pulsed microcurrent: the wound reduction rate in the electrical stimulation period, the reduction rate in the placebo period, and the difference between these two reduction rates. Furthermore, the patients were divided into two groups, one with a wound reduction rate of more than 10% and the other with less than 10%, and the relationship between each variable was compared. As a result, the wound reduction rate in the electrical stimulation period and the difference in the reduction rate between the two periods showed significant positive correlations with patients' body mass index. In addition, a significant difference was observed in the body mass index between subjects with a reduction rate of 10% or higher and those with a reduction rate of less than 10%. This study found a correlation between the effect of monophasic pulsed microcurrent for pressure injury healing and the level of patients' body mass index.

Activation of healing and reduction of pain by single-use automated microcurrent electrical stimulation therapy in patients with hard-to-heal wounds

Evidence shows that Electrical Stimulation Therapy (EST) accelerates healing and reduces pain, but EST has yet to become widely used. One reason is the historical use of complex, clinic-based EST devices. This evaluation assessed the early response of different hard-to-heal wounds to a simple, wearable, single-use, automated microcurrent EST device (Accel-Heal, Accel-Heal Technologies Limited - Hever, UK). Forty wounds (39 patients: 18 female - 21 male), mean age 68.9 ± 14.0 years comprised of: seven post-surgical, three trauma, 12 diabetic foot (DFU), 10 venous (VLU), four pressure injuries (PI), four mixed venous or arterial ulcers (VLU/arterial) received automated microcurrent EST for 12 days. Early clinical responses were scored on a 0-5 scale (5-excellent-0-no response). Pain was assessed at 48 h, seven days, and 14 days on a 0-10 visual analogue scale (VAS). Overall, 78% of wounds showed a marked positive clinical response (scores of 5 and 4). Sixty eight percent of wounds were painful with a mean VAS score of 5.5. Almost every patient (96%) with pain experienced reduction within 48 h. All patients with painful wounds experienced pain reduction after seven days: 2.50 VAS (45% reduction) and further pain reduction after 14 days: 1.83 VAS (33%).

Pressure Injuries and Management after Spinal Cord Injury

Spinal cord injury (SCI) results in motor paralysis and sensory loss that places individuals at particularly high risk of pressure injuries. Multiple comorbidities associated with autonomic, cardiovascular, pulmonary, endocrine, gastrointestinal, genitourinary, neurological, and musculoskeletal dysfunction makes it even more likely that pressure injuries will occur. This manuscript will review the structure and function of the integumentary system, and address the multidisciplinary approach required to prevent and manage pressure injuries in this vulnerable population.

Electrical Shunting Prevents the Decline of Galvanotaxis After Monophasic Pulsed Microcurrent Stimulation in Human Dermal Fibroblasts

BACKGROUND

Electrical stimulation (ES) therapy is recommended for healing pressure injuries. Monophasic pulsed microcurrent stimulation promotes the migration of human dermal fibroblasts (HDFs) to the cathode, and ES potentially accelerates pressure injury healing. A reverse current is generated after ES in the human body; however, the effects of the electrical shunt in preventing the reverse current from migrating are unclear. Therefore, this study aimed to investigate the effects of an electrical shunt on the migration of HDFs.

METHODS

In the shunt groups, HDFs were electrically stimulated (0, 200, 400, and 600 µA) for 8 hours, and an electrical shunt was used to remove the electricity after ES. HDFs were observed under time-lapse microscopy for 24 hours. The migration ratio toward the cathode was calculated for each dish.

RESULTS

The migration ratio was significantly higher in the 200-µA group than in the other groups. HDFs migrated toward the anode after ES in the non-shunt groups with greater than 400 µA ES; however, HDFs did not migrate toward the anode with electrical shunting.

CONCLUSIONS

A post-ES electrical shunt is important in preventing a decline in the migration effect of ES.

Effectiveness and safety of electrical stimulation for treating pressure ulcers: A systematic review and meta-analysis

AIM

This study aims to synthesize qualitative evidence on the effectiveness and safety of electrical stimulation for treating pressure ulcers.

BACKGROUND

Electrical stimulation is often used clinically to treat pressure ulcers, but its effectiveness and safety and some potential problems are not clear.

DESIGN

This is a qualitative systematic review.

DATA SOURCES

The data sources are four English databases (PubMed, EMBASE, The Cochrane Library and Web of Science) and four Chinese databases (CNKI, SinoMed, VIP and WANFANG).

METHODS

Two reviewers independently examined the records according to the eligibility criteria and extracted the data of each included study. We used the Review Manager 5.3 software to perform data analysis.

RESULTS

Seventeen randomized controlled trials including 740 patients were included in this study. Meta-analysis of eight randomized controlled trials demonstrated that electrical stimulation significantly reduced the ulcer surface in contrast with standard wound care alone or pulsed sham electrical stimulation. Nine studies showed that electrical stimulation increased the risk of pressure ulcers being completely healed than the controlled group. Three studies reported that adverse reactions were rare.

CONCLUSIONS

This study demonstrated that electrical stimulation was a relatively effective and safe adjunctive therapy for pressure ulcers treatment.

The effects of electrical stimulation on diabetic ulcers of foot and lower limb: A systematic review

Diabetic foot ulcer (DFU) is a life-threatening condition affecting a third of diabetic patients. Many adjuvant therapies aimed at improving the healing rate (HR) and accelerating healing time are currently under investigation. Electrical stimulation (ES) is a physical-based therapy able to increase cells activity and migration into wound bed as well as inhibiting bacterial activity. The aim of this paper was to collect and analyse findings on the effects of ES used in combination with standard wound care (SWC) in the treatment of diabetic foot ulceration compared with SWC alone. A systematic review was performed to synthesise data from quantitative studies from eight databases. Article quality was assessed using the Crowe critical appraisal tool. Seven articles out of 560 publications met the inclusion criteria. A meta-analysis was not performed due to the heterogeneity of the studies and the results were narratively synthetised. Findings showed that HR appears to be higher among diabetic ulcers treated with ES; however, the reliability of these findings is affected by the small sample sizes of the studies. Furthermore, four studies are considered as moderate or high risk of bias. The evidence to suggest the systematic usage of ES in the treatment of DFUs is still insufficient.

Efficacy of Low-frequency Monophasic Pulsed Microcurrent Stimulation Therapy in Undermining Pressure Injury: A Double-blind Crossover-controlled Study

Objectives:

This double-blind crossover-controlled trial aimed to verify the effect of electrical stimulation therapy on pressure injuries with undermining.

Methods

: In this trial, we compared the healing rates between a sham period and a treatment period using monophasic pulsed microcurrent therapy. The participants were randomly assigned to the sham or treatment group and received stimulation for 2 weeks. All the participants, physical therapists, and researchers were blinded to the allocation. For the main analysis, data on the effect of the intervention on changes in weekly healing and contraction rates of the wound areas, including undermining, were analyzed based on a two-period crossover study design. The intervention effect was estimated by examining the mean treatment difference for each period using Wilcoxon’s signed-rank test.

Results

: The reduction of the entire wound area, including the undermining area, resulted in significantly higher healing and contraction rates in the treatment group (overall wound area reduction rate: contraction rate, P=0.008; period healing rate, P=0.002).

Conclusions

: Electrical stimulation therapy for pressure injuries, using conditions based on the findings of an in vivo culture study, was effective in reducing the wound area.

Conductive Biomaterials as Bioactive Wound Dressing for Wound Healing and Skin Tissue Engineering

Conductive biomaterials based on conductive polymers, carbon nanomaterials, or conductive inorganic nanomaterials demonstrate great potential in wound healing and skin tissue engineering, owing to the similar conductivity to human skin, good antioxidant and antibacterial activities, electrically controlled drug delivery, and photothermal effect. However, a review highlights the design and application of conductive biomaterials for wound healing and skin tissue engineering is lacking. In this review, the design and fabrication methods of conductive biomaterials with various structural forms including film, nanofiber, membrane, hydrogel, sponge, foam, and acellular dermal matrix for applications in wound healing and skin tissue engineering and the corresponding mechanism in promoting the healing process were summarized. The approaches that conductive biomaterials realize their great value in healing wounds via three main strategies (electrotherapy, wound dressing, and wound assessment) were reviewed. The application of conductive biomaterials as wound dressing when facing different wounds including acute wound and chronic wound (infected wound and diabetic wound) and for wound monitoring is discussed in detail. The challenges and perspectives in designing and developing multifunctional conductive biomaterials are proposed as well.

Electrical stimulation for pain reduction in hard-to-heal wound healing

OBJECTIVE

Despite treatment advances over the past 30 years, the societal impact of hard-to-heal wounds is increasingly burdensome. An unresolved issue is wound pain, which can make many treatments, such as compression in venous leg ulcers, intolerable. The aim of this review is to present the evidence and stimulate thinking on the use of electrical stimulation devices as a treatment technology with the potential to reduce pain, improve adherence and thus hard-to-heal wound outcomes.

METHOD

A literature search was conducted for clinical studies up to August 2020 reporting the effects of electrical stimulation devices on wound pain. Devices evoking neuromuscular contraction or direct spinal cord stimulation were excluded.

RESULTS

A total of seven publications (three non-comparative and four randomised trials) were identified with four studies reporting a rapid (within 14 days) reduction in hard-to-heal wound pain. Electrical stimulation is more widely known for accelerated healing and is one of the most evidence-based technologies in wound management, supported by numerous in vitro molecular studies, five meta-analyses, six systematic reviews and 30 randomised controlled trials (RCTs). Despite this wealth of supportive evidence, electrical stimulation has not yet been adopted into everyday practice. Some features of electrical stimulation devices may have hampered adoption in the past.

CONCLUSION

As new, pocket-sized, portable devices allowing convenient patient treatment and better patient adherence become more widely available and studied in larger RCTs, the evidence to date suggests that electrical stimulation should be considered part of the treatment options to address the challenges of managing and treating painful hard-to-heal wounds.

In vitro stimulation with radiofrequency currents promotes proliferation and migration in human keratinocytes and fibroblasts

Capacitive-resistive electric transfer (CRET) therapies have been proposed as strategies for regeneration of cutaneous tissue lesions. Previous studies by our group have shown that intermittent stimulation with 448 kHz CRET currents at subthermal densities promotes in vitro proliferation of human stem cells involved in tissue regeneration. The present study investigates the effects of the in vitro exposure to these radiofrequency (RF) currents on the proliferation and migration of keratinocytes and fibroblasts, the main cell types involved in skin regeneration. The effects of the electric stimulation on cell proliferation and migration were studied through XTT and wound closure assays, respectively. The CRET effects on the expression and location of proteins involved in proliferation and migration were assessed by immunoblot and immunofluorescence. The obtained results reveal that electrostimulation promotes proliferation and/or migration in keratinocytes and fibroblasts. These effects would be mediated by changes observed in the expression and location of intercellular adhesion proteins such as β-catenin and E-cadherin, of proteins involved in cell-to-substrate adhesion such as vinculin, p-FAK and the metalloproteinase MMP-9, and of other proteins that control both processes: MAP kinases p-p38, p-JUNK and p-ERK1/2. These responses could represent a mechanism underlying the promotion of normotrophic wound regeneration induced by CRET. Indeed, electric stimulation would favor completion of granulation tissue formation prior to the closure of the outer tissue layers, thus preventing abnormal wound cicatrization or chronification.

Monophasic Pulsed Current Stimulation of Duty Cycle 10% Promotes Differentiation of Human Dermal Fibroblasts into Myofibroblasts

OBJECTIVE

Many clinical trials have shown the therapeutic effects of electrical stimulation (ES) in various conditions. Our previous studies showed that ES (200 μA and 2 Hz) promotes migration and proliferation of human dermal fibroblasts (HDFs). However, the effective duty cycle and the effect of ES on myofibroblast differentiation are unclear. This study aimed to investigate the relationship between duty cycle and myofibroblast differentiation.

METHODS

HDFs were subjected to ES (200 μA and 2 Hz) for 24 h with the duty cycle adapted at 0% (control), 10%, 50%, or 90%. α-smooth muscle actin (SMA) and transforming growth factor (TGF)-β1 mRNA and α-SMA protein expressions were assessed. Collagen gel contraction was observed for 48 h after ES initiation and the gel area was measured. Cell viability and pH of culture medium were analyzed for cytotoxicity of the ES.

RESULTS

Cell viabilities were decreased in the 50% and the 90% groups but ES did not influence on pH of culture media. ES with a duty cycle of 10% significantly promoted the mRNA expression of α-SMA and TGF-β1. α-SMA protein expression in the 10% group was also significantly higher than that of the control group. Collagen gel subjected to ES with a duty cycle of 10% was contracted.

CONCLUSION

Duty cycle can influence on myofibroblast differentiation and ES with a duty cycle 10% is the effective for wound healing.

Neuromuscular stimulation of the common peroneal nerve increases arterial and venous velocity in patients with venous leg ulcers

Activation of the venous muscle pumps by neuromuscular stimulation of the common peroneal nerve has been previously shown to increase venous and arterial flow in the legs of healthy subjects. The aim of this study is to determine whether a similar effect is observed in patients with chronic venous leg ulcers. 1 Hz intermittent electrostimulation of the common peroneal nerve was applied to 14 patients with ulcers between 1 and 10 cm in diameter, eliciting a small, painless, regular, muscular twitch of the leg. Flow was measured using Duplex ultrasound in the popliteal vein and the popliteal artery. Peak arterial velocity increased from 57 to 78 cm/s (P = .001) in sitting position, and from 79 to 98 cm/s in recumbent position (P = .001). Peak venous velocity increased from 10 to 33 cm/s (P = .001) sitting, and from 14 to 47 cm/s (P = .001) recumbent. Significant increases were observed in both venous and arterial blood flow in the lower limb. This suggestsed that activation of the venous muscle pump and improvement of arterial flow assisted oxygen delivery at the wound site. Moreover this may be a worthwhile intervention to assist in the healing of venous leg ulcers, and may provide a mechanistic explanation for the increased healing rates previously reported with neuromuscular stimulation of the common peroneal nerve.

Electrical stimulation for treating pressure ulcers

BACKGROUND

Pressure ulcers (also known as pressure sores, decubitus ulcers or bedsores) are localised injuries to the skin or underlying tissue, or both. Pressure ulcers are a disabling consequence of immobility. Electrical stimulation (ES) is widely used for the treatment of pressure ulcers. However, it is not clear whether ES is effective.

OBJECTIVES

To determine the effects (benefits and harms) of electrical stimulation (ES) for treating pressure ulcers.

SEARCH METHODS

In July 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. We did not impose any restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials (RCTs) comparing ES (plus standard care) with sham/no ES (plus standard care) for treating pressure ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 20 studies with 913 participants. The mean age of participants ranged from 26 to 83 years; 50% were male. ES was administered for a median (interquartile range (IQR)) duration of five (4 to 8) hours per week. The chronicity of the pressure ulcers was variable, ranging from a mean of four days to more than 12 months. Most of the pressure ulcers were on the sacral and coccygeal region (30%), and most were stage III (45%). Half the studies were at risk of performance and detection bias, and 25% were at risk of attrition and selective reporting bias. Overall, the GRADE assessment of the certainty of evidence for outcomes was moderate to very low. Nineteen studies were conducted in four different settings, including rehabilitation and geriatric hospitals, medical centres, a residential care centre, and a community-based centre. ES probably increases the proportion of pressure ulcers healed compared with no ES (risk ratio (RR) 1.99, 95% confidence interval (CI) 1.39 to 2.85; I² = 0%; 11 studies, 501 participants (512 pressure ulcers)). We downgraded the evidence to moderate certainty due to risk of bias. It is uncertain whether ES decreases pressure ulcer severity on a composite measure compared with no ES (mean difference (MD) -2.43, 95% CI -6.14 to 1.28; 1 study, 15 participants (15 pressure ulcers) and whether ES decreases the surface area of pressure ulcers when compared with no ES (12 studies; 494 participants (505 pressure ulcers)). Data for the surface area of pressure ulcers were not pooled because there was considerable statistical heterogeneity between studies (I² = 96%) but the point estimates for the MD of each study ranged from -0.90 cm² to 10.37 cm². We downgraded the evidence to very low certainty due to risk of bias, inconsistency and imprecision. It is uncertain whether ES decreases the time to complete healing of pressure ulcers compared with no ES (hazard ratio (HR) 1.06, 95% CI 0.47 to 2.41; I² = 0%; 2 studies, 55 participants (55 pressure ulcers)). We downgraded the evidence to very low certainty due to risk of bias, indirectness and imprecision. ES may be associated with an excess of, or difference in, adverse events (13 studies; 586 participants (602 pressure ulcers)). Data for adverse events were not pooled but the types of reported adverse events included skin redness, itchy skin, dizziness and delusions, deterioration of the pressure ulcer, limb amputation, and occasionally death. We downgraded the evidence to low certainty due to risk of selection and attrition bias and imprecision. ES probably increases the rate of pressure ulcer healing compared with no ES (MD 4.59% per week, 95% CI 3.49 to 5.69; I² = 25%; 12 studies, 561 participants (613 pressure ulcers)). We downgraded the evidence to moderate certainty due to risk of bias. We did not find any studies that looked at quality of life, depression, or consumers' perception of treatment effectiveness.

AUTHORS' CONCLUSIONS

ES probably increases the proportion of pressure ulcers healed and the rate of pressure ulcer healing (moderate certainty evidence), but its effect on time to complete healing is uncertain compared with no ES (very low certainty evidence). It is also uncertain whether ES decreases the surface area of pressure ulcers. The evidence to date is insufficient to support the widespread use of ES for pressure ulcers outside of research. Future research needs to focus on large-scale trials to determine the effect of ES on all key outcomes.

Efficacy of Bimodal High-Voltage Monopulsed Current in the Treatment of Pressure Ulcer: A Systematic Review

BACKGROUND

We aimed to systematically evaluate the efficacy of high-voltage pulsed current (HVPC) in the treatment of pressure ulcer.

METHODS

We searched the databases of PubMed, Cochrane Library, Elsevier and EMBASE to identify randomized controlled studies on the application of HVPC in pressure ulcer treatment, up to January 2019. Two authors independently screened the literature according to the inclusion and exclusion criteria, extracted the data and evaluated the quality. RevMan 5.3 software was used for statistical analysis. Four randomized controlled trials involving a total of 176 patients were included in the study.

RESULTS

Meta-analysis showed that the percentage of wound area reduction in the HVPC treatment group was higher than that in the control group (95%CI 24.59, 47.76, P<0.001). Descriptive analysis showed that there was no significant difference in wound healing between the HVPC treatment group and the control group. One study reported that there was contact dermatitis, and the rest of the studies reported no adverse events.

CONCLUSION

Compared with the conventional therapy, the combination with HVPC therapy can reduce the area of pressure ulcers more effectively. However, due to the small number of the studies included in this evaluation, the conclusions need to be verified by more high-quality studies.

Wireless Direct Microampere Current in Wound Healing: Clinical and Immunohistological Data from Two Single Case Reports

Chronic pressure ulcers are hard-to-heal wounds that decrease the patient’s quality of life. Wireless Micro Current Stimulation (WMCS) is an innovative, non-invasive, similar to electrode-based electrostimulation (ES) technology, that generates and transfers ions that are negatively-charged to the injured tissue, using accessible air gases as a transfer medium. WMCS is capable of generating similar tissue potentials, as electrode-based ES, for injured tissue. Here, through immunohistochemistry, we intended to characterize the induced tissue healing biological mechanisms that occur during WMCS therapy. Two single cases of bedridden due to serious stroke white men with chronic non-healing pressure ulcers have been treated with WMCS technology. WMCS suppresses inflammatory responses by decreasing the aggregation of granulocytes, followed by stimulating myofibroblastic activity and a new formation of collagen fibers, as depicted by immunohistochemistry. As a result, WMCS provides a special adjunct or stand-alone therapy choice for chronic and non-healing injuries, similar to electrode-based ES, but with added (i.e., contactless) benefits towards its establishment as a routine clinical wound healing regime.

Electrically stimulated cell migration and its contribution to wound healing

Naturally occurring electric fields are known to be morphogenetic cues and associated with growth and healing throughout mammalian and amphibian animals and the plant kingdom. Electricity in animals was discovered in the eighteenth century. Electric fields activate multiple cellular signaling pathways such as PI3K/PTEN, the membrane channel of KCNJ15/Kir4.2 and intracellular polyamines. These pathways are involved in the sensing of physiological electric fields, directional cell migration (galvanotaxis, also known as electrotaxis), and possibly other cellular responses. Importantly, electric fields provide a dominant and over-riding signal that directs cell migration. Electrical stimulation could be a promising therapeutic method in promoting wound healing and activating regeneration of chronic and non-healing wounds. This review provides an update of the physiological role of electric fields, its cellular and molecular mechanisms, its potential therapeutic value, and questions that still await answers.

Using a Modified ADAPTE Process to Enable Effective Implementation of Electrical Stimulation Therapy for Treating Pressure Ulcers in Persons With Spinal Cord Injury

Objectives:

To apply a modified ADAPTE process to adapt best practices to a local context for successful implementation of electrical stimulation therapy (EST) for treating pressure injuries in persons with spinal cord injury (SCI).

Participants:

An expert team of health care professionals and a consumer participated in a 2-day workshop to assist in the development of the locally adapted EST document in Southwest Ontario, Canada.

Results:

A process map illustrating the flow of activities to initiate EST for treating pressure injuries in persons with SCI based on the challenges and opportunities existing within this region was created. The team also developed a summary of roles and responsibilities delineating tasks specific to providing EST and identified a set of challenges likely to be encountered.

Conclusions:

The modified ADAPTE process provided a clear and flexible structure to adaptation when used for implementation planning. This article shares some challenges associated with using this process for local adaptation and shares strategies of improvement for future studies aimed at adapting a practice to their local environment.

Electrical Stimulation for Pressure Injuries: A Health Technology Assessment

BACKGROUND

Pressure injuries (bedsores) are common and reduce quality of life. They are also costly and difficult to treat. This health technology assessment evaluates the effectiveness, cost-effectiveness, budget impact, and lived experience of adding electrical stimulation to standard wound care for pressure injuries.

METHODS

We conducted a systematic search for studies published to December 7, 2016, limited to randomized and non-randomized controlled trials examining the effectiveness of electrical stimulation plus standard wound care versus standard wound care alone for patients with pressure injuries. We assessed the quality of evidence through Grading of Recommendations Assessment, Development, and Evaluation (GRADE). In addition, we conducted an economic literature review and a budget impact analysis to assess the cost-effectiveness and affordability of electrical stimulation for treatment of pressure ulcers in Ontario. Given uncertainties in clinical evidence and resource use, we did not conduct a primary economic evaluation. Finally, we conducted qualitative interviews with patients and caregivers about their experiences with pressure injuries, currently available treatments, and (if applicable) electrical stimulation.

RESULTS

Nine randomized controlled trials and two non-randomized controlled trials were found from the systematic search. There was no significant difference in complete pressure injury healing between adjunct electrical stimulation and standard wound care. There was a significant difference in wound surface area reduction favouring electrical stimulation compared with standard wound care.The only study on cost-effectiveness of electrical stimulation was partially applicable to the patient population of interest. Therefore, the cost-effectiveness of electrical stimulation cannot be determined. We estimate that the cost of publicly funding electrical stimulation for pressure injuries would be $0.77 to $3.85 million yearly for the next 5 years.Patients and caregivers reported that pressure injuries were burdensome and reduced their quality of life. Patients and caregivers also noted that electrical stimulation seemed to reduce the time it took the wounds to heal.

CONCLUSIONS

While electrical stimulation is safe to use (GRADE quality of evidence: high) there is uncertainty about whether it improves wound healing (GRADE quality of evidence: low). In Ontario, publicly funding electrical stimulation for pressure injuries could result in extra costs of $0.77 to $3.85 million yearly for the next 5 years.

Monophasic Pulsed 200-μA Current Promotes Galvanotaxis With Polarization of Actin Filament and Integrin α2β1 in Human Dermal Fibroblasts

OBJECTIVE

The monophasic pulsed microcurrent is used to promote wound healing, and galvanotaxis regulation has been reported as one of the active mechanisms in the promotion of tissue repair with monophasic pulsed microcurrent. However, the optimum monophasic pulsed microcurrent parameters and intracellular changes caused by the monophasic pulsed microcurrent have not been elucidated in human dermal fibroblasts. The purpose of this study was to investigate the optimum intensity for promoting galvanotaxis and the effects of electrical stimulation on integrin α2β1 and actin filaments in human dermal fibroblasts.

METHODS

Human dermal fibroblasts were treated with the monophasic pulsed microcurrent of 0, 100, 200, or 300 μA for 8 hours, and cell migration and cell viability were measured 24 hours after starting monophasic pulsed microcurrent stimulation. Polarization of integrin α2β1 and lamellipodia formation were detected by immunofluorescent staining 10 minutes after starting monophasic pulsed microcurrent stimulation.

RESULTS

The migration toward the cathode was significantly higher in the cells treated with the 200-μA monophasic pulsed microcurrent than in the controls (P < .01) without any change in cell viability; treatment with 300-μA monophasic pulsed microcurrent did not alter the migration ratio. The electrostimulus of 200 μA also promoted integrin α2β1 polarization and lamellipodia formation at the cathode edge (P < .05).

CONCLUSION

The results show that 200 μA is an effective monophasic pulsed microcurrent intensity to promote migration toward the cathode, and this intensity could regulate polarization of migration-related intracellular factors in human dermal fibroblasts.