Home-Based Electrical Stimulation to Accelerate Wound Healing-A Double-Blinded Randomized Control Trial

Arterial Leg Ulcers in the Octogenarian

Arterial leg ulcers are a debilitating sequela of chronic ischemia, and their management, particularly in the octogenarian, is an immense challenge. ALUs are frequently a manifestation of end-stage peripheral arterial disease, and their presence portends a high morbidity and mortality. Management primarily relies on restoration of flow, but in the geriatric population, interventions may carry undue risk and pathologies may not be amenable. Adjunctive therapies that improve quality of life and decrease morbidity and mortality are therefore essential, and understanding their benefits and limitations is crucial in developing a multimodal treatment algorithm of care for the uniquely challenging octogenarian population.

The Application of Digital Frailty Screening to Triage Nonhealing and Complex Wounds

OBJECTIVE

We investigated the association between the complexity of diabetic foot ulcers (DFUs) and frailty.

RESEARCH DESIGN AND METHODS

Individuals (n = 38) with Grade 2 Wagner DFU were classified into 3 groups based on the Society for Vascular Surgery risk-stratification for major limb amputation as Stage 1 at very low risk (n = 19), Stage 2 at low risk (n = 9), and Stage 3 to 4 at moderate-to-high risk (n = 10) of major limb amputation. Frailty status was objectively assessed using a validated digital frailty meter (FM). The FM works by quantifying weakness, slowness, rigidity, and exhaustion over a 20-second repetitive elbow flexion-extension exercise using a wrist-worn sensor. FM generates a frailty index (FI) ranging from 0 to 1; higher values indicate progressively greater severity of frailty. Skin perfusion pressure (SPP), albumin, and tissue oxygenation level (SatO2) were also measured. One-way analysis of variance (ANOVA) was used to identify group effect for wound complexity. Pearson's correlation coefficient was used to assess the associations with frailty and clinical endpoints.

RESULTS

Frailty index was higher in Stage 3 and 4 as compared to Stage 1 (d = 1.4, P < .01) and Stage 2 (d = 1.2, P < .01). Among assessed frailty phenotypes, exhaustion was correlated with SPP (r = -0.63, P < .01) and albumin (r = -0.5, P < .01).

CONCLUSION

Digital biomarkers of frailty may predict complexity of DFU and thus triage individuals who can be treated more simply in their primary clinic versus higher risk patients who require prompt referral to multidisciplinary, more complex care.

Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: A systematic review

BACKGROUND

It is critical that interventions used to enhance the healing of chronic foot ulcers in diabetes are backed by high-quality evidence and cost-effectiveness. In previous years, the systematic review accompanying guidelines published by the International Working Group of the Diabetic Foot performed 4-yearly updates of previous searches, including trials of prospective, cross-sectional and case-control design.

AIMS

Due to a need to re-evaluate older studies against newer standards of reporting and assessment of risk of bias, we performed a whole new search from conception, but limiting studies to randomised control trials only.

MATERIALS AND METHODS

For this systematic review, we searched PubMed, Scopus and Web of Science databases for published studies on randomised control trials of interventions to enhance healing of diabetes-related foot ulcers. We only included trials comparing interventions to standard of care. Two independent reviewers selected articles for inclusion and assessed relevant outcomes as well as methodological quality.

RESULTS

The literature search identified 22,250 articles, of which 262 were selected for full text review across 10 categories of interventions. Overall, the certainty of evidence for a majority of wound healing interventions was low or very low, with moderate evidence existing for two interventions (sucrose-octasulfate and leucocyte, platelet and fibrin patch) and low quality evidence for a further four (hyperbaric oxygen, topical oxygen, placental derived products and negative pressure wound therapy). The majority of interventions had insufficient evidence.

CONCLUSION

Overall, the evidence to support any other intervention to enhance wound healing is lacking and further high-quality randomised control trials are encouraged.

Flexible Organic Photovoltaic-Powered Hydrogel Bioelectronic Dressing With Biomimetic Electrical Stimulation for Healing Infected Diabetic Wounds

Electrical stimulation (ES) is proposed as a therapeutic solution for managing chronic wounds. However, its widespread clinical adoption is limited by the requirement of additional extracorporeal devices to power ES-based wound dressings. In this study, a novel sandwich-structured photovoltaic microcurrent hydrogel dressing (PMH dressing) is designed for treating diabetic wounds. This innovative dressing comprises flexible organic photovoltaic (OPV) cells, a flexible micro-electro-mechanical systems (MEMS) electrode, and a multifunctional hydrogel serving as an electrode-tissue interface. The PMH dressing is engineered to administer ES, mimicking the physiological injury current occurring naturally in wounds when exposed to light; thus, facilitating wound healing. In vitro experiments are performed to validate the PMH dressing's exceptional biocompatibility and robust antibacterial properties. In vivo experiments and proteomic analysis reveal that the proposed PMH dressing significantly accelerates the healing of infected diabetic wounds by enhancing extracellular matrix regeneration, eliminating bacteria, regulating inflammatory responses, and modulating vascular functions. Therefore, the PMH dressing is a potent, versatile, and effective solution for diabetic wound care, paving the way for advancements in wireless ES wound dressings.

Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update)

AIMS

Principles of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are of utmost importance when attempting to heal a chronic diabetes-related foot ulcer. However, the rising incidence and costs of diabetes-related foot ulcer management necessitate that interventions to enhance wound healing of chronic diabetes-related foot ulcers are supported by high-quality evidence of efficacy and cost effectiveness when used in conjunction with established aspects of gold-standard multidisciplinary care. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on wound healing interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.

MATERIALS AND METHODS

We followed the GRADE approach by devising clinical questions and important outcomes in the Patient-Intervention-Control-Outcome (PICO) format, undertaking a systematic review, developing summary of judgements tables, and writing recommendations and rationale for each question. Each recommendation is based on the evidence found in the systematic review and, using the GRADE summary of judgement items, including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability, we formulated recommendations that were agreed by the authors and reviewed by independent experts and stakeholders.

RESULTS

From the results of the systematic review and evidence-to-decision making process, we were able to make 29 separate recommendations. We made a number of conditional supportive recommendations for the use of interventions to improve healing of foot ulcers in people with diabetes. These include the use of sucrose octasulfate dressings, the use of negative pressure wound therapies for post-operative wounds, the use of placental-derived products, the use of the autologous leucocyte/platelet/fibrin patch, the use of topical oxygen therapy, and the use of hyperbaric oxygen. Although in all cases it was stressed that these should be used where best standard of care was not able to heal the wound alone and where resources were available for the interventions.

CONCLUSIONS

These wound healing recommendations should support improved outcomes for people with diabetes and ulcers of the foot, and we hope that widescale implementation will follow. However, although the certainty of much of the evidence on which to base the recommendations is improving, it remains poor overall. We encourage not more, but better quality trials including those with a health economic analysis, into this area.

Bioelectricity in dental medicine: a narrative review

BACKGROUND

Bioelectric signals, whether exogenous or endogenous, play crucial roles in the life processes of organisms. Recently, the significance of bioelectricity in the field of dentistry is steadily gaining greater attention.

OBJECTIVE

This narrative review aims to comprehensively outline the theory, physiological effects, and practical applications of bioelectricity in dental medicine and to offer insights into its potential future direction. It attempts to provide dental clinicians and researchers with an electrophysiological perspective to enhance their clinical practice or fundamental research endeavors.

METHODS

An online computer search for relevant literature was performed in PubMed, Web of Science and Cochrane Library, with the keywords "bioelectricity, endogenous electric signal, electric stimulation, dental medicine."

RESULTS

Eventually, 288 documents were included for review. The variance in ion concentration between the interior and exterior of the cell membrane, referred to as transmembrane potential, forms the fundamental basis of bioelectricity. Transmembrane potential has been established as an essential regulator of intercellular communication, mechanotransduction, migration, proliferation, and immune responses. Thus, exogenous electric stimulation can significantly alter cellular action by affecting transmembrane potential. In the field of dental medicine, electric stimulation has proven useful for assessing pulp condition, locating root apices, improving the properties of dental biomaterials, expediting orthodontic tooth movement, facilitating implant osteointegration, addressing maxillofacial malignancies, and managing neuromuscular dysfunction. Furthermore, the reprogramming of bioelectric signals holds promise as a means to guide organism development and intervene in disease processes. Besides, the development of high-throughput electrophysiological tools will be imperative for identifying ion channel targets and precisely modulating bioelectricity in the future.

CONCLUSIONS

Bioelectricity has found application in various concepts of dental medicine but large-scale, standardized, randomized controlled clinical trials are still necessary in the future. In addition, the precise, repeatable and predictable measurement and modulation methods of bioelectric signal patterns are essential research direction.

Electromechanical therapy in diabetic foot ulcers patients: A systematic review and meta-analysis

Purpose

Diabetic foot ulcer (DFU) is one of the most devastating and troublesome consequences of diabetes. The current therapies are not always effective because of the complicated aetiology and interactions of local and systemic components in DFU. However, adjunctive therapy (electromechanical therapy) has become the latest modality in recent years, although there is a lack of significant research to support its utilization as a treatment standard. The purpose of this systematic research was to review the literature on the application of electromechanical therapies in the healing of DFUs.

Methods

For this systematic review, we searched PubMed, Medline, EmBase, the Cochrane library, and Google Scholar for the most current research (1990-2022) on electromechanical therapies for DFUs. We used the PICO method (where P is population, I is intervention, C is comparator/control, and O is outcome for our study) to establish research question with the terms [Electromechanical therapy OR Laser therapy OR photo therapy OR Ultrasound therapy OR Shockwave therapy] AND [diabetic foot ulcers OR diabetes] were used as search criteria. Searches were restricted to English language articles only. Whereas, Cochrane handbook of "Systematic Reviews of Interventions" with critical appraisal for medical and health sciences checklist for systematic review was used for risk of bias assessment. There were 39 publications in this study that were deemed to be acceptable. All the suitably selected studies include 1779 patients.

Results

The meta-analysis of 15 included research articles showed the overall effect was significant (P = 0.0002) thus supporting experimental groups have improvement in the DFUs healing in comparison to the control group.

Conclusion

This systematic review and meta-analysis revealed electromechanical treatments are significantly viable options for patients with DFUs. Electromechanical therapy can considerably reduce treatment ineffectiveness, accelerate healing, and minimize the time it takes for complete ulcer healing.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01240-2.

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%).

How Might Consideration of Cell Polarity Affect Daily Therapeutic Practices?A Literature Review:

BACKGROUND

In addition to biochemical gradients and transcriptional networks, cell behaviour is controlled by endogenous bioelectrical signals resulting from the action of ion channels and pumps. Cells are regulated not only by their own membrane resting potential (Vmem) but also by the Vmem of neighbouring cells, establishing networks through electrical synapses known as gap junctions. V mem is the primary factor in producing a polarity that can regulate cell assimilation of various substances. This article aimed to examine how cell polarity can change and how variations in cell polarity may lead to clinical demonstrations.

MATERIALS AND METHODS

Using Cochrane Central, PubMed, Scopus, Web of Science (WOS), and Embase, a comprehensive qualitative literature review was conducted from February 1, 2018, to February 1, 2023, to identify studies addressing bioelectric, cell polarity, and electroceuticals in patients with foot and ankle problems.

RESULTS

Out of 1,281 publications, 27 were included. One study investigated bioelectric wound-healing. Twenty-five studies examined bioelectric nerve cell growth, whereas one study evaluated bioelectricity-induced cellular differentiation in the treatment of arteriopathies.

CONCLUSION

The author of this systematic review support addressing the predisposing factors and healing impediments for a disease, thereby enhancing the healing process and reducing the likelihood of recurrence or parallel conditions. This method of treatment has provided a summary of evidence indicating that cell polarity could be addressed for the treatment and prevention of most if not all, foot and ankle problems. However, owing to the limitations of V mem and bioelectricity measurement and the direct or indirect involvement of genetics and chemical gradients, further studies are required to confirm these results.

The effect of high-voltage monophasic pulsed current on diabetic ulcers and their potential pathophysiologic factors: A systematic review and meta-analysis

The present review was conducted to determine the efficacy of high-voltage monophasic pulsed current (HVMPC) in treating diabetic ulcers, assess its effect on skin lesions with each of the pathophysiologic factors potentially contributing to diabetic ulcers, evaluate its safety, and identify treatment parameters. Electronic search of PubMed, Scopus, PEDro and Google Scholar databases was conducted. The revised tool for assessing risk of bias in randomised trials (RoB 2), the risk of bias in non-randomised studies-of interventions (ROBINS-I) and the Joanna Briggs Institute (JBI) critical appraisal tool were used to assess risk of bias and methodological quality. Overall quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) principles. Thirty-two studies matched the eligibility criteria, and included 1061 patients with 1103 skin lesions of selected aetiologies; 12 randomised controlled trials were included in quantitative synthesis. HVMPC plus standard wound care (SWC) likely increased the probability of complete wound healing of pressure ulcers (PrUs) compared with sham/no stimulation plus SWC; relative risk (RR) 2.08; 95% CI: [1.42, 3.04], p = 0.0002; I²  = 0%, p = 0.61; eight studies, 358 ulcers. Although conclusive evidence regarding the effect of HVMPC on diabetic ulcers was not found, collateral evidence might suggest a potential benefit. Direct evidence, with moderate certainty, may support its efficacy in treating PrUs, albeit few adverse reactions were reported. Other observations, moreover, might indicate that this efficacy may not be limited to PrUs. Nonetheless, several aspects remain to be clarified for safe and effective application of electrical stimulation for wound healing.

Safety and efficacy of electrical stimulation for lower-extremity muscle weakness in intensive care unit 2019 Novel Coronavirus patients: A phase I double-blinded randomized controlled trial

Background

Intensive care unit (ICU) prolonged immobilization may lead to lower-extremity muscle deconditioning among critically ill patients, particularly more accentuated in those with 2019 Novel Coronavirus (COVID-19) infection. Electrical stimulation (E-Stim) is known to improve musculoskeletal outcomes. This phase I double-blinded randomized controlled trial examined the safety and efficacy of lower-extremity E-Stim to prevent muscle deconditioning.

Methods

Critically ill COVID-19 patients admitted to the ICU were randomly assigned to control (CG) or intervention (IG) groups. Both groups received daily E-Stim (1 h) for up to 14 days on both gastrocnemius muscles (GNMs). The device was functional in the IG and non-functional in the CG. Primary outcomes included ankle strength (Ankle_s) measured by an ankle-dynamometer, and GNM endurance (GNM_e) in response to E-Stim assessed with surface electromyography (sEMG). Outcomes were measured at baseline, 3 and 9 days.

Results

Thirty-two (IG = 16, CG = 16) lower extremities in 16 patients were independently assessed. The mean time between ICU admission and E-Stim therapy delivery was 1.8 ± 1.9 days (p = 0.29). At 3 days, the IG showed an improvement compared to the CG with medium effect sizes for Ankle_s (p = 0.06, Cohen's d = 0.77) and GNM_e (p = 0.06, d = 0.69). At 9 days, the IG GNM_e was significantly higher than the CG (p = 0.04, d = 0.97) with a 6.3% improvement from baseline (p = 0.029). E-Stim did not alter vital signs (i.e., heart/respiratory rate, blood saturation of oxygen), showed no adverse events (i.e., pain, skin damage, discomfort), nor interfere with ICU standard of care procedures (i.e., mechanical ventilation, prone rotation).

Conclusion

This study supports the safety and efficacy of early E-Stim therapy to potentially prevent deterioration of lower-extremity muscle conditions in critically ill COVID-19 patients recently admitted to the ICU. If confirmed in a larger sample, E-Stim may be used as a practical adjunctive therapy.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT04685213].

Engineering diabetic human skin equivalent for in vitro and in vivo applications

The prevalence of diabetes is increasing worldwide. Diabetes contributes to 70% of all non-traumatic lower-limb amputations, which are directly caused by diabetic foot ulcers (DFU) that are difficult to heal. Non-healing diabetic ulcers represent one of modern society’s most difficult medical challenges. One of the promising initiatives to treat DFU is the grafting of autologous skin or stimulating the skin cells at the edge of the wound to proliferate and close the wound. The present study was to engineer a diabetic human skin equivalent (DHSE) that contains fibroblasts and keratinocytes extracted from the skin collected from diabetic patients. The DHSE was used to investigate whether exposure to low-intensity electrical stimulation (ES) could promote diabetic cell activity. The ES was generated by a direct current (DC) electric field of 20 or 40 mV/mm. We demonstrated that the fibroblasts and keratinocytes could be extracted from older diabetics, cultured, and used to engineer DHSE. Interestingly, the exposure of DHSE to ES led to a structural improvement through tissue stratification, increased Ki-67 expression, and the deposition of basement membrane proteins (laminin and type IV collagen). The DHSE exposed to ES showed a high level of keratin 5 and 14 expressions in the basal and supra-basal layers. The keratinocyte proliferation was supported by an increased secretion of the keratinocyte growth factor (FGF-7). Exposure to ES decreased the activity of metalloproteinases (MMP) 2 and 9. In conclusion, we extracted keratinocytes and fibroblasts from the skin of diabetic-old donors. These cells were used to engineer skin equivalents and demonstrate that ES can promote diabetic wound healing. This DHSE can be a promising tool for various in vitro studies to understand the wound healing mechanisms under chronic inflammatory conditions such as diabetes. The DHSE could also be used as an autologous substrate to cover the DFU permanently.

Effect of electrical stimulation on patients with diabetes-related ulcers: a systematic review and meta-analysis

BACKGROUND

This study aimed to systematically review the literature to better understand the efficacy of electrical stimulation (ES) for the treatment of patients with diabetes-related ulcers.

METHODS

We searched the Embase, Medline, and Cochrane Library databases through July 31, 2021. Original trials for ES treatment of patients with diabetes-related ulcers with placebo or standard care as the control group were included. The primary outcomes were ulcer area reduction and healing rates. Meta-analyses were performed to compare the standardized mean difference (SMD) in the percentage of ulcer reduction and risk ratio of non-healing rates between ES treatment and placebo or standard care. We used the Revised Cochrane risk-of-bias tool for randomized trials to assess the risk of bias for each included article. Funnel plots and Egger's test were used to assess publication bias.

RESULTS

Compared to placebo or standard care, ES had a significant benefit for the treatment of patients with diabetes-related ulcers in terms of percentage of ulcer reduction (SMD = 2.56, 95% CI: 1.43-3.69; P < 0.001 (Q-test), I² = 93.9%) and ulcer healing rates [risk ratio of non-healing rates for the ES group was 0.72 (95% CI: 0.54-0.96; P = 0.38 (Q-test), I² = 2.3%)]. Two, four, and three of the included studies were categorized into low risk of bias, some concerns, and high risk of bias, respectively. No publication bias was found.

CONCLUSIONS

Based on the findings of this meta-analysis, ES could be used to treat patients with diabetes-related ulcers. ES treatment was effective for ulcer area reduction and ulcer healing, although it had a high heterogeneity level among the included studies. Pulsed current ES has the potential benefit of increasing ulcer healing compared to direct current ES. Further large-scale clinical trials are needed to define the adverse events and potentiators of ES in the treatment of patients with diabetes-related ulcers.