The use of sensory electrical stimulation for pressure ulcer prevention

Efficacy and safety of neuromuscular electrical stimulation in the prevention of pressure injuries in critically ill patients: a randomized controlled trial

Background

Pressure injuries (PIs), especially in the sacral region are frequent, costly, and increase morbidity and mortality of patients in an intensive care unit (ICU). These injuries can occur as a result of prolonged pressure and/or shear forces. Neuromuscular electrical stimulation (NMES) can increase muscle mass and improve local circulation, potentially reducing the incidence of PI.

Methods

We performed a randomized controlled trial to assess the efficacy and safety of NMES in preventing PI in critically ill patients. We included patients with a period of less than 48 h in the ICU, aged ≥ 18 years. Participants were randomly selected (1:1 ratio) to receive NMES and usual care (NMES group) or only usual care (control group—CG) until discharge, death, or onset of a PI. To assess the effectiveness of NMES, we calculated the relative risk (RR) and number needed to treat (NNT). We assessed the muscle thickness of the gluteus maximus by ultrasonography. To assess safety, we analyzed the effects of NMES on vital signs and checked for the presence of skin burns in the stimulated areas. Clinical outcomes were assessed by time on mechanical ventilation, ICU mortality rate, and length of stay in the ICU.

Results

We enrolled 149 participants, 76 in the NMES group. PIs were present in 26 (35.6%) patients in the CG and 4 (5.3%) in the NMES group (p ˂ 0.001). The NMES group had an RR = 0.15 (95% CI 0.05–0.40) to develop a PI, NNT = 3.3 (95% CI 2.3–5.9). Moreover, the NMES group presented a shorter length of stay in the ICU: Δ = − 1.8 ± 1.2 days, p = 0.04. There was no significant difference in gluteus maximus thickness between groups (CG: Δ = − 0.37 ± 1.2 cm vs. NMES group: Δ = 0 ± 0.98 cm, p = 0.33). NMES did not promote deleterious changes in vital signs and we did not detect skin burns.

Conclusions

NMES is an effective and safe therapy for the prevention of PI in critically ill patients and may reduce length of stay in the ICU.

Trial registration RBR-8nt9m4. Registered prospectively on July 20th, 2018, https://ensaiosclinicos.gov.br/rg/RBR-8nt9m4

Effects of Electrical Stimulation on Risk Factors for Developing Pressure Ulcers in People with a Spinal Cord Injury: A Focused Review of Literature

Pressure ulcers (PUs) are a common and serious problem for wheelchair users, such as individuals with a spinal cord injury (SCI), resulting in great discomfort, loss of quality of life, and significant medical care costs. Therefore, it is of utmost importance to prevent PUs. In this literature overview, the effects of electrical stimulation (ES) on the risk factors for developing PUs in people with an SCI are examined and synthesized from January 1980 to January 2015. Thirty-four relevant studies of PU prevention in SCI were identified. Four were randomized clinical trials, 24 were case series, 6 had other designs. Three types of ES modalities were identified. The methodological quality varied from poor to fairly strong, with a large variety in used ES parameters. Twenty-three studies were identified describing short-term effects of ES on interface pressure, oxygenation, and/or blood flow, and 24 studies described the long-term effects of ES on muscle volume, muscle strength, and histology. Whereas there is a lack of controlled studies on the effects of ES on PU incidence, which disallows definite conclusions, there is moderate evidence to suggest that ES-induced muscle activation has a positive influence on several risk factors for developing PUs in people with an SCI.

Telehealth monitor to measure physical activity and pressure relief maneuver performance in wheelchair users

This study demonstrated the feasibility of a device for monitoring pressure relief maneuvers and physical activity for wheelchair users. The device counts the number of wheel pushes based on wheelchair acceleration and measures pressure relief maneuvers using a seat sensor consisting of three force sensing resistors (FSRs). To establish the feasibility of the seat sensor for the detection of pressure relief maneuvers, 10 wheelchair users and 10 non-disabled controls completed a series of wheelchair depression raises, forward trunk leans, and lateral trunk leans. The seat sensor was placed underneath the user's seat cushion. To establish the feasibility of wheel push counting, 10 full-time wheelchair users navigated a flat 50-m outdoor track and a 100-m outdoor obstacle course during self-propulsion (e.g., wheel pushes) and during assisted-propulsion (e.g., no wheel pushes). Of the 240 performed pressure relief, 225 were properly classified by the seat sensor (accuracy: 94%, sensitivity: 96%, specificity: 80%). Sensitivity was highest for depression raises (98%) and lowest for front lean maneuvers (80%). The wheelchair activity monitor measured 2,112 pushes during the self-propulsion trials compared to 2,162 pushes measured with the instrumented push-rim (97.7%). During assisted-propulsion trials, there were 477 incorrectly identified pushes (8.0 per trial).

Functional Electrical Stimulation in Spinal Cord Injury: Clinical Evidence Versus Daily Practice

Functional electrical stimulation (FES) has clinical evidence in the rehabilitation of patients with spinal cord injury as indicated by several studies. Both inpatients and outpatients benefit from the therapeutic effect of the FES. The application areas are multifaceted and can be customized on the need for patients. This is represented by the individuality of the programmability of the stimulators and the variety of stimulation schedules that are based on the knowledge about the effects of FES on structural and functional level. Nevertheless, looking into daily clinical practice, the use of FES is rather poor. Expenditure of time, complexity of technical equipment, and compliance and acceptance of therapists and patients should be taken into account as limiting factors.

Assistive technologies for self-managed pressure ulcer prevention in spinal cord injury: a scoping review

Pressure ulcers (PUs) in individuals with spinal cord injury (SCI) present a persistent and costly problem. Continuing effort in developing new technologies that support self-managed care is an important prevention strategy. Specifically, the aims of this scoping review are to review the key concepts and factors related to self-managed prevention of PUs in individuals with SCI and appraise the technologies available to assist patients in self-management of PU prevention practices. There is broad consensus that sustaining long-term adherence to prevention regimens is a major concern. Recent literature highlights the interactions between behavioral and physiological risk factors. We identify four technology categories that support self-management: computer-based educational technologies demonstrated improved short-term gains in knowledge (2 studies), interface pressure mapping technologies demonstrated improved adherence to pressure-relief schedules up to 3 mo (5 studies), electrical stimulation confirmed improvements in tissue tolerance after 8 wk of training (3 studies), and telemedicine programs demonstrated improvements in independence and reduced hospital visits over 6 mo (2 studies). Overall, self-management technologies demonstrated low-to-moderate effectiveness in addressing a subset of risk factors. However, the effectiveness of technologies in preventing PUs is limited due to a lack of incidence reporting. In light of the key findings, we recommend developing integrated technologies that address multiple risk factors.

A systematic review of electrical stimulation for pressure ulcer prevention and treatment in people with spinal cord injuries

CONTEXT

Electrical stimulation (ES) can confer benefit to pressure ulcer (PU) prevention and treatment in spinal cord injuries (SCIs). However, clinical guidelines regarding the use of ES for PU management in SCI remain limited.

OBJECTIVES

To critically appraise and synthesize the research evidence on ES for PU prevention and treatment in SCI.

METHOD

Review was limited to peer-reviewed studies published in English from 1970 to July 2013. Studies included randomized controlled trials (RCTs), non-RCTs, prospective cohort studies, case series, case control, and case report studies. Target population included adults with SCI. Interventions of any type of ES were accepted. Any outcome measuring effectiveness of PU prevention and treatment was included. Methodological quality was evaluated using established instruments.

RESULTS

Twenty-seven studies were included, 9 of 27 studies were RCTs. Six RCTs were therapeutic trials. ES enhanced PU healing in all 11 therapeutic studies. Two types of ES modalities were identified in therapeutic studies (surface electrodes, anal probe), four types of modalities in preventive studies (surface electrodes, ES shorts, sacral anterior nerve root implant, neuromuscular ES implant).

CONCLUSION

The methodological quality of the studies was poor, in particular for prevention studies. A significant effect of ES on enhancement of PU healing is shown in limited Grade I evidence. The great variability in ES parameters, stimulating locations, and outcome measure leads to an inability to advocate any one standard approach for PU therapy or prevention. Future research is suggested to improve the design of ES devices, standardize ES parameters, and conduct more rigorous trials.

Electrical stimulation for difficult wounds: only an alternative procedure?

In the wound healing research, the exact mechanism of action of different modalities of electrical stimulation (ES) remains controversial and unresolved. In this study we discuss a particular ES, with a different type of waveform, corresponding to the principle of stochastic resonance. Between July 2008 and May 2010, 32 patients were enrolled and ES was applied to wounds using the bioelectrical signal therapy (BST) device (LifeWave, Petach Tiqwa, Israel). The outcome evaluated in group 1 (n = 21) was wound healing, while group 2 (n = 11) was evaluated for wound-related pain [Visual Number Scale (VNS) pain scale] during treatment. In group 1, 87% of the wounds closed in an average time of 97 days (range 10-150 days); three patients were lost to follow-up. In group 2, 45% of the patients experienced a complete pain disappearance after 7 days of treatment; 36% reported a reduction in VNS from 9·3 to 3·2 in 7 days; 19% stopped morphine-like painkillers after 2 weeks. The clinical application of the stochastic resonance enables the usage of easy-to-use, non-invasive, painless and pain-relief treatment. Our experience with ES has demonstrated the BST device to be a very good alternative in cases of small size defects, compared with other therapies such as surgery, dressing and negative pressure devices.

Seat pressure changes after eight weeks of functional electrical stimulation cycling: a pilot study

BACKGROUND

Pressure ulcers (PUs) are a common secondary condition associated with spinal cord injury (SCI). PUs can potentially interfere with activities of daily living, occupational duties, and rehabilitation programs, and in severe cases they may threaten life. Functional electrical stimulation (FES) cycling has been proposed as an activity that may decrease the risk of PUs through the promotion of increased blood flow and thickening of the gluteus maximus. The purpose of this pilot study was to measure the effects of home-based FES cycling on the average and maximal seat pressure of wheelchair-reliant individuals with SCI.

METHOD

Eight male veterans with C5-T6 SCI participated in FES cycling 3 times per week. Cycling parameters were individualized depending on the comfort of the participants and the amount of current needed to perform the cycling activity. Pressure mapping was completed immediately before and after the 8 weeks of FES cycling with the measurement performed by a force sensitive application (FSA) 4 pressure mapping system.

RESULTS

The mean average seat pressure decreased by 3.69 ± 4.46 mm Hg (35.57 ± 11.99 to 31.88 ± 13.02), while the mean maximum seat pressure decreased by 14.56 ±18.45 mm Hg (112 ± 34.73 to 98.36 ± 25.89). Although neither measurement was statistically significant, there was a strong trend toward a reduction in average and maximal seat pressure (P = .052 and P = .061, respectively).

CONCLUSION

The positive trend of decreased seat pressure in our study creates incentive for further investigation of the effects of electrical stimulation activities on seat pressure and the prevention of PUs.