Evaluation of the Healing Progress of Pressure Ulcers Treated with Cathodal High-Voltage Monophasic Pulsed Current: Results of a Prospective, Double-blind, Randomized Clinical Trial

Wireless control of nerve growth using bipolar electrodes: a new paradigm in electrostimulation

Electrical activity underpins all life, but is most familiar in the nervous system, where long range electrical signalling is essential for function. When this is lost (e.g., traumatic injury) or it becomes inefficient (e.g., demyelination), the use of external fields can compensate for at least some functional deficits. However, its potential to also promote biological repair at the cell level is underplayed despite abundant in vitro evidence for control of neuron growth. This perspective article considers specifically the emerging possibility of achieving cell growth through the interaction of external electric fields using conducting materials as unwired bipolar electrodes, and without intending stimulation of neuron electrical activity to be the primary consequence. The use of a wireless method to create electrical interactions represents a paradigm shift and may allow new applications in vivo where physical wiring is not possible. Within that scheme of thought an evaluation of specific materials and their dynamic responses as bipolar unwired electrodes is summarized and correlated with changes in dynamic nerve growth during stimulation, suggesting possible future schemes to achieve neural growth using bipolar unwired electrodes with specific characteristics. This strategy emphasizes how nerve growth can be encouraged at injury sites wirelessly to induce repair, as opposed to implanting devices that may substitute the neural signals.

Electric field modulation of ERK dynamics shows dependency on waveform and timing

Different exogenous electric fields (EF) can guide cell migration, disrupt proliferation, and program cell development. Studies have shown that many of these processes were initiated at the cell membrane, but the mechanism has been unclear, especially for conventionally non-excitable cells. In this study, we focus on the electrostatic aspects of EF coupling with the cell membrane by eliminating Faradaic processes using dielectric-coated microelectrodes. Our data unveil a distinctive biphasic response of the ERK signaling pathway of epithelial cells (MCF10A) to alternate current (AC) EF. The ERK signal exhibits both inhibition and activation phases, with the former triggered by a lower threshold of AC EF, featuring a swifter peaking time and briefer refractory periods than the later-occurring activation phase, induced at a higher threshold. Interestingly, the biphasic ERK responses are sensitive to the waveform and timing of EF stimulation pulses, depicting the characteristics of electrostatic and dissipative interactions. Blocker tests and correlated changes of active Ras on the cell membrane with ERK signals indicated that both EGFR and Ras were involved in the rich ERK dynamics induced by EF. We propose that the frequency-dependent dielectric relaxation process could be an important mechanism to couple EF energy to the cell membrane region and modulate membrane protein-initiated signaling pathways, which can be further explored to precisely control cell behavior and fate with high temporal and spatial resolution.

Electrical Stimulation in the Treatment of Pressure Injuries: A Systematic Review of Clinical Trials

GENERAL PURPOSE

To provide information on evidence-based practice regarding the use of electrical stimulation for pressure injury management.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Apply clinical practice recommendations related to the use of electrical stimulation in the treatment of pressure injuries.2. Identify issues related to the use of electrical stimulation to treat pressure injuries.

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.

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.

Wound Healing with Electrical Stimulation Technologies: A Review

Electrical stimulation (ES) is an attractive field among clinicians in the topic of wound healing, which is common yet complicated and requires multidisciplinary approaches. The conventional dressing and skin graft showed no promise on complete wound closure. These urge the need for the exploration of electrical stimulation to supplement current wound care management. This review aims to provide an overview of electrical stimulation in wound healing. The mechanism of galvanotaxis related to wound repair will be reviewed at the cellular and molecular levels. Meanwhile, different modalities of externally applied electricity mimicking a physiologic electric field will be discussed and compared in vitro, in vivo, and clinically. With the emerging of tissue engineering and regenerative medicine, the integration of electroconductive biomaterials into modern miniaturised dressing is of interest and has become possible with the advancing understanding of smart biomaterials.

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.

Randomized Controlled Trials and Quasi-Experimental Studies Published in Nursing Journals: Findings From a Scoping Review With Implications for Further Research

BACKGROUND

Experimental studies are considered capable of generating substantial evidence; therefore, their production and diffusion are continuously encouraged. However, their trends as publication outputs in nursing journals have rarely been evaluated to date.

AIMS

To describe experimental study design features among the highest indexed nursing journals.

METHODS

A scoping review was performed by retrieving and analyzing experimental studies published between 2009 and 2016 in nursing journals with a 5-year impact factor >1.5 according to Thomson's Journal Citation Reports.

RESULTS

A total of 602 studies were reviewed and 340 (56%) were included; in all, 298/340 (87.6%) were randomized controlled trials (RCTs) and 37/340 (10.9%) pilot studies. The publication trend exhibited a fluctuating pattern with a slight decrease over time (from 54 studies in 2009 to 32 in 2016). Researchers working in Asia and Europe have published more frequently in the selected journals. Published studies most often involved oncological (n = 69, 20%), surgical (n = 41, 12%), and elderly patients (n = 38, 11%). Educational and supportive (n = 119, 35%) interventions were mainly tested for effectiveness. Approximately half of studies enrolled <100 patients, and only two-thirds had included an a priori sample size calculation. Less than one quarter (n = 76) of the research teams were multiprofessional, and 70% of studies were funded, generally, by public institutions.

LINKING EVIDENCE TO ACTION

A broad range of research questions has been investigated to date by using experimental study designs. However, study methods and multidisciplinary collaborations must be enhanced with the intent of producing large-scale and methodologically sound studies. Furthermore, reasons for limited funding and, particularly, the lack of support from private funding should be further investigated.

Effect of laser therapy on expression of angio- and fibrogenic factors, and cytokine concentrations during the healing process of human pressure ulcers

Objective: To evaluate the effect of laser irradiation at different wavelengths on the expression of selected growth factors and inflammatory mediators at particular stages of the wound healing process. Methods: Sixty-seven patients were recruited, treated, and analyzed (group A - 940 nm: 17 patients; group B - 808 nm: 18 patients; group C - 658 nm: 16 patients; group D - sham therapy: 17 patients). Patients received a basic treatment, including repositioning and mobilization, air pressure mattress and bed support surfaces, wound cleansing and drug therapy. Additionally, patients received laser therapy once a day, 5 times a week for 1 month in use of a semiconductor lasers (GaAlAs) which emitted a continuous radiation emission at separate wavelengths of 940 nm (group A), 808 nm (group B) and 658 nm (group C). In group D (sham therapy), laser therapy was applied in the same manner, but the device was off during each session (only the applicator was switched on to scan pressure ulcers using none coherent red visible light). Results: The positive changes in the measured serum (IL-2, IL-6 and TNF-α) and wound tissue (TNF-α, VEGF and TGFβ1) parameters appeared to be connected only with the wavelength of 658 nm. The significant change in pro-inflammatory mediator levels [interleukin 2 (IL-2) with p=0.008 and interleukin 6 (IL-6) with p=0.016] was noticed after two weeks of laser therapy. In the other groups, the inflammation was also reduced, but the process was not as marked as in group C. Similarly, in the case of tumor necrosis factor (TNF-α) concentration, where after two weeks of treatment with irradiation at a wavelength of 658 nm, a rapid suppression was observed (p=0.001), whereas in the other groups, these results were much slower and not as obvious. Interestingly, again in the case of group C, the change in TNF-α concentration in wound tissue was most intensive (≈75% reduction), whereas the changes in other groups were not as obvious (≈50% reduction). After irradiation (658 nm), the VEGF expression increased significantly within the first two weeks, and then it decreased and maintained a stable level. In contrast, the TGFβ1 activity remained level, but always higher in comparison to other groups Conclusions: The effective healing of pressure ulcers is connected with laser irradiation at a wavelength of 658 nm. We believe that this effect is related to the inhibition of inflammatory processes in the wound and stimulation of angiogenesis and fibroblast proliferation at this specific radiation (based both on concentration of interleukins and TNF-α serum level and VEGF, TGFβ1, TNF-α activities in wound biopsies). Laser therapy at wavelengths of 940 and 808 nm does not significantly affect the above-mentioned repair processes, which explains its low effectiveness in the treatment of pressure ulcers.

Combined use of modulated ultrasound and electric current stimulation for diabetic foot ulcers: a case series

OBJECTIVE

Diabetic foot ulcers (DFUs) are a significant challenge in wound care practice. Our aim was to evaluate the combined use of of two therapies, ultrasound and electrostimulation, in the treatment of DFUs.

METHOD

This study employed a prospective, non-comparative, case series design, undertaken in a podiatry-led diabetic foot clinic, in an acute hospital setting, in an urban location in Ireland. We recruited patinets with hard-to-heal DFUs who were treated twice a week with combined modulated ultrasound and electric current stimulation.

RESULTS

We recruited seven patients with eight chronic DFUs. A mean wound size reduction of 71% was achieved and there were no adverse reactions to the therapy.

CONCLUSION

The results of this small case series indicate that combined modulated ultrasound and electric current stimulation offers promise as an adjunct therapy for DFUs. Further large scale trials are now warranted.

The Efficacy of Pressure Ulcer Treatment With Cathodal and Cathodal-Anodal High-Voltage Monophasic Pulsed Current: A Prospective, Randomized, Controlled Clinical Trial

BACKGROUND

Studies show that anode and cathode electrical stimulation (ES) promotes the healing of wounds, but specific protocols for both electrodes are not available.

OBJECTIVE

To compare the effectiveness of cathodal versus cathodal+anodal ES in the treatment of Category II-IV pressure ulcers (PrUs).

DESIGN

Prospective, randomized, controlled, clinical study.

SETTING

Three nursing and care centers.

PATIENTS

Sixty-three participants with PrUs were randomly formed into a cathodal ES group (CG: N = 23; mean age of 79.35; SD 8.48), a cathodal+anodal ES group (CAG: N = 20; mean age of 79.65; SD 11.44) and a placebo ES group (PG: N = 20; mean age of 76.75; SD 12.24).

INTERVENTION

All patients were treated with standard wound care and high-voltage monophasic pulsed current (HVMPC; twin-peak impulses; 154 μs; 100 pps; 0.25 A; 250 μC/s) for 50 minutes per day, 5 times a week, for 6 weeks. The CG, CAG, and PG received, respectively, cathodal, cathodal+anodal, and sham ES through electrodes placed on a moist gauze pad. The treatment electrode was placed on the wound, and the return electrode was positioned on healthy skin at least 20 cm from the PrU.

MEASUREMENTS

Measurements were made at baseline, and after each of the 6 weeks of treatment. Primary outcome was percentage wound surface area reduction at week 6.

RESULTS

Wound surface area decreased in the CG by 82.34% (95% confidence interval [CI] 70.06-94.63) and in the CAG by 70.77% (95% CI 53.51-88.04). These reductions were significantly greater than in the PG (40.53%; 95% CI 23.60-57.46). The CG and CAG were not statistically significantly different regarding treatment results.

LIMITATIONS

The time of treatment proved insufficient for PrUs to close.

CONCLUSIONS

Cathodal and cathodal+anodal HVMPC similarly reduced the area of Category II-IV PrUs.