Mr J is a 67 year-old man with a history of multiple sclerosis complicated by paraplegia, bilateral upper and lower extremity contractures, and multiple pressure ulcers. He had required multiple hospitalizations for his wounds, and I met him after an extended hospitalization necessitating debridement when he was transferred to a skilled nursing facility for ongoing wound care. Given the extent of his wounds, he was started on electrical stimulation therapy. I had never heard of this type of treatment, so I wondered, in patients with pressure ulcers, is electrical stimulation therapy more effective than standard wound care?
Electrical stimulation therapy is the application of a current across a wound. The theoretical mechanism of this therapy is to replicate the “current of injury” that occurs normally when there is a break in the skin. This current of injury has been shown in various models to promote angiogenesis, fibroblast migration promoting granulation, and keratinocyte migration promoting epithelialization.
I searched the terms “electrical stimulation treatment pressure ulcers” on PubMed Clinical Queries looking for a meta-analysis. I found an article that pooled data from 15 different studies, including both randomized control trials and observational studies, for a sample of 909 electrical stimulation patients and 371 controls. The main outcome was mean percent wound healing, which was coded or calculated independently by 2 authors.
The results showed that patients who received electrical stimulation to their pressure ulcers had a mean percent wound healing of 13.5 more than the controls, which translates to 144% increase in wound healing. This effect was the same when analyzing just the randomized control trials, suggesting that the effect is not driven by a placebo effect.
In summary, it seems that electrical stimulation can improve wound healing compared to standard wound care. Although statistically significant, it is hard to know if this outcome is clinically significant, as the potentially more important outcome is complete closure of the wound. Further, the analysis included studies that employed different electrical stimulation modalities, which raises the question about what is the best way to deliver electrical stimulation therapy. For example, what is the optimal positioning of the electrodes relative to the wound? What is the optimal current (direct or alternating) setting? How long should the electrical current be applied and at what frequency?
Back to the Patient: Mr J received several treatments with electrical stimulation with some improvement in his wounds. However, one wound did not heal and was found to be infected necessitating further surgical debridement so he was readmitted to the hospital.
Take Home Points:
Electrical stimulation can improve wound healing for patients with pressure ulcers.
There are still more questions to be answered about the best way to deliver electrical stimulation therapy to be most effective.
Reference: Gardner, S. E., Frantz, R. A., & Schmidt, F. L. Effect of electrical stimulation on chronic wound healing: A meta-analysis. Wound Repair Regen. 1999 Nov-Dec;7(6):495-503.
Picture Courtersy: las - initially
Picture Courtersy: las - initially
by: Natalie Young, MD, MS, Geriatrics and Palliative Medicine fellow at Icahn School of Medicine at Mount Sinai, New York.
This post is part of the #GeriCases series, in which we discuss a clinical case in geriatrics and palliative medicine and the attempt to provide patient-centered care with the use of best available evidence.
Ravishankar Ramaswamy, MD
Section Editor, #GeriCases