Electrical Stimulation and Cutaneous Wound Healing: A Review of Clinical Evidence

Sara Ud-Din, Ardeshir Bayat, Sara Ud-Din, Ardeshir Bayat

Abstract

Electrical stimulation (ES) has been shown to have beneficial effects in wound healing. It is important to assess the effects of ES on cutaneous wound healing in order to ensure optimization for clinical practice. Several different applications as well as modalities of ES have been described, including direct current (DC), alternating current (AC), high-voltage pulsed current (HVPC), low-intensity direct current (LIDC) and electrobiofeedback ES. However, no one method has been advocated as the most optimal for the treatment of cutaneous wound healing. Therefore, this review aims to examine the level of evidence (LOE) for the application of different types of ES to enhance cutaneous wound healing in the skin. An extensive search was conducted to identify relevant clinical studies utilising ES for cutaneous wound healing since 1980 using PubMed, Medline and EMBASE. A total of 48 studies were evaluated and assigned LOE. All types of ES demonstrated positive effects on cutaneous wound healing in the majority of studies. However, the reported studies demonstrate contrasting differences in the parameters and types of ES application, leading to an inability to generate sufficient evidence to support any one standard therapeutic approach. Despite variations in the type of current, duration, and dosing of ES, the majority of studies showed a significant improvement in wound area reduction or accelerated wound healing compared to the standard of care or sham therapy as well as improved local perfusion. The limited number of LOE-1 trials for investigating the effects of ES in wound healing make critical evaluation and assessment somewhat difficult. Further, better-designed clinical trials are needed to improve our understanding of the optimal dosing, timing and type of ES to be used.

Keywords: current; electrical stimulation; electrobiofeedback; treatment; wound healing; wounds.

Figures

Figure 1
Figure 1
A diagram to demonstrate some of the available treatment strategies for the management of chronic wounds including; compression bandaging, wound dressings, negative pressure wound therapy, ultrasound, debridement, skin substitute therapy and electrical stimulation.
Figure 2
Figure 2
Electrical stimulation (ES), in the form of alternating current (AC), direct current (DC) and pulsed current (PC), has been shown to have beneficial effects on cutaneous wound healing in chronic wounds. When ES is applied to a chronic wound, this produces beneficial effects throughout the three phases of wound healing: inflammation, proliferation and remodelling phases. Inflammatory phase: ES increases blood flow, tissue oxygenation and stimulates fibroblasts whilst reducing oedema and providing an increased antibacterial effect. Proliferative phase: ES increases membrane transport, collagen matrix organization, wound contraction and the stimulation of DNA and protein synthesis. Remodelling phase: ES increases epidermal cell proliferation, and migration as well as stimulation of fibroblasts thus enabling enhanced wound closure [19,20,21,22,23,24,25,26,27].
Figure 3
Figure 3
Electrical stimulation (ES), in the form of biofeedback ES, direct current (DC) and pulsed current (PC), has been shown to have beneficial effects on cutaneous wound healing in acute wounds. When ES is applied to an acute wound, this produces beneficial effects throughout the three phases of wound healing: inflammation, proliferation and remodelling phases. Inflammatory phase: ES increases blood flow, skin temperature and vasodilation. Proliferative phase: ES increases keratinocyte proliferation and wound contraction. Remodelling phase: ES advances the remodelling face and increases re-epithelialisation enabling enhanced wound healing [28,29,30,31,32,33,34].
Figure 4
Figure 4
The current of injury is thought to be significant in initiating repair. Undamaged human skin has an endogenous electrical potential and a transcutaneous current potential of 20–50 mV. This is generated by the movement of sodium ions through Na+/K+ ATPase pumps in the epidermis. The current of injury is generated through epithelial disruption. Following an injury to the skin, a flow of current through the wound pathway generates a lateral electrical field and this is termed the “current of injury” or “skin battery” effect.
Figure 5
Figure 5
Diagram demonstrating the various modes of application of electrical stimulation (ES). (a) Application of ES by electrodes placed near or on the wound site and connected to a device (this is the most common application of ES) [40]; (b) Application of a bioelectric dressing to the wound site [41]; (c) Wireless application of ES to a wound [42]; (d) Practitioner application of ES in the form electro biofeedback by the use of a device with an electrode placed in different areas around the wound site [43].
Figure 6
Figure 6
Illustrations showing one example of each of the various electrical waveforms available for the treatment of acute and chronic cutaneous wounds including alternating current, direct current, pulsed current and degenerate wave (please note that there are other subtypes of each of these waveforms).
Figure 7
Figure 7
A flowchart demonstrating the methodology and process of selecting relevant articles for review.
Figure 8
Figure 8
Graphical representation of the three phases of acute cutaneous wound healing and where the different waveforms of electrical stimulation are effective in each phase: inflammatory, proliferative and remodelling.

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