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12244
REVIEW
Electrical stimulation vs. standard care for chronic ulcer
healing: a systematic review and meta-analysis of
randomised controlled trials
Rachel Barnes, Yousef Shahin, Risha Gohil and Ian Chetter
Academic Vascular Surgical Unit, Hull York Medical School, University of Hull, Hull, UK
ABSTRACT
Background We conducted a systematic review to investigate the effect of electrical stimulation on ulcer
healing compared to usual treatment and/or sham stimulation. This systematic review also aimed to investigate
the effect of different types of electrical stimulation on ulcer size reduction.
Materials and Methods MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL)
were searched from inception to October 2013 on randomised controlled trials (RCTs), in English and on human
subjects, which assessed the effect of electrical stimulation on ulcer size as compared to standard care and/or
sham stimulation. Data from included RCTs were pooled with use of fixed and random effects meta-analysis of
the weighted mean change differences between the comparator groups. Heterogeneity across studies was
assessed with the I2 statistic.
Results Twenty-one studies were eligible for inclusion in the meta-analysis. In six trials (n = 210), electrical
stimulation improved mean percentage change in ulcer size over total studies periods by 2462%, 95% confidence interval (CI) 19982927, P < 000001 with no heterogeneity. In three trials (n = 176), electrical stimulation insignificantly improved mean weekly change in ulcer size by 164%, 95% (CI) 381 to 709, P = 056
with significant heterogeneity (I2 = 96%, P < 000001). In six trials (n = 266), electrical stimulation decreased
ulcer size by 242 cm2, 95% (CI) 166317, P < 000001, with significant heterogeneity. In one trial (n = 16),
electrical stimulation also insignificantly improved the mean daily percentage change in ulcer size by 063%,
95% (CI) 012 to 137, P = 010, with significant heterogeneity.
Conclusions Electrical stimulation appears to increase the rate of ulcer healing and may be superior to standard
care for ulcer treatment.
Keywords Chronic ulcers, electrical stimulation, meta-analysis, systematic review, ulcer healing.
Eur J Clin Invest 2014; 44 (4): 429440
Introduction
Healing involves the interplay of both cellular and biochemical
processes and disruption of these processes due to either
patient factors or wound factors can result in failure to heal. As
defined by the Scottish Intercollegiate Guideline Network [1],
leg ulceration is a break in the skin on the lower leg, which
takes more than 46 weeks to heal. They are described as
chronic if they fail to heal within 3 months. Patients have predisposing conditions which impair the normal healing processes and as such the tissues are unable to maintain integrity
or heal damage [2].
Leg ulcers are classified according to their aetiology: venous
leg ulcers are the most common type of leg ulceration,
accounting for approximately 70% of patients diagnosed [3]. In
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Methods
Search strategy
A systematic review of the published literature was carried out
via searches of MEDLINE, EMBASE and the Cochrane Central
Register of Controlled Trials (CENTRAL) from inception until
October 2013 including OVID MEDLINE In-process and other
nonindexed citations. The MeSH and free keywords used were
elect* AND stim* and chronic AND ulcer*. The searches
were limited to randomised controlled trials, relating to human
subjects. The references of identified studies were examined to
highlight any additional studies that were missed on electronic
search and could be included in the review. We used preferred
reporting items for systematic reviews and meta-analyses
(PRISMA) in the reporting of our study [47].
Inclusion criteria
Studies were deemed eligible to be included in our metaanalysis if they were (i) randomised controlled trials which
compared any kind of electrical stimulation with standard
treatment and/or sham stimulation, in terms of its impact on
ulcer healing rates where standard care involves dressings and
or compression therapy, and (ii) published in English from 1946
until October 2013.
Data extraction
Figure 1
430
The following data were recorded for each study: first author,
year of publication, study design, number and mean age of all
subjects, number of patients randomised to electrical stimulation, no treatment or placebo, number of ulcers treated, ulcer
aetiology, type of electrical stimulation used, duration of follow-up, percentage change in wound surface area or change in
ulcer size. The methodological quality of the studies was also
examined to establish the Jadad score as was information on
missing data.
Statistical analysis
Generic inverse variance based on calculating absolute differences of mean changes in ulcer healing rates or sizes between
the experimental and control groups and standard errors for
each comparison within each study was used. We converted
standard deviation and 95% confidence interval to standard
error by a standard formula [48]. We conducted a sensitivity
analysis to assess the contribution of each study to the pooled
treatment effect by excluding each study one at a time and
recalculating the pooled treatment effect for the remaining
studies. Treatment effect was significant if P < 005. Heterogeneity between studies was tested with use of both the chisquare test (significant if P < 01) and the I2 test (with substantial heterogeneity defined as values > 50%). When studies
showed significant heterogeneity, a random effects model was
used to calculate the pooled effect sizes. On the other hand, a
fixed effects model was used to calculate the pooled effect sizes
when studies did not show heterogeneity. REVIEW MANAGER
(version 5.0, The Cochrane Collaboration 2008) was used for
data analysis [48].
Risk of bias
Risk of bias was assessed for all of the articles using both the
Cochrane Collaborations tool [48] for assessing risk of bias and
the Jadad scoring system [49] (Table 1).
Publication bias
Publication bias was assessed using the funnel plot technique
[48]. The effect sizes of electrical stimulation were plotted
against their standard errors.
Results
Literature search
The search identified 171 potentially eligible studies of which
126 studies were excluded on title and abstract. A further 12
studies were found on reference review [944,5057]. Full
articles of the remaining 45 studies were collected and evaluated 21 studies met our inclusion criteria and were included
in the meta-analysis [9,2443] (Table 2). The reasons for
excluding the 23 studies were a nonrandomised design
[1012,16,17,2023,44,53,54,56,57], different outcome measures
such as limb salvage or oedema reduction [13,14,19,5052],
results previously reported [15] or not adequately reported
for analysis, such as data only presented in graph form and
unable to extrapolate values or no reported standard
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Blinding
(patient)
Adequate
report on
loss to
follow-up
Free of other
sources of bias
Jadad score
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No*
Yes
Yes
Yes
Yes
Yes
Yes
Houghton/2003 [38]
NR
Yes
Yes
Yes
Yes
Yes
Griffin/1991 [31]
NR
Yes
Yes
Yes
Yes
Yes
Feedar/1991 [39]
Yes
Yes
Yes
Yes
Yes
Yes
Study/year
Adequate
sequence
generation
Allocation
concealment
Blinding
(observer)
Houghton/2010 [37]
Yes
Yes
Junger/2008 [29]
NR
Adunsky/2005 [36]
Kloth/1988 [9]
No
No
No
Yes
NR
No
Lundeberg/1992 [40]
Yes
Yes
No
Yes
Yes
Yes
Ahmad/2008 [25]
NR
No
No
No
NR
No
Peters/2001 [41]
NR
Yes
Yes
Yes
Yes
Yes
Jercinovic/1994 [33]
NR
No
No
No
Yes
No
Baker/1997 [42]
NR
Yes
Yes
Yes
Yes
Yes
Goldman/2004 [32]
Yes
Yes
No
Yes
Yes
Yes
Jankovic/2008 [34]
NR
No
No
No
Yes
No
Carley/1985 [30]
No
No
No
No
No
No
Adegoke/2001 [24]
NR
Yes
Yes
Yes
Yes
Yes
Baker/1996 [43]
NR
No
No
Yes
Yes
Yes
Asbjorsen/1990 [35]
NR
NR
Yes
Yes
Yes
No*
Gentzkow/1991 [26]
NR
Yes
Yes
Yes
Yes
Yes
Wood/1993 [27]
NR
Yes
Yes
Yes
Yes
Yes
Ogrin/2009 [28]
Yes
Yes
Yes
Yes
Yes
Yes
No comparison was done between treatment and control group for demographics.
Significant differences in age and ulcer duration between treatment and control.
432
Country
Canada
Australia
Germany
Egypt
Serbia
Israel
USA
Canada
USA
Nigeria
USA
USA
Slovenia
Germany
Sweden
Study/year
Houghton/2010 [37]
Ogrin/2009 [28]
Junger/2008 [29]
Ahmad/2008 [25]
Jankovic/2008 [34]
Adunsky/2005 [36]
Goldman/2004 [32]
Houghton/2003 [38]
Peters/2001 [41]
Adegoke/2001 [24]
Baker/1997 [42]
Baker/1996 [43]
Jercinovic/1994 [33]
Wood/1993 [27]
Lundeberg/1992 [40]
Parallel,
placebo
Parallel,
no placebo
Parallel,
placebo
Parallel,
placebo
Parallel,
placebo
Parallel,
placebo
Parallel,
placebo
Parallel,
placebo
Parallel,
placebo
Parallel,
no placebo
Parallel,
placebo
Parallel,
placebo
Parallel,
placebo
Parallel,
no placebo
Design
Open
Double
Open
Open
Open
Open
Open
Double
Single
Double
Open
Open
Double
Double
Single
Blinding
67
76
36
53
44
57
64
72
72
69
39
67
76
51
Mean
age
12
49, 6, 55
12
14
21
86
143
12
12
Length of
follow-up
(weeks)
51
71
73
80
80
40
27
63
35
60
39
29
34
Subjects
(n)
24
41
42
20, 21, 20
21, 20, 19
20
14
35
20
45 (3
groups,
15 in
each)
14
16
ES (n)
27
30
31
19
20
20
13
28
15
15
15
18
Control
(n)
51
74
109
192
114
40
27
63
43
60
40
29
34
Ulcers (n)
Venous
Pressure
Pressure
Pressure
Diabetic
Pressure
Diabetic
Diabetic,
arterial,
venous
Arterial
Pressure
ulcers
Venous,
arterial,
arteriovenous,
diabetic
Pressure
Venous
Venous
Pressure
ulcers
Ulcer
aetiology
Alternating
current
Pulsed
current
Pulsed
current
Pulsed and
alternating
current
Alternating
current
Direct
current
Pulsed
current
Pulsed
current
Pulsed
current
Direct
current
Pulsed
current
Pulsed
current
(60 and
120 min)
Pulsed
current
Alternating
current
Pulsed
current
ES type
433
434
Direct
current
Mixed
15
30
Parallel,
no placebo
Open
72
15
30
Pulsed
current
Pressure
7
16
Parallel,
placebo
Carley/1985 [30]
USA
Kloth/1988 [9]
Open
69
73
16
Alternating
current
Pressure
9
16
Open
Parallel,
placebo
Asbjorsen/1990 [35]
USA
Gentzkow/1991 [26]
83
16
Pulsed
current
Pressure
19
40
USA
Feedar/1991 [39]
Parallel,
placebo
Open
63
21
40
Pulsed
current
Pressure,
vascular,
surgical
wounds
24
50
USA
Griffin/1991 [31]
Parallel,
no placebo
Double
64
26
50
Pulsed
current
9
17
Country
Parallel,
placebo
Double
29
29
17
Pressure
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Study/year
Table 2 Continued
Design
Blinding
Mean
age
Length of
follow-up
(weeks)
Subjects
(n)
ES (n)
Control
(n)
Ulcers (n)
Ulcer
aetiology
ES type
R. BARNES ET AL.
Publication bias
There was clear asymmetry in the funnel plot (Fig. 7) on visual
inspection indicating that few studies with negative results
have been published.
Discussion
This meta-analysis aimed to assess the impact of electrical
stimulation on the healing of chronic ulcers irrespectively of
aetiology. The results suggest that use of electrical stimulation
as an adjunct to ulcer treatment accelerates healing when
compared to standard care and/or sham stimulation. Electrical
stimulation significantly improved mean percentage change in
ulcer size over total studies periods by 2462% and significantly
improved ulcer size by 242 cm2. On the other hand, electrical
stimulation improved the mean weekly and daily change in
ulcer size; however, this treatment effect did not reach statistical significance. This could be explained by the small number of
published studies assessing weekly and daily change in ulcer
size and the small number of study participants. Chronic ulcers
have a significantly negative impact on patients quality of life
Identification
Eligibility
Screening
Records screened
(n = 171)
Records excluded
(n = 126)
Included
Studies included in
qualitative synthesis
(n = 21)
Figure 2
Studies included in
quantitative synthesis
(meta-analysis)
(n = 21)
Figure 3 Forest plot illustrating electrical stimulation effect on mean percentage change in ulcer size over total studies periods
compared to standard treatment sham stimulation. Small squares represent the differences in mean percentage changes in ulcer
size across individual studies between study groups (electrical stimulation vs. standard treatment sham stimulation). The 95%
confidence intervals (CI) for individual studies are represented by a horizontal line and by a diamond for pooled effect. SE, standard
error; IV, inverse variance.
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Figure 4 Forest plot illustrating electrical stimulation effect on mean perecentage weekly change in ulcer size compared to
standard treatment sham stimulation. For further detail, see legend for Fig. 3. CI, confidence interval; SE, standard error; IV,
inverse variance.
Figure 5 Forest plot illustrating electrical stimulation effect on mean change in ulcer size (cm2) compared to standard
treatment sham stimulation. For further detail, see legend for Fig. 3. CI, confidence interval; SE, standard error; IV, inverse
variance.
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Figure 6 Forest plot illustrating electrical stimulation effect on mean percentage daily change in ulcer size compared to standard
treatment sham stimulation. CI, confidence interval; SE, standard error; IV, inverse variance.
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R. BARNES ET AL.
Acknowledgements
None.
Funding
The authors declare that there are no sources of funding for this
work.
Disclosure
None.
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Address
Academic Vascular Surgical Unit, Hull York Medical School,
University of Hull, Hull HU3 2JZ, UK (R. Barnes, Y. Shahin, R.
Gohil, I. Chetter).
Correspondence to: Dr Yousef Shahin, Academic Vascular
Surgery Department, Hull Royal Infirmary, Anlaby Road, Hull
HU3 2JZ, UK. Tel.: 00441482674178; fax: 00441482674765;
e-mail: yousef.shahin@yahoo.co.uk
Received 5 February 2013; accepted 14 January 2014
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