Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 43

CLINICAL PRACTICE GUIDELINE

E L E C T R I C A L S T IMULAT ION

17. Use electrical stimulation (ES) to promote
closure of category/stage III or IV pressure
ulcers, unless contraindicated in the
cases of untreated, underlying osteomyelitis
or infection.
(Scientific evidence-I, II, III, IV V; Grade of
,
recommendation-A; Strength of panel opinion-Strong)

Electrical stimulation to promote
wound closure
Electrical stimulation may facilitate pressure
ulcer healing by multiple mechanisms:
maintenance of appropriate transepithelial
potential in the non-intact skin, antibacterial
effects, as well as promotion of angiogenesis
through vascular endothelial growth factor
(VEGF), promotion of granulation and
re-epithelialization.
Houghton et al. (2010) reported the results
of a single blind parallel group randomized
control study comparing community based
standard wound care (SWC) to SWC plus 3
months of high voltage pulsed ES applied to the
ulcer wound bed an average of 3 hours per day
for three months in thirty-four persons with SCI
and category/stage II to IV pressure ulcers. Those
in the SWC plus ES group had a decrease in
wound surface area of 70% as compared to the
SWC group, which had a decrease of 36 %. In
another small randomized sample (n=7) of
persons with SCI and category/stage IV pressure
ulcers, investigators reported that interrupted
direct current stimulation accelerated healing of
pressure ulcers when used in conjunction with
routine nursing care (Adegoke and Bardmos,
2001). Data from three randomized, controlled
clinical trials involving more than 250 individuals
with SCI, each with at least one wound, supported
the efficacy of ES by accelerating the healing rate
of pressure ulcers that had not responded
favorably to standard wound care (Baker et al.,
1996; Griffin et al., 1991; Stefanovska et al.,
1993). Other controlled trials also demonstrated
significantly better healing rates for wounds
treated with ES compared with control wounds
((Stefanovska et al. (1993), Baker et al. (1996)).
A double-blind multicenter study, in which ES
below sensory perception was used to treat
pressure ulcers, demonstrated that more than
50% of wounds healed in 8 weeks, whereas only
3% of ulcers in the control group healed and most
other control wounds increased in size (Wood et
al., 1993).

Electrical stimulation to promote
muscle bulk and tissue health
When continuous ES and intermittent
ES to the bilateral gluteal muscles are compared,
both treatments are found to reduce pressure
around the ischial bony prominences and
provide significant sustained increases in tissue
oxygenation (Gyawali et al., 2011).
There is sufficient evidence supporting only
the efficacy of ES for a recommendation to be
made. Literature reviews were done for several
adjunctive wound therapies. These include
negative pressure wound therapy, ultrasound,
laser therapy, skin substitutes, growth factors,
and autologous platelet rich plasma
Negative Pressure Wound Therapy
Negative pressure wound therapy (NPWT)
is a mechanical wound care treatment that
uses controlled negative pressure to accelerate
wound healing by evacuating wound exudate,
stimulating granulation tissue formation,
reducing the wound bacterial bioburden,
increasing blood flow in the wound and adjacent
tissue, and maintaining a moist wound
environment Morykwas et al. (1997). Intermittent
negative pressure application when compared
to continuous negative pressure application has
been shown to increase blood flow as well as
improve wound contraction and granulation
formation to a greater degree (Malmsjo et al.
(2012); Lindstedt et al. (2010).
Mullner et al. (1997) evaluated the efficacy
of NPWT on the healing of pressure ulcers,
acute traumatic wounds, and infected soft tissue
wounds in 45 individuals. Seventeen of the 45
individuals with infected sacral pressure ulcers,
including one with SCI, were treated with NPWT
for 4 weeks. Of these, one ulcer achieved
primary closure, eight ulcers granulated and
were closed secondarily by grafting, and three
ulcers decreased in size by 80%. Argenta and
Morykwas (1997) reported on a case series of
141 category/stage III and IV pressure ulcers
using variable treatment durations in which 32%
of the wounds closed completely in 2 to 16
weeks; 46% decreased in size more than 80%
and were subsequently treated with either skin
grafts, muscle flaps, primary closure, or dressing
changes, while another 15% decreased in size
from 50% to 80% and were either grafted or
flapped. Published results demonstrating
effectiveness of the treatment of pressure ulcers
in persons with SCI with NPWT is not robust. If
nutritional status is poor in persons with SCI and
pressure ulcers, Ho et al. (2010) reported that
NPWT is not effective.

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Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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