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DOI: 10.1111/eci.

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

venous disease, ulcers are usually located in the gaiter area


between the ankle and the calf, often on the medial aspect of the
leg. Arterial leg ulcers result from inadequate blood supply as
seen in atherosclerosis and can occur anywhere on the lower
leg. They are often deeper and rounded, with clearly defined
borders. Diabetic ulcers are also referred to as neurotrophic
ulcers and typically occur on the feet, or pressure areas of
patients or may be related to trauma. Neuropathy, secondary to
diabetes and peripheral arterial disease often coexist in
patients. Pressure ulcers refer to the breakdown of skin which
occurs when constant pressure affects the skin circulation
causing necrosis. They are most common over bony prominences.
Chronic ulcers represent a significant burden on health
resources, and in 2008, it was approximated that 200 000

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R. BARNES ET AL.

patients had a chronic wound at an estimated cost of


2331 billion per year (20052006 costs) [4]. In the United
States, an estimated 6 million persons are currently afflicted by
chronic wounds of the lower extremity, i.e. ulcers of any aetiology [5] while in the EU 49 000 to 13 million people are estimated to have an open lower-limb ulcer [6]. Chronic ulcers also
have a marked impact on patients well-being with a recent
multicentre study demonstrating that such patients with
chronic ulcers report a significantly poorer quality of life [7]
which is directly related to ulcer size and duration. It has also
been shown that current/active ulceration results in significantly poorer quality of life than reported by patients with
healed ulceration [8].
Electrical stimulation to aid and promote wound healing has
been reported in the literature for decades, and as early as 1688,
changed gold leaf was used on small pox lesions to reduce
scarring [9]. Recently, there has been renewed interest in its role
as evidenced by the number of published studies exploring its
use [944]. These studies have utilised several different electrical stimulation devices; however, the results of all the trials
appear to suggest that electrical stimulation accelerates wound
healing irrespective of the device used or the aetiology of the
ulcers. The devices can be categorised according to the type of
electrical current delivered to the tissues: direct current, pulsed
current and alternating current [43] (Fig. 1).
The variation in the device used combined with the small
number of patients included in the individual published trials
has resulted in electrical stimulation not being recognised as an
effective adjunct to the accepted treatment modalities for
chronic ulcers.
Several studies have been carried out to examine whether
electrical stimulation is a cost-effective treatment adjunct for

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the healing of chronic ulcers. Taylor et al. [45] concluded that it


is cost-effective, offering improved outcome for less cost in
patients with chronic venous ulceration. Mittmann et al. [46]
evaluated the role of electrical stimulation in the treatment for
pressure ulcers and also determined it to be a cost-effective
treatment option.
In the light of the significant implications on patient quality
of life and the burden on health care providers, an examination
of the literature to establish the effectiveness of electrical stimulation on the healing rates of chronic ulcers, of all aetiologies,
when compared to standard treatment and/or sham stimulation by increasing the statistical power of the existing small
randomised controlled studies was deemed a necessity. This
study also aimed to compare the effect of the differing types of
electrical stimulation.

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

Types of electrical stimulation.

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.

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ELECTRICAL STIMULATION FOR ULCER HEALING

The literature search, assessment for inclusion and data


extraction were carried out by two independent reviewers (RB,
YS) and any disagreements were resolved by consensus and a
third author (RG).

deviation or standard error [18,55]. In the case of inadequate


results, reporting attempts were made to contact the corresponding author; however, no further data were obtained. A
PRISMA flow diagram and exclusion criteria are presented in
Fig. 2.

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

Characteristics of patients and trials


Our analysis included 21 trials [9,2443] and 866 patients of
whom 34 were randomised in one parallel nonplacebo singleblind trial [38], 50 were randomised in one parallel nonplacebo
double-blind trial [40], 138 were randomised in three parallel
nonplacebo open trials [31,34,35], eight were randomised in one
parallel-placebo single-blind trial [33], 246 were randomised in
six parallel-placebo double-blind trials [2830,32,37,39] and 390
were randomised in nine parallel-placebo open trials [9,2427,
36,4143]. The mean age of patients ranged from 2925 [32] to
830 [36] years. The aetiology of ulcers varied between trials
with 11 studies examining pressure ulcers [9,2427,31,33,3537,
43], three studies examining venous ulcers [28,29,40], two
studies examining diabetic ulcers [41,43], one study examining
arterial ulcers [52] and four examining ulcers of mixed aetiology [30,34,38,39].
The current type used for electrical stimulation also varied
between trials with 14 trials utilising pulsed currents [9,2527,
2934,3739,41,42], two trials utilising direct currents [30,36]
and five trials utilising alternating currents [28,35,40,42,43].
The outcome measures varied between the trials with 12
trials examining the percentage change in wound surface area
over the study period [9,24,26,27,29,3134,3744]. The remaining trials examined the change in size over the study period in
centimetre square (cm2) [24,25,2730,34,36]. For the purposes of
a meta-analysis, we planned to harmonise outcomes; however,
studies reported different outcome measures in terms of electrical stimulation efficacy. For instance, some trials reported
efficacy as change in ulcer size in square centimetre or percentage weekly or daily change in ulcer size or percentage
change in ulcer size over total study periods. Harmonisation of
these outcome measures could have been possible if we did not
need to harmonise accompanying standard errors or standard
deviations or confidence intervals. Hence, we opted to synthesise outcome measures separately to maintain rigour and
accuracy of our study.

Methodological quality of included studies


The methodological quality of the included trials ranged from
poor to good, with a median Jadad score of 3 (range 15). This
resulted from poor description of randomisation and allocation
concealment methods and the lack of double-blinding. Two
studies had poorly matched treatment and control groups
[29,35]. Three studies [9,25,30] lacked adequate reporting on
loss to follow-up and withdrawals.

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R. BARNES ET AL.

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Table 1 Risk of bias assessment and Jadad score

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

NR, not reported.


*Treatment and control group are not well matched.

No comparison was done between treatment and control group for demographics.

Significant differences in age and ulcer duration between treatment and control.

Data pooling and meta-analysis


Mean percentage change in ulcer size over total studies
periods. Electrical stimulation effect on percentage change in
ulcer size over the total studies periods was assessed in six
RCTs [26,32,3740]. These studies included a total of 210
patients. Overall, electrical stimulation significantly increased
the percentage mean change in ulcer size by 2462%, 95% CI
19982927, P < 000001 with no heterogeneity (I2 = 0%,
P = 066) when compared to standard care and/or sham stimulation. In the five RCTs [26,32,3739] which used pulsed current for electrical stimulation, the percentage mean change in
ulcer size increased by 2831%, 95% CI 22083454, P < 000001

432

with no heterogeneity. On the other hand, in the one trial [40]


which used alternating current for electrical stimulation, the
percentage mean change in ulcer size increased by 20%, 95% CI
13032697, P < 000001 (Fig. 3).
Mean percentage weekly change in ulcer size. Electrical
stimulation effect on percentage weekly change in ulcer size
was assessed in three RCTs [9,42,43]. These studies included a
total of 176 patients. Overall, electrical stimulation insignificantly increased the percentage weekly change in ulcer size by
164%, 95% CI 381 to 709, P = 056 with significant heterogeneity across trials (I2 = 96%, P < 000001) when compared to
standard care and/or sham stimulation. In trials which used

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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]

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Parallel,
placebo

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

Table 2 Patients and trials characteristics

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

59, 64, 67

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

ELECTRICAL STIMULATION FOR ULCER HEALING

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.

pulsed current [9,43] for electrical stimulation, the percentage


weekly change in ulcer size increased by 511%, 95% CI 426
to 1447, P = 028, whereas, it decreased by 021%, 95% CI 759
to 716, P = 096 in trials which used alternating current for
electrical stimulation [42,43] (Fig. 4).
Mean change in ulcer size (cm2). Electrical stimulation effect
on ulcer size (cm2) was assessed in six RCTs [24,25,27,30,34,36].
These studies included a total of 266 patients. Electrical stimulation effect on ulcer size was superior to standard care and/
or sham stimulation, as it improved ulcer size by 242 cm2, 95%
CI 166317, P < 000001 compared to standard care and/or
sham stimulation. However, there was significant heterogeneity across trials (I2 = 94%, P < 000001). In the three trials
[25,27,34] which used pulsed current for electrical stimulation,
ulcer size decreased by 253 cm2, 95% CI 151354,
P < 000001. On the other hand, ulcer size decreased by
253 cm2, 95% CI 228279, P < 000001 in the three trials
[24,30,36] which used direct current for electrical stimulation
(Fig. 5).
Mean percentage daily change in ulcer size. Electrical stimulation effect on mean percentage daily change in ulcer size
was assessed in one RCT [33]. This trial included a total of 16
patients. Electrical stimulation insignificantly improved the
percentage daily change in ulcer size by 063%, 95% CI 012 to
137, P = 010 when compared to standard care and/or sham
stimulation. Pulsed current was used for electrical stimulation
in this trial (Fig. 6).

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

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Identification

ELECTRICAL STIMULATION FOR ULCER HEALING

Records identified through


database search
(n = 250)

Additional records identified


through reference review
(n = 12)

Eligibility

Screening

Records after duplicates removed


(n = 171)

Records screened
(n = 171)

Full-text articles assessed


for eligibility
(n = 45)

Records excluded
(n = 126)

Full-text articles excluded, with


reasons (n = 24)
16 non-randomised design
6 different outcome measures
1 previously reported results
3 inadequate reporting

Included

Studies included in
qualitative synthesis
(n = 21)

Figure 2

Studies included in
quantitative synthesis
(meta-analysis)
(n = 21)

PRISMA flow diagram and exclusion criteria.

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.

[58,59], and the financial burden of chronic ulceration on the


NHS is also significant with estimates of 23bn31bn per year
[4]. As such, it may be argued that any interventions and
treatments which may accelerate the healing should be implemented.
The results of this meta-analysis are in agreement with the
findings of a previous meta-analysis by Gardner et al. [60].
Nevertheless, our meta-analysis included only randomised

436

control trials and included 10 trials which were not published


at the time of the previous meta-analysis. The latter [60]
included randomised and nonrandomised controlled trials as
well as cohort studies and attempted to standardise the outcome measures by estimating a value for the percentage healing
per week for the included trials. However, this might have
masked the actual treatment effect of electrical stimulation on
ulcer healing.

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ELECTRICAL STIMULATION FOR ULCER HEALING

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.

Figure 7 Funnel plot illustrating publication bias across 15


RCTs included in the meta-analysis (represented by small
boxes on the plot). The treatment effects (mean differences) on
the X axis are plotted against their corresponding standard
errors on the Y axis.

The high heterogeneity experienced across some of the trials


included in our meta-analysis can be explained by the different
aetiology of ulcers studied and the different current types used
for electrical stimulation. However, electrical stimulation was
superior to standard treatment and/or sham stimulation in its
effect on ulcer healing.
Endogenous electrical fields are naturally occurring in vivo
and are known to be vital for tissue development and repair.
They occur as a result of ionic transport across polarised epithelium and endothelium. Several disease processes are known
to interfere with the generation of these natural electrical fields.
It is known that wounds show a comparative positive electrical
charge with the surrounding skin, and this potential difference
results in a current which has been shown to stimulate the
biological repair mechanism [61].

Exogenous electrical stimulation is believed to restart and


stimulate these electrical fields and as such promote healing.
There is an increasing body of evidence that exogenous electrical currents can enhance the natural bioelectrical signals
present in the human body. Many studies have examined the
physiological effects of electrical stimulation. They have
shown that macrophages, granulocytes, fibroblasts and epithelial cells migrate with increased magnitude and velocity
when electrical stimulation is applied to a wound [6264]. It
has also been shown that collagen formation increases, as does
its distribution around the wound edge, and as such, wounds
treated with electrical stimulation demonstrate greater tensile
strength [65].
Electrical stimulation has been shown to stimulate endothelial cells to migrate and promotes the release of vascular
endothelial growth factor (VEGF) levels promoting angiogenesis [46,6669]. As a result, the granulation tissue displays a
dense network of capillaries; however, these are unstable in
nature and the effects are believed to be short-lived.
It has also been shown that exogenous electrical stimulation
can have an antibacterial effect and inhibits the effects of the
pathogens known to commonly colonise wounds. This effect is
most commonly seen with direct currents [69].
While it can be seen that electrical stimulation can improve
ulcer healing, the inconsistencies in the protocols, as seen in
this meta-analysis, make decisions regarding its use complicated. It is not possible to establish the relative effectiveness of
each treatment protocol as too many variables exist including
type of current applied, duration of therapy and ulcer
aetiology.

Implications for future research


Further studies are required to establish the relative effectiveness of the differing treatment modalities, i.e. the effect of
differing current types. The optimum regime also needs to be
investigated to determine the most effective duration of

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therapy. It is also necessary to establish whether this


improvement in healing applies equally to all ulcer aetiologies. A standardised method of measuring healing would
provide comparable outcome data which would facilitate
future analyses.
Future studies should concentrate on study methodology to
minimise bias. The predominant weaknesses encountered in
the aforementioned trials included poor description of randomisation and allocation concealment methods, the lack of
double-blinding and absence of multivariate analysis of
demographics to establish comparability of the treatment and
control groups.
Furthermore, few studies have examined the cost-effectiveness of electrical stimulation when compared to standard
treatment for the healing of chronic ulcers. One trial which
examined electrical stimulation in the treatment for pressure
ulcers in spinal cord injured patients revealed that the
treatment is cost-effective within this patient cohort [51].
Similarly, a study by Taylor et al. [45] established that electrical stimulation is a cost-effective treatment adjunct in the
treatment for chronic venous leg ulcer; however, it stated that
this was dependant on the number of required treatment
units, the costs of these units and the degree of required
nurse input. It is clear that these vary greatly between the
devices tested.

Study strengths and limitations


The strengths of this meta-analysis include a comprehensive
literature search which included randomised controlled trials
only and a duplicate data extraction. Although authors were
contacted as appropriate for missing data and to clarify areas of
concern, we received no responses on our queries. Therefore,
this meta-analysis included published data only. The limitations of this meta-analysis included the high heterogeneity
among included studies, the poor to moderate methodological
quality and the variability of measurements of ulcer healing
and electrical stimulation used.
This meta-analysis evaluated the effect of electrical stimulation on the healing of chronic ulcers of differing aetiologies
which might explain the high heterogeneity among patients
cohorts.

Acknowledgements
None.

Funding
The authors declare that there are no sources of funding for this
work.

Disclosure
None.

438

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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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