A systematic review of neuromuscular electrical stimulation for pressure ulcer care in spinal cord injuries.

Introduction and Aim Pressure ulcer (PU) is one of the most common secondary complications following a spinal cord injury (SCI). Electrical stimulation (ES) can confer the benefit to pressure ulcer care in SCI. However, to date, the clinical guidelines regarding the use of ES for PU management in SCI remain limited. This systematic review was therefore conducted to identify the updated evidence, and to pinpoint the scope of the feasibility of future studies implementing electrical stimulation for PU management in SCI. The overall aim of this review was to critically appraise and synthesize the research evidence on neuromuscular ES for the prevention and treatment of PU in spinal cord injuries. Material and Method Review was limited to peer-reviewed studies published in English from 1970 to 2013. A Free-text and keyword/MESH terms search of five databases (Medline, CINAHL, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials.), in addition to manual searches of other resources and retrieved articles was undertaken on 18th July 2013. Studies included randomized controlled trials (RCTs), non-randomized controlled trials, prospective cohort studies, case series, case control studies and case report studies. Target population included adults with SCI. Interventions of any type of neuromuscular ES were accepted. Any outcome measuring the effectiveness of PU prevention and treatment was included. Methodological quality was evaluated using established instruments by two independent reviewers. Results Twenty-seven studies were included in this review, 9/27 studies were RCTs. Six of RCTs were therapeutic trials. ES enhanced PU healing in all therapeutic studies. The evidence of long-term benefit of ES for pressure ulcer prevention is uncertain. Five types of ES modalities (surface electrodes, ES shorts, sacral anterior nerve root implant, neuromuscular electrical stimulation implant and anal probe) were identified in this review. Conclusion The great variability in the parameters and locations of ES application and outcome measure leads to an inability to advocate any one standard therapeutic approach for PU therapy or prevention. The methodological quality of the studies was generally poor, in particular for those prevention studies. Future research is suggested to improve the design of ES devices, standardize ES parameters and conduct more rigorous trials.

Introduction and Aim
Pressure ulcer (PU) is one of the most common secondary complications following a spinal cord injury (SCI). Electrical stimulation (ES) can confer the benefit to pressure ulcer care in SCI. However, to date, the clinical guidelines regarding the use of ES for PU management in SCI remain limited. This systematic review was therefore conducted to identify the updated evidence, and to pinpoint the scope of the feasibility of future studies implementing electrical stimulation for PU management in SCI. The overall aim of this review was to critically appraise and synthesize the research evidence on neuromuscular ES for the prevention and treatment of PU in spinal cord injuries.

Material and Method
Review was limited to peer-reviewed studies published in English from 1970 to 2013. A Free-text and keyword/MESH terms search of five databases (Medline, CINAHL, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials.), in addition to manual searches of other resources and retrieved articles was undertaken on 18th July 2013. Studies included randomized controlled trials (RCTs), non-randomized controlled trials, prospective cohort studies, case series, case control studies and case report studies. Target population included adults with SCI. Interventions of any type of neuromuscular ES were accepted. Any outcome measuring the effectiveness of PU prevention and treatment was included. Methodological quality was evaluated using established instruments by two independent reviewers.

Results
Twenty-seven studies were included in this review, 9/27 studies were RCTs. Six of RCTs were therapeutic trials. ES enhanced PU healing in all therapeutic studies. The evidence of long-term benefit of ES for pressure ulcer prevention is uncertain. Five types of ES modalities (surface electrodes, ES shorts, sacral anterior nerve root implant, neuromuscular electrical stimulation implant and anal probe) were identified in this review.

Conclusion
The great variability in the parameters and locations of ES application and outcome measure leads to an inability to advocate any one standard therapeutic approach for PU therapy or prevention. The methodological quality of the studies was generally poor, in particular for those prevention studies. Future research is suggested to improve the design of ES devices, standardize ES parameters and conduct more rigorous trials.