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Pressure Ulcer Treatment Strategies: A Systematic Comparative Effectiveness Review FREE

M.E. Beth Smith, DO; Annette Totten, PhD; David H. Hickam, MD, MPH; Rongwei Fu, PhD; Ngoc Wasson, MPH; Basmah Rahman, MPH; Makalapua Motu’apuaka, BS; and Somnath Saha, MD, MPH
[+] Article and Author Information

From the Oregon Evidence-based Practice Center, Oregon Health & Science University, and Portland Veterans Affairs Medical Center, Portland, Oregon.

Disclaimer: The findings and conclusions in this article are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this article should be construed as an official position of AHRQ, the U.S. Department of Health and Human Services, or the U.S. Department of Veterans Affairs.

Acknowledgment: The authors thank Robin Paynter, MLIS; Leah Williams, BS; Alexander Ginsburg, MA; Elaine Graham, MLS; Sujata Thakurta, MA; Bernadette Zakher, MBBS; Susan Carson, MPH; and AHRQ Task Order Officer, Christine Chang, MD.

Grant Support: By AHRQ (contract 290-2007-10057-I, Task Order 8). Dr. Saha is supported by the U.S. Department of Veterans Affairs.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2182.

Requests for Single Reprints: M.E. Beth Smith, DO, Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098; e-mail, smithbet@ohsu.edu.

Current Author Addresses: Drs. Smith, Totten, Hickman, Fu, and Saha, Ms. Wasson, Ms. Rahman, and Ms. Motu’apuaka: Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098.

Author Contributions: Conception and design: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, S. Saha.

Analysis and interpretation of the data: M.E.B. Smith, A. Totten, D.H. Hickam, R. Fu, N. Wasson, S. Saha.

Drafting of the article: M.E.B. Smith, D.H. Hickam, N. Wasson, B. Rahman, S. Saha.

Critical revision of the article for important intellectual content: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, S. Saha.

Final approval of the article: M.E.B. Smith, A. Totten, N. Wasson, B. Rahman, S. Saha.

Provision of study materials or patients: D.H. Hickam, N. Wasson, M. Motu’apuaka.

Statistical expertise: R. Fu, N. Wasson.

Administrative, technical, or logistic support: N. Wasson, B. Rahman, M. Motu’apuaka.

Collection and assembly of data: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, B. Rahman, M. Motu’apuaka, S. Saha.


Ann Intern Med. 2013;159(1):39-50. doi:10.7326/0003-4819-159-1-201307020-00007
Text Size: A A A

Background: Pressure ulcers affect as many as 3 million Americans and are major sources of morbidity, mortality, and health care costs.

Purpose: To summarize evidence comparing the effectiveness and safety of treatment strategies for adults with pressure ulcers.

Data Sources: MEDLINE, EMBASE, CINAHL, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database for English- or foreign-language studies; reference lists; gray literature; and individual product packets from manufacturers (January 1985 to October 2012).

Study Selection: Randomized trials and comparative observational studies of treatments for pressure ulcers in adults and noncomparative intervention series (n > 50) for surgical interventions and evaluation of harms.

Data Extraction: Data were extracted and evaluated for accuracy of the extraction, quality of included studies, and strength of evidence.

Data Synthesis: 174 studies met inclusion criteria and 92 evaluated complete wound healing. In comparison with standard care, placebo, or sham interventions, moderate-strength evidence showed that air-fluidized beds (5 studies [n = 908]; high consistency), protein-containing nutritional supplements (12 studies [n = 562]; high consistency), radiant heat dressings (4 studies [n = 160]; moderate consistency), and electrical stimulation (9 studies [n = 397]; moderate consistency) improved healing of pressure ulcers. Low-strength evidence showed that alternating-pressure surfaces, hydrocolloid dressings, platelet-derived growth factor, and light therapy improved healing of pressure ulcers. The evidence about harms was limited.

Limitation: Applicability of results is limited by study quality, heterogeneity in methods and outcomes, and inadequate duration to assess complete wound healing.

Conclusion: Moderate-strength evidence shows that healing of pressure ulcers in adults is improved with the use of air-fluidized beds, protein supplementation, radiant heat dressings, and electrical stimulation.

Primary Funding Source: Agency for Healthcare Research and Quality.


Pressure ulcers affect 3 million adults in the United States. Healing rates, which are dependent on comorbid conditions, clinical interventions, and ulcer severity, vary. Ulcer severity is assessed using various staging or grading systems, but the National Pressure Ulcer Advisory Panel staging system is most commonly used (Figure 1) (1). Ulcers can range from stage I with intact skin to stage IV with full-thickness tissue loss and exposed bone, tendon, or muscle. They can also be described as unstageable when the base of a full-thickness ulcer is covered with slough or as suspected deep-tissue injury when the skin is intact but the underlying tissue has evidence of damage. Comorbid conditions predisposing pressure ulcer development and affecting ulcer healing include those affecting patient mobility (such as spinal cord injury), wound environments (such as incontinence), and wound healing (such as diabetes and vascular disease). Delayed healing can add to the length of hospitalization, impede return to full functioning (2), and require long-term care. Cost estimates for pressure ulcer treatment range between $37 800 and $70 000 per ulcer, with total annual costs in the United States as high as $11 billion (1, 3).

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Figure 1.

National Pressure Ulcer Advisory Panel pressure ulcer stages.

Pressure ulcer stages I to IV and the 2 additional categories of suspected deep-tissue injury and unstageable are defined. National Pressure Ulcer Advisory Panel copyright; photos used with permission. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

* Not pictured.

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Pressure ulcer treatment involves various approaches, including interventions to treat the conditions that lead to pressure ulcers (support surfaces and nutritional support), interventions to protect and promote healing of the ulcer (wound dressings; topical applications; and various adjunctive therapies, such as electrical stimulation, light therapy, and vacuum-assisted devices), and surgical repair of the ulcer (1, 3). Treatments for pressure ulcers have been described and evaluated with varying degrees of rigor and completeness (34) with continued uncertainty around the best treatment options. The purpose of this review is to examine the comparative effectiveness and harms of therapies and approaches to treating pressure ulcers (5). Common terms used in this article are defined in the Glossary.

Scope

We followed a standard protocol for systematic reviews and developed an analytic framework with input from key informants (clinicians, wound care researchers, and patient advocates) to answer the following key questions: In adults with pressure ulcers, what is the comparative effectiveness of treatment strategies for improved health outcomes, including but not limited to complete wound healing, healing time, reduced wound size, pain, and prevention of serious complications of infection? What are the harms of treatments for pressure ulcers? See Figure 2 for more details.

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Figure 2.

Analytic framework of pressure ulcer treatment strategies.

From reference (5).

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We also attempted to discern whether the balance of benefits and harms of treatment options varied according to characteristics of the pressure ulcer, patient, or setting in which care was delivered. We met regularly throughout the review with members of a technical expert panel, some of whom served as key informants during the development phase, to oversee the clinical applicability, content completeness, and methodological rigor of the review process.

The population comprises adults with pressure ulcers. Interventions include support surfaces; nutritional supplements; local wound applications (including wound dressings, topical therapies, and biological agents); surgical procedures; and various adjunctive therapies with comparators of standard wound care, placebo, or sham therapy. In some cases, alternative treatment options were compared. At the recommendation of our technical expert panel, complete wound healing was considered the most clinically important outcome, but we also included other measures of wound improvement, such as reduction in ulcer size or rate of change over time, pain, and prevention of serious complications. Harms of therapy included but were not limited to pain, dermatologic complications, bleeding, and infection.

Data Sources and Searches

We searched for relevant English- and foreign-language studies and systematic reviews in MEDLINE, EMBASE, CINAHL, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, gray literature, scientific information packets, and reference lists. Given the technological advancement in treatment interventions, we restricted our search to January 1985 to October 2012 to find studies of current relevance.

Study Selection

We included randomized trials and comparative observational studies of treatments for pressure ulcers in adults. We included noncomparative intervention series (n > 50) for surgical interventions and evaluation of harms. Exclusion criteria were wrong population (children; adolescents; and patients with non–pressure-related ulcers, including but not limited to venous ulcers and diabetic foot ulcers), studies of interventions without comparators, hospice care settings unless complete wound healing was an outcome measured, and case reports.

At least 2 investigators independently evaluated each study to determine inclusion eligibility. Disagreement was settled by consensus or adjudication by a senior investigator when consensus could not be reached.

Data Extraction and Quality Assessment

From the included studies, details of the patient population, study design, analysis, follow-up, and results were extracted by a team member and reviewed for accuracy and completeness by an investigator. For comparability across studies, when possible, ulcer stage or grade was translated to the corresponding stage as defined by the National Pressure Ulcer Advisory Panel (Appendix Table 1). Investigators rated the quality (risk of bias) of the individual studies and strength of the body of evidence, and results were reviewed by at least 1 other investigator for accuracy, with disagreements being settled by consensus (68). We used an approach adapted from the Agency for Healthcare Research and Quality (AHRQ) Methods Guide for Effectiveness and Comparative Effectiveness Reviews (9) for determining the strength of evidence as “high,” “moderate,” “low,” or “insufficient” on the basis of the design, quantity, size, and quality (risk of bias) of studies, consistency across studies, precision of estimates and directness of evidence.

Table Jump PlaceholderAppendix Table 1. Stages of Pressure Ulcer Equivalency 
Data Synthesis and Analysis

Data were synthesized qualitatively with attention to characteristics, such as ulcer grade and location, patient characteristics and settings, and risk of bias of individual studies.

We conducted meta-analyses in selected instances for comparisons examining the outcome of complete wound healing where the number, quality, and homogeneity of studies permitted. We chose to limit meta-analysis to the outcome of complete wound healing because this was the principal health outcome of interest and because of the wide variability in the measurement of other outcomes, including reduction in wound size. When a meta-analysis was conducted, we used relative risk as the effect measure. We assessed the presence of statistical heterogeneity among the studies using standard chi-square tests and the magnitude of heterogeneity using the I2 statistic (10). We used random-effects models to account for variation among studies (11) and fixed-effects Mantel–Haenszel models when variation among studies was estimated to be zero. Sensitivity analysis was conducted to assess the effect of quality on combined estimates, and meta-regression was conducted to assess the association of effect measure with study duration. All quantitative analyses were done using STATA, version 11.0 (StataCorp, College Station, Texas).

Role of the Funding Source

This research was funded by AHRQ. The draft report was reviewed by content experts, AHRQ program officers, and collaborative partners. Investigators worked with AHRQ staff to develop and refine the scope, analytic framework, and key questions; resolve issues arising during the project; and review the final report to ensure methodological standards for systematic reviews were met. The complete report (5), including the list of included and excluded studies, can be found at www.effectivehealthcare.ahrq.gov. The AHRQ had no role in study selection, quality assessment, synthesis, or development of conclusions. The investigators are solely responsible for the content and the decision to submit the manuscript for publication.

The results of the search and study selection are shown in Appendix Figure 1. We reviewed 7149 abstracts and titles and 1846 full-text articles; we found 174 studies (182 full-text articles) that met our inclusion criteria. Gray literature was assessed but did not provide additional results. Study quality was generally poor, sample sizes were small, and follow-up was frequently too short to assess complete wound healing.

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Appendix Figure 1.

Summary of evidence search and selection.

Full-text articles that were reviewed include additional studies identified through other sources, hand-searches of reference lists, peer review and public comment, scientific information packets, and gray literature searches. Quality-of-life outcomes and results related to histologic outcomes are in the full report (5) but not included in this article.

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Effectiveness of Therapies Used to Treat Pressure Ulcers

The overall findings and strength of the evidence are summarized in the Table and Appendix Table 2, and the risk-of-bias assessments for individual studies are summarized in the Supplement. We found data on the outcomes of complete wound healing and wound improvement, including reduction in wound size, rate of change over time, or change in ulcer stage, but not on outcomes of pain and prevention of serious complications. Most studies enrolled older hospital patients and long-term care residents with stage II to IV pressure ulcers, although some studies enrolled younger, neurologically impaired adults. When available, we reported on whether the effectiveness of interventions varied according to characteristics of the pressure ulcer, patient, or setting in which care was delivered, but in general, few studies conducted subgroup analysis and data were insufficient to draw any conclusions in these subgroups.

Table Jump PlaceholderTable. Summary of Evidence of Benefits and Harms of Pressure Ulcer Treatment Strategies 
Table Jump PlaceholderAppendix Table 2. Summary of Evidence of Differences of Intervention Effectiveness 
Support Surfaces

We found 24 studies (21 trials and 3 observational studies) that provided evidence on various support surfaces, including air-fluidized beds, alternating-pressure beds and chair cushions, and low–air-loss beds. Of these, 4 were rated good-quality, 10 as fair-quality, and 10 as poor-quality. Eight studies evaluated the outcome of complete wound healing (1219). No differences were found in complete wound healing when comparing types of support surfaces. We found moderate-strength evidence that wound improvement (including rate of reduction in wound size and ulcer stage) was superior with air-fluidized beds, although they were most often compared with standard hospital beds rather than other advanced support surfaces. This was based on 5 studies with highly consistent results (2024). Healing was similar between alternating-pressure mattresses and other support surfaces (19, 2527) (low-strength evidence), and different types of alternating-pressure mattresses provided similar benefit (moderate-strength evidence) (1213, 2831). Evidence about the effectiveness of alternating-pressure seat cushions was insufficient because only 2 studies with very different populations were identified (3233). We found low-strength evidence that low–air-loss beds are similar to foam surfaces or foam mattresses (4 studies) (15, 17, 3334), and wound healing did not differ when comparing low–air-loss beds with low–air-loss overlays (1 study) (35). Most studies of support surfaces were older and compared these surfaces with standard care that may not be considered high-quality care today.

Nutrition

We found 16 studies (11 trials and 5 observational studies) that addressed nutritional support, including protein-containing nutritional supplementation and specific nutrient supplementation with vitamins or minerals, such as ascorbic acid (vitamin C) or zinc. Three trials were rated good-quality (3638), 2 were fair-quality (3940), and 6 were poor-quality (4146). Four observational studies were rated fair-quality (4750), and 1 was poor-quality (51). Eight studies considered the outcome of complete wound healing (36, 3842, 46, 48).

Although the formulations varied greatly, most of the 12 studies of protein supplementation found greater reduction in ulcer size with supplementation than without, but not more complete wound healing. Because of the small number of head-to-head trials, the existing evidence base does not clarify whether any specific type of protein supplementation is superior to others. Low-strength evidence indicated no benefits in wound healing with vitamin C based on 1 good-quality study (n = 88) (37). Evidence about zinc supplementation was insufficient to draw conclusions (49).

Local Wound Applications

We identified 89 original studies that examined the effectiveness of local wound applications for pressure ulcers in 7115 patients. Seventy-six of the original studies were clinical trials. Of these, 11 were rated good-quality, 20 were fair-quality, and 45 were poor-quality. Sample sizes ranged from 10 to 168 patients. There were 13 observational studies. One cohort study was rated fair-quality, and the other observational studies were poor-quality. Fifty-nine studies addressed the outcome of complete wound healing (52111). No differences were found in complete wound healing when comparing types of local wound applications.

We found 10 studies (1 good-quality [52], 2 fair-quality [5354], and 7 poor-quality [5559, 112113]) that compared hydrocolloid with gauze dressings and provided low-strength evidence indicating greater reduction in wound size with hydrocolloid dressings. Statistical heterogeneity precluded quantitative pooling of results across these studies. Complete wound healing was equivalent with hydrocolloid and foam dressings (pooled relative risk, 1.12 [95% CI, 0.88 to 1.41]; I2 = 16.4%; P = 0.301) (8 studies; moderate-strength evidence) (7279). Radiant heat dressings produced more rapid reduction in wound size than other dressings based on moderately consistent results from 2 good-quality and 2 fair-quality trials, but there was no evidence of benefit in terms of complete wound healing (pooled relative risk, 1.23 [CI, 0.70 to 2.14]; I2 = 0.0%; P = 0.916) (8386). Evidence about the comparative effectiveness of other dressing types was insufficient.

The most commonly evaluated topical therapies were debriding enzymes (primarily collagenase), phenytoin solution, dextranomer paste, and collagen applications. Low-strength evidence showed that dextranomer is less effective than other wound dressings based on 1 good-quality trial (114) and 1 poor-quality trial (115). Evidence about enzymes and phenytoin was inconsistent and insufficient to draw conclusions. Collagen applications did not seem to provide wound-healing benefit compared with standard care, based on low-strength evidence from 1 good-quality (116) and 2 poor-quality (95, 117) trials. The most commonly evaluated biological agent was platelet-derived growth factor, for which 1 fair-quality (110) and 3 poor-quality (103, 107, 118119) studies provided low-strength evidence of benefit compared with placebo in promoting healing of severe (stage III or IV) ulcers. Evidence about the effectiveness of other biological agents was insufficient.

Surgery

Surgical interventions for pressure ulcers identified in studies that met our inclusion criteria were primarily surgical flaps (most commonly myocutaneous and fasciocutaneous flaps). One poor-quality trial (120) and 5 fair-quality intervention series (121125), including 1094 pressure ulcers in 647 patients, provided evidence on the effectiveness of surgical techniques to treat stage III or IV pressure ulcers. We found low-strength evidence for a lower rate of ulcer recurrence with sacral ulcers than ischial ulcers, a higher rate of recurrent ulcer among patients with spinal cord injuries than among others, and greater wound dehiscence rates with surgeries in which bone was removed. Because of heterogeneity in patient populations and surgical procedures, there was insufficient evidence that 1 approach to closure of stage III or IV pressure ulcers was superior to another.

Adjunctive Therapies

Thirty-four trials (3 good-quality, 29 fair-quality, and 2 poor-quality) and 5 observational studies (2 fair-quality and 3 poor-quality) that evaluated adjunctive therapies met our inclusion criteria. Adjunctive therapies identified in our review included electrical stimulation, electromagnetic therapy, therapeutic ultrasound, negative-pressure wound therapy, hydrotherapy, light therapy, and laser therapy. Evidence about other adjunctive therapies—including vibration, shock wave, and hyperbaric oxygen—was limited to small, single studies that provided insufficient evidence for comparative effectiveness conclusions. Seventeen studies addressed the outcome of complete wound healing (126142). Moderately consistent results from 1 good-quality (126) and 8 fair-quality (127131, 143145) trials showed that electrical stimulation improved healing rates (moderate-strength evidence) but evidence about the effect of electrical stimulation on complete wound healing was insufficient because of heterogeneous findings across studies.

Low-strength evidence showed that light therapies provided benefit in terms of reduced wound size but not complete wound healing (139140, 146148). There was also low-strength evidence that electromagnetic therapy (132133, 149150), therapeutic ultrasound (135137), negative-pressure wound therapy (138, 151152), and laser therapy (137, 142, 153) were no different from sham treatment or standard care in wound-healing outcomes. There was insufficient evidence to draw conclusions about hydrotherapy (152, 154).

Harms of Therapies Used to Treat Pressure Ulcers
Support Surfaces

The reported harms of support surface options were minimal, although harms were infrequently and inconsistently reported in studies of this option.

Nutrition

There was insufficient evidence to adequately describe the harms of nutritional supplementation in this patient population.

Local Wound Applications

Moderate-strength evidence from 36 studies showed that the most common harms of wound dressings and topical agents were dermatologic complications, including irritation, inflammation, and maceration. However, variability across studies precluded an estimate of adverse events for specific dressings or topical therapies, and evidence was insufficient to determine whether certain types of dressings or topical therapies were more likely to cause these complications than others. Few harms were reported with biological agents, but the evidence about the harms of these agents was insufficient to reach conclusions about adverse event rates.

Surgery

We found low-strength evidence that more adverse events occur with surgery for ischial ulcers than for sacral or trochanteric ulcers (121122). Surgical flap failures requiring reoperation ranged from 12% to 24% (121, 124).

Adjunctive Therapies

Low-strength evidence showed that the most common adverse effect of electrical stimulation was local skin irritation and that harms were more common in frail elderly populations than in younger populations (126128). There was insufficient evidence to evaluate the harms of electromagnetic therapy, therapeutic ultrasound, negative-pressure wound therapy, and hydrotherapy. Light (139140, 146148) and laser (137, 141142, 153) therapy were not associated with substantial adverse events on the basis of low-strength evidence.

There was insufficient evidence to draw any other conclusions about the effectiveness or harms of interventions based on features of the pressure ulcers, characteristics of the patient, or features of the patient care setting.

We identified 174 studies that addressed the comparative effectiveness and harms of pressure ulcer treatment and found moderate-strength evidence that air-fluidized beds, protein-containing nutritional supplements, radiant heat dressings, and electrical stimulation improved healing of pressure ulcers. Alternating-pressure surfaces, platelet-derived growth factor, hydrocolloid dressings, and light therapy may also improve healing, although the evidence was more limited and of low strength. Dermatologic reaction was noted with several local wound applications and adjunctive therapies, but in general evidence about the harms of treatments was limited.

Our review expands on previous systematic reviews by including observational studies, surgical interventions, and evaluation of harms of treatment and by extending the search to October 2012 (4). Our findings are qualitatively similar to those of other studies, with the exception of the benefit of air-fluidized surfaces and lack of evidence of benefit with electromagnetic therapy. Because the most comprehensive systematic review was published in 2008, 4 additional studies on air-fluidized surfaces were available and led to our finding of moderate-strength evidence that air-fluidized beds were more effective than other surfaces, primarily standard hospital beds, in reducing wound size. Few trials compared air-fluidized beds with other advanced support surfaces, precluding strong conclusions about comparative effectiveness. Our findings were consistent with a recent update on support surfaces by the Cochrane Collaboration (155156). The Cochrane review also reported some benefit from the use of sheepskins, but this finding was based on a study excluded from our review because it was published in 1964. The authors of this review concluded, as we did, that the evidence base was weak, with small studies that had serious methodological limitations. Our finding of no significant wound improvement with electromagnetic therapy is also consistent with a previous Cochrane review (157) but inconsistent with others that commented on a trend toward an improved healing rate (4, 158159). The clinical significance of this trend remains unknown.

The applicability of our findings to real-world clinical settings is supported by the broad representation of patients with pressure ulcers cared for in various settings with interventions representing most of the therapeutic methods commonly used. However, several other features limit applicability of this review. These include the frequent use of the surrogate outcome of reduction in wound size rather than complete wound healing and that, in practice, the treatment of pressure ulcers is typically multimodal and often involves the sequential use of different therapies. Most studies were of poor- to fair-quality; small; underpowered to detect statistically significant differences; and highly variable in patient populations, ulcer characteristics (for example, anatomical site, duration, and stage), interventions (even within a given intervention category, such as different types of foam dressings), and comparators (especially in implementation of standard, or usual, care), which limited our ability to combine or compare results across studies. Studies of surgery are also limited in that most were observational and conducted in 1 center or a few centers at most. Because surgical technique and quality are often operator- or site-dependent and outcomes are influenced by local practices, staffing, and other features of the environment, it is difficult to generalize our findings for surgical interventions.

Implications for clinical and policy decision making are difficult to generate from our review, given the limitations in applicability, potential influence of selective reporting and publication bias, and lack of high-strength evidence, with most of our findings being based on low-strength or insufficient evidence. Future studies are needed with larger sample sizes, more rigorous adherence to methodological standards, information about cointerventions, standardization of comparators, and longer follow-up to allow for clinically meaningful outcome measures, including complete wound healing. Similarly, stratification of findings by patient characteristics (for example, comorbid conditions and ulcer stage) would help determine the applicability of different interventions for specific patients and situations. It is particularly important for future studies to report findings according to ulcer stage because the rate of healing, conditions necessary to promote healing, and treatment choices may differ for partial- and full-thickness ulcers.

We found limited evidence for better wound healing with air-fluidized beds, protein supplementation, radiant heat dressings, and electrical stimulation than with standard care, placebo, or sham interventions. However, the benefit seen in all cases was reduction in wound size or better healing rates rather than completely healed wounds. In addition, there was low-strength or insufficient evidence about treatment harms, and the balance of benefits versus costs and harms for pressure ulcer therapies remains unclear. Advancing pressure ulcer care will require more rigorous study to solidify the evidence base for this widely used, and needed, set of treatments.

Bergstrom N, Allman RM, Alvarez OM, Bennett MA, Carlson CE, Frantz RA, et al.  Pressure Ulcer Treatment. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 15. Rockville, MD: U.S. Department of Health and Human Services; 1994. Accessed at www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/archive.html on 17 May 2013.
 
Graves N, Birrell F, Whitby M. Effect of pressure ulcers on length of hospital stay. Infect Control Hosp Epidemiol. 2005; 26:293-7.
PubMed
CrossRef
 
Lyder CH. Pressure ulcer prevention and management. JAMA. 2003; 289:223-6.
PubMed
CrossRef
 
Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA. Treatment of pressure ulcers: a systematic review. JAMA. 2008; 300:2647-62.
PubMed
CrossRef
 
Saha S, Smith B, Totten A, Fu R, Wasson N, Rahman B, et al.  Pressure Ulcer Treatment Strategies: Comparative Effectiveness. Comparative Effectiveness Review no. 90. (Prepared by Oregon Evidence-based Practice Center under contract no. 290-2007-10057-I.) AHRQ Publication no. 13-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2013. Accessed at www.effectivehealthcare.ahrq.gov/reports/final.cfm on 17 May 2013.
 
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998; 52:377-84.
PubMed
CrossRef
 
Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al, Methods Work Group, Third US Preventive Services Task Force. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001; 20:21-35.
PubMed
CrossRef
 
U.S. Preventive Services Task Force.  Section 4: evidence report development. In: U.S. Preventive Services Task Force Procedure Manual. AHRQ Publication No. 08-05118-EF. Rockville, MD: Agency for Healthcare Research and Quality;2008. Accessed at www.uspreventiveservicestaskforce.org/uspstf08/methods/procmanual.htm on 6 July 2011.
 
Agency for Healthcare Research and Quality.  Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Research and Quality; 2011. Accessed at www.effectivehealthcare.ahrq.gov on 6 July 2011.
 
Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002; 21:1539-58.
PubMed
CrossRef
 
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986; 7:177-88.
PubMed
CrossRef
 
Tissue Viability Society. Laboratory measurement of the interface pressures applied by active therapy support surfaces: a consensus document. J Tissue Viability. 2010; 19:2-6.
PubMed
 
Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum , et al, PRESSURE Trial Group. Pressure relieving support surfaces: a randomised evaluation. Health Technol Assess. 2006; 10:iii-iv, ix-x, 1-163.
PubMed
 
Keogh A, Dealey C. Profiling beds versus standard hospital beds: effects on pressure ulcer incidence outcomes. J Wound Care. 2001; 10:15-9.
PubMed
 
Ferrell BA, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA. 1993; 269:494-7.
PubMed
 
Groen HW, Groenier KH, Schuling J. Comparative study of a foam mattress and a water mattress. J Wound Care. 1999; 8:333-5.
PubMed
 
Mulder G, Taro N, Seeley J, Andrews A. A study of pressure ulcer response to low air loss beds vs. conventional treatment. Journal of Geriatric Dermatology. 1994; 2:87-91.
 
Clark MD, Donald IP.  A randomised controlled trial comparing the healing of pressure sores upon two pressure-redistributing seat cushions. Proceedings of the 7th European Conferences on Advances in Wound Management, Harrogate, UK, 18–20 November 1998:122-5.
 
Valente SA, Greenough Iii WB, DeMarco SL, Andersen RE. More expensive surfaces are not always better. Kuwait Med J. 2012; 44:40-5.
 
Allman RM, Walker JM, Hart MK, Laprade CA, Noel LB, Smith CR. Air-fluidized beds or conventional therapy for pressure sores. A randomized trial. Ann Intern Med. 1987; 107:641-8.
PubMed
CrossRef
 
Munro BH, Brown L, Heitman BB. Pressure ulcers: one bed or another? Geriatr Nurs. 1989; 10:190-2.
PubMed
 
Strauss MJ, Gong J, Gary BD, Kalsbeek WD, Spear S. The cost of home air-fluidized therapy for pressure sores. A randomized controlled trial. J Fam Pract. 1991; 33:52-9.
PubMed
 
Jackson BS, Chagares R, Nee N, Freeman K. The effects of a therapeutic bed on pressure ulcers: an experimental study. J Enterostomal Ther. 1988; 15:220-6.
PubMed
 
Ochs RF, Horn SD, van Rijswijk L, Pietsch C, Smout RJ. Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents. Ostomy Wound Manage. 2005; 51:38-68.
PubMed
 
Russell L, Reynolds TM, Towns A, Worth W, Greenman A, Turner R. Randomized comparison trial of the RIK and the Nimbus 3 mattresses. Br J Nurs. 2003; 12:254, 256-9.
PubMed
 
Izutsu T, Matsui T, Satoh T, Tsuji T, Sasaki H. Effect of rolling bed on decubitus in bedridden nursing home patients. Tohoku J Exp Med. 1998; 184:153-7.
PubMed
CrossRef
 
Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, et al. A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. J Tissue Viability. 2010; 19:7-15.
PubMed
CrossRef
 
Evans D, Land L, Geary A. A clinical evaluation of the Nimbus 3 alternating pressure mattress replacement system. J Wound Care. 2000; 9:181-6.
PubMed
 
Russell L, Reynolds TM, Carr J, Evans A, Holmes M. Randomised controlled trial of two pressure-relieving systems. J Wound Care. 2000; 9:52-5.
PubMed
 
Russell L, Reynolds T, Carr J, Evans A, Holmes M. A comparison of healing rates on two pressure-relieving systems. Br J Nurs. 2000; 9:2270-80.
PubMed
 
Land L, Evans D, Geary A, Taylor C. A clinical evaluation of an alternating-pressure mattress replacement system in hospital and residential care settings. J Tissue Viability. 2000; 10:6-11.
PubMed
 
Makhsous M, Lin F, Knaus E, Zeigler M, Rowles DM, Gittler M, et al. Promote pressure ulcer healing in individuals with spinal cord injury using an individualized cyclic pressure-relief protocol. Adv Skin Wound Care. 2009; 22:514-21.
PubMed
CrossRef
 
Warner DJ. A clinical comparison of two pressure-reducing surfaces in the management of pressure ulcers. Decubitus. 1992; 5:52-5, 58-60, 62-4.
PubMed
 
Day A, Leonard F. Seeking quality care for patients with pressure ulcers. Decubitus. 1993; 6:32-43.
PubMed
 
Caley L, Jones S, Freer J, Miller S.  Randomized prospective trial: treatment outcomes and cost-effectiveness of two types of low-air-loss therapy. Proceedings of the 9th Annual Clinical Symposium on Pressure Ulcer and Wound Management, Nashville, TN. October 1994:1-2.
 
Cereda E, Gini A, Pedrolli C, Vanotti A. Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial. J Am Geriatr Soc. 2009; 57:1395-402.
PubMed
CrossRef
 
ter Riet G, Kessels AG, Knipschild PG. Randomized clinical trial of ascorbic acid in the treatment of pressure ulcers. J Clin Epidemiol. 1995; 48:1453-60.
PubMed
CrossRef
 
Leigh B, Desneves K, Rafferty J, Pearce L, King S, Woodward MC, et al. The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers. J Wound Care. 2012; 21:150-6.
PubMed
 
Meaume S, Kerihuel JC, Constans T, Teot L, Lerebours E, Kern J, et al. Efficacy and safety of ornithine alpha-ketoglutarate in heel pressure ulcers in elderly patients: results of a randomized controlled trial. J Nutr Health Aging. 2009; 13:623-30.
PubMed
CrossRef
 
van Anholt RD, Sobotka L, Meijer EP, Heyman H, Groen HW, Topinková E, et al. Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients. Nutrition. 2010; 26:867-72.
PubMed
CrossRef
 
Chernoff R. The effect of a high protein formula (Replete) on decubitus ulcer healing in long term tube fed institutionalized patients. J Am Diet Assoc. 1990; 90:A130.
 
Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial. Clin Nutr. 2005; 24:979-87.
PubMed
CrossRef
 
Benati G, Delvecchio S, Cilla D, Pedone V. Impact on pressure ulcer healing of an arginine-enriched nutritional solution in patients with severe cognitive impairment. Arch Gerontol Geriatr Suppl. 2001; 7:43-7.
PubMed
 
Lee SK, Posthauer ME, Dorner B, Redovian V, Maloney MJ. Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial. Adv Skin Wound Care. 2006; 19:92-6.
PubMed
CrossRef
 
Myers SA, Takiguchi S, Slavish S, Rose CL. Consistent wound care and nutritional support in treatment. Decubitus. 1990; 3:16-28.
PubMed
 
Ohura T, Nakajo T, Okada S, Omura K, Adachi K. Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states (randomized controlled trial). Wound Repair Regen. 2011; 19:330-6.
PubMed
 
Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc. 1993; 41:357-62.
PubMed
 
Brewer S, Desneves K, Pearce L, Mills K, Dunn L, Brown D, et al. Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients. J Wound Care. 2010; 19:311-6.
PubMed
 
Houston S, Haggard J, Williford J Jr, Meserve L, Shewokis P. Adverse effects of large-dose zinc supplementation in an institutionalized older population with pressure ulcers [Letter]. J Am Geriatr Soc. 2001; 49:1130-2.
PubMed
CrossRef
 
Yamamoto T, Fujioka M, Kitamura R, Yakabe A, Kimura H, Katagiri Y, et al. Evaluation of nutrition in the healing of pressure ulcers: are the EPUAP nutritional guidelines sufficient to heal wounds. European Pressure Ulcer Advisory Panel. Wounds. 2009; 21:153-7.
 
Barnes P Jr, Sauter TE, Zaheri S. Subnormal prealbumin levels and wound healing. Tex Med. 2007; 103:65-8.
PubMed
 
Hollisaz MT, Khedmat H, Yari F. A randomized clinical trial comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers [ISRCTN33429693]. BMC Dermatol. 2004; 4:18.
PubMed
CrossRef
 
Alm A, Hornmark AM, Fall PA, Linder L, Bergstrand B, Ehrnebo M, et al. Care of pressure sores: a controlled study of the use of a hydrocolloid dressing compared with wet saline gauze compresses. Acta Derm Venereol Suppl (Stockh). 1989; 149:1-10.
PubMed
 
Xakellis GC, Chrischilles EA. Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: a cost-effectiveness analysis. Arch Phys Med Rehabil. 1992; 73:463-9.
PubMed
 
Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and cost-effectiveness of two methods of managing pressure ulcers. Decubitus. 1993; 6:28-36.
PubMed
 
Gorse GJ, Messner RL. Improved pressure sore healing with hydrocolloid dressings. Arch Dermatol. 1987; 123:766-71.
PubMed
CrossRef
 
Kim YC, Shin JC, Park CI, Oh SH, Choi SM, Kim YS. Efficacy of hydrocolloid occlusive dressing technique in decubitus ulcer treatment: a comparative study. Yonsei Med J. 1996; 37:181-5.
PubMed
 
Neill K, Conforti C, Kedas A, Burris JF. Pressure sore response to a new hydrocolloid dressing. Wounds. 1989; 1:173-85.
 
Winter A, Hewitt H. Testing a hydrocolloid. Nurs Times. 1990; 86:59-62.
PubMed
 
Matzen S, Peschardt A, Alsbjørn B. A new amorphous hydrocolloid for the treatment of pressure sores: a randomised controlled study. Scand J Plast Reconstr Surg Hand Surg. 1999; 33:13-5.
PubMed
 
Kaya AZ, Turani N, Akyüz M. The effectiveness of a hydrogel dressing compared with standard management of pressure ulcers. J Wound Care. 2005; 14:42-4.
PubMed
 
Thomas DR, Goode PS, LaMaster K, Tennyson T. Acemannan hydrogel dressing versus saline dressing for pressure ulcers. A randomized, controlled trial. Adv Wound Care. 1998; 11:273-6.
PubMed
 
Parnell LK, Ciufi B, Gokoo CF. Preliminary use of a hydrogel containing enzymes in the treatment of stage II and stage III pressure ulcers. Ostomy Wound Manage. 2005; 51:50-60.
PubMed
 
Payne WG, Posnett J, Alvarez O, Brown-Etris M, Jameson G, Wolcott R, et al. A prospective, randomized clinical trial to assess the cost-effectiveness of a modern foam dressing versus a traditional saline gauze dressing in the treatment of stage II pressure ulcers. Ostomy Wound Manage. 2009; 55:50-5.
PubMed
 
Kraft MR, Lawson L, Pohlmann B, Reid-Lokos C, Barder L. A comparison of Epi-Lock and saline dressings in the treatment of pressure ulcers. Decubitus. 1993; 6:42-4, 46, 48.
PubMed
 
Sebern MD. Pressure ulcer management in home health care: efficacy and cost effectiveness of moisture vapor permeable dressing. Arch Phys Med Rehabil. 1986; 67:726-9.
PubMed
CrossRef
 
Kurzuk-Howard G, Simpson L, Palmieri A. Decubitus ulcer care: a comparative study. West J Nurs Res. 1985; 7:58-79.
PubMed
CrossRef
 
Day A, Leonard F. Seeking quality care for patients with pressure ulcers. Decubitus. 1993; 6:32-43.
PubMed
 
Darkovich SL, Brown-Etris M, Spencer M. Biofilm hydrogel dressing: a clinical evaluation in the treatment of pressure sores. Ostomy Wound Manage. 1990; 29:47-60.
PubMed
 
Motta G, Dunham L, Dye T, Mentz J, O'Connell-Gifford E, Smith E. Clinical efficacy and cost-effectiveness of a new synthetic polymer sheet wound dressing. Ostomy Wound Manage. 1999; 45:41, 44-6, 48-49.
PubMed
 
Brown-Etris M, Milne C, Orsted H, Gates JL, Netsch D, Punchello M, et al. A prospective, randomized, multisite clinical evaluation of a transparent absorbent acrylic dressing and a hydrocolloid dressing in the management of Stage II and shallow Stage III pressure ulcers. Adv Skin Wound Care. 2008; 21:169-74.
PubMed
CrossRef
 
Bale S, Squires D, Varnon T, Walker A, Benbow M, Harding KG. A comparison of two dressings in pressure sore management. J Wound Care. 1997; 6:463-6.
PubMed
 
Hondé C, Derks C, Tudor D. Local treatment of pressure sores in the elderly: amino acid copolymer membrane versus hydrocolloid dressing. J Am Geriatr Soc. 1994; 42:1180-3.
PubMed
 
Seeley J, Jensen JL, Hutcherson J. A randomized clinical study comparing a hydrocellular dressing to a hydrocolloid dressing in the management of pressure ulcers. Ostomy Wound Manage. 1999; 45:39-44, 46-7.
PubMed
 
Banks V, Bale SE, Harding KG. Comparing two dressings for exuding pressure sores in community patients. J Wound Care. 1994; 3:175-8.
 
Banks V, Bale S, Harding K. The use of two dressings for moderately exuding pressure sores. J Wound Care. 1994; 3:132-4.
 
Brod M, McHenry E, Plasse TF, Fedorczyk D, Trout JR. A randomized comparison of poly-hema and hydrocolloid dressings for treatment of pressure sores [Letter]. Arch Dermatol. 1990; 126:969-70.
PubMed
CrossRef
 
Bale S, Hagelstein S, Banks V, Harding KG. Costs of dressings in the community. J Wound Care. 1998; 7:327-30.
PubMed
 
Thomas S, Banks V, Bale S, Fear-Price M, Hagelstein S, Harding KG, et al. A comparison of two dressings in the management of chronic wounds. J Wound Care. 1997; 6:383-6.
PubMed
 
Belmin J, Meaume S, Rabus MT, Bohbot S, Investigators of the Sequential Treatment of the Elderly with Pressure Sores (STEPS) Trial. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc. 2002; 50:269-74.
PubMed
CrossRef
 
Maume S, Van De Looverbosch D, Heyman H, Romanelli M, Ciangherotti A, Charpin S. A study to compare a new self-adherent soft silicone dressing with a self-adherent polymer dressing in stage II pressure ulcers. Ostomy Wound Manage. 2003; 49:44-51.
PubMed
 
Viamontes L, Temple D, Wytall D, Walker A. An evaluation of an adhesive hydrocellular foam dressing and a self-adherent soft silicone foam dressing in a nursing home setting. Ostomy Wound Manage. 2003; 49:48-52, 54-6, 58.
PubMed
 
Thomas DR, Diebold MR, Eggemeyer LM. A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3-4 pressure ulcers: a pilot study. J Am Med Dir Assoc. 2005; 6:46-9.
PubMed
 
Price P, Bale S, Crook H, Harding KG. The effect of a radiant heat dressing on pressure ulcers. J Wound Care. 2000; 9:201-5.
PubMed
 
Kloth LC, Berman JE, Nett M, Papanek PE, Dumit-Minkel S. A randomized controlled clinical trial to evaluate the effects of noncontact normothermic wound therapy on chronic full-thickness pressure ulcers. Adv Skin Wound Care. 2002; 15:270-6.
PubMed
 
Whitney JD, Salvadalena G, Higa L, Mich M. Treatment of pressure ulcers with noncontact normothermic wound therapy: healing and warming effects. J Wound Ostomy Continence Nurs. 2001; 28:244-52.
PubMed
 
Bito S, Mizuhara A, Oonishi S, Takeuchi K, Suzuki M, Akiyama K, et al. Randomised controlled trial evaluating the efficacy of wrap therapy for wound healing acceleration in patients with NPUAP stage II and III pressure ulcer. BMJ Open. 2012; 2:000371.
PubMed
CrossRef
 
Small N, Mulder M, Mackenzie MJ, Nel M. A comparative analysis of pressure sore treatment modalities in community settings. Curationis. 2002; 25:74-82.
PubMed
CrossRef
 
Yapucu Güneş U, Eşer I. Effectiveness of a honey dressing for healing pressure ulcers. J Wound Ostomy Continence Nurs. 2007; 34:184-90.
PubMed
CrossRef
 
Burgos A, Gimenez J, Moreno E, Laberto E, Ultrera M, Urraca EM, et al. Collagenase ointment application at 24- versus 48-hour intervals in the treatment of pressure ulcers. A randomised multicentre study. Clin Drug Investig. 2000; 19:399-407.
 
Alvarez OM, Fernandez-Obregon A, Rogers RS, Bergamo L, Masso J, Black M. Chemical debridement of pressure ulcers: a prospective, randomized, comparative trial of collagenase and papain/urea formulations. Wounds. 2000; 12:15-25.
 
Müller E, van Leen MW, Bergemann R. Economic evaluation of collagenase-containing ointment and hydrocolloid dressing in the treatment of pressure ulcers. Pharmacoeconomics. 2001; 19:1209-16.
PubMed
 
Rhodes RS, Heyneman CA, Culbertson VL, Wilson SE, Phatak HM. Topical phenytoin treatment of stage II decubitus ulcers in the elderly. Ann Pharmacother. 2001; 35:675-81.
PubMed
CrossRef
 
Graumlich JF, Blough LS, McLaughlin RG, Milbrandt JC, Calderon CL, Agha SA, et al. Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am Geriatr Soc. 2003; 51:147-54.
PubMed
CrossRef
 
Nisi G, Brandi C, Grimaldi L, Calabrò M, D'Aniello C. Use of a protease-modulating matrix in the treatment of pressure sores. Chir Ital. 2005; 57:465-8.
PubMed
 
Sherman RA. Maggot versus conservative debridement therapy for the treatment of pressure ulcers. Wound Repair Regen. 2002; 10:208-14.
PubMed
CrossRef
 
Wang SY, Wang JN, Lv DC, Diao YP, Zhang Z. Clinical research on the bio-debridement effect of maggot therapy for treatment of chronically infected lesions. Orthop Surg. 2010; 2:201-6.
PubMed
 
Sipponen A, Jokinen JJ, Sipponen P, Papp A, Sarna S, Lohi J. Beneficial effect of resin salve in treatment of severe pressure ulcers: a prospective, randomized and controlled multicentre trial. Br J Dermatol. 2008; 158:1055-62.
PubMed
CrossRef
 
Kuflik A, Stillo JV, Sanders D, Roland K, Sweeney T, Lemke PM. Petrolatum versus Resurfix ointment in the treatment of pressure ulcers. Ostomy Wound Manage. 2001; 47:52-6.
PubMed
 
Hsu YC, Chang HH, Chen MF, Chen JC. Therapeutic effect of sheng-ji-san on pressure ulcers. Am J Chin Med. 2000; 28:391-9.
PubMed
CrossRef
 
Felzani G, Spoletini I, Convento A, Di Lorenzo B, Rossi P, Miceli M, et al. Effect of lysine hyaluronate on the healing of decubitus ulcers in rehabilitation patients. Adv Ther. 2011; 28:439-45.
PubMed
CrossRef
 
Narayanan S, Van Vleet J, Strunk B, Ross RN, Gray M. Comparison of pressure ulcer treatments in long-term care facilities: clinical outcomes and impact on cost. J Wound Ostomy Continence Nurs. 2005; 32:163-70.
PubMed
CrossRef
 
Mustoe TA, Cutler NR, Allman RM, Goode PS, Deuel TF, Prause JA, et al. A phase II study to evaluate recombinant platelet-derived growth factor-BB in the treatment of stage 3 and 4 pressure ulcers. Arch Surg. 1994; 129:213-9.
PubMed
CrossRef
 
Landi F, Aloe L, Russo A, Cesari M, Onder G, Bonini S, et al. Topical treatment of pressure ulcers with nerve growth factor: a randomized clinical trial. Ann Intern Med. 2003; 139:635-41.
PubMed
CrossRef
 
Payne WG, Wright TE, Ochs D, Mannari RJ, Robson MD, The Dermagraft Pressure Ulcer Study Group. An exploratory study of dermal replacement therapy in the treatment of stage III pressure ulcers. J Appl Res. 2004; 4:12-23.
 
Hirshberg J, Coleman J, Marchant B, Rees RS. TGF-beta3 in the treatment of pressure ulcers: a preliminary report. Adv Skin Wound Care. 2001; 14:91-5.
PubMed
CrossRef
 
Robson MC, Phillips LG, Thomason A, Robson LE, Pierce GF. Platelet-derived growth factor BB for the treatment of chronic pressure ulcers. Lancet. 1992; 339:23-5.
PubMed
 
Payne WG, Ochs DE, Meltzer DD, Hill DP, Mannari RJ, Robson LE, et al. Long-term outcome study of growth factor-treated pressure ulcers. Am J Surg. 2001; 181:81-6.
PubMed
CrossRef
 
Zuloff-Shani A, Adunsky A, Even-Zahav A, Semo H, Orenstein A, Tamir J, et al. Hard to heal pressure ulcers (stage III-IV): efficacy of injected activated macrophage suspension (AMS) as compared with standard of care (SOC) treatment controlled trial. Arch Gerontol Geriatr. 2010; 51:268-72.
PubMed
CrossRef
 
Rees RS, Robson MC, Smiell JM, Perry BH. Becaplermin gel in the treatment of pressure ulcers: a phase II randomized, double-blind, placebo-controlled study. Wound Repair Regen. 1999; 7:141-7.
PubMed
CrossRef
 
Danon D, Madjar J, Edinov E, Knyszynski A, Brill S, Diamantshtein L, et al. Treatment of human ulcers by application of macrophages prepared from a blood unit. Exp Gerontol. 1997; 32:633-41.
PubMed
CrossRef
 
Chang KW, Alsagoff S, Ong KT, Sim PH. Pressure ulcers—randomised controlled trial comparing hydrocolloid and saline gauze dressings. Med J Malaysia. 1998; 53:428-31.
PubMed
 
Mulder GD, Altman M, Seeley JE, Tintle T. Prospective randomized study of the efficacy of hydrogel, hydrocolloid, and saline solution-moistened dressings on the management of pressure ulcers. Wound Repair Regen. 1993; 1:213-8.
PubMed
CrossRef
 
Sayag J, Meaume S, Bohbot S. Healing properties of calcium alginate dressings. J Wound Care. 1996; 5:357-62.
PubMed
 
Colin D, Kurring PA, Yvon C. Managing sloughy pressure sores. J Wound Care. 1996; 5:444-6.
PubMed
 
Graumlich JF, Blough LS, McLaughlin RG, Milbrandt JC, Calderon CL, Agha SA, et al. Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am Geriatr Soc. 2003; 51:147-54.
PubMed
CrossRef
 
Zerón HM, Krötzsch Gómez FE, Muñoz RE. Pressure ulcers: a pilot study for treatment with collagen polyvinylpyrrolidone. Int J Dermatol. 2007; 46:314-7.
PubMed
CrossRef
 
Robson MC, Phillips LG, Thomason A, Altrock BW, Pence PC, Heggers JP, et al. Recombinant human platelet-derived growth factor-BB for the treatment of chronic pressure ulcers. Ann Plast Surg. 1992; 29:193-201.
PubMed
CrossRef
 
Scevola S, Nicoletti G, Brenta F, Isernia P, Maestri M, Faga A. Allogenic platelet gel in the treatment of pressure sores: a pilot study. Int Wound J. 2010; 7:184-90.
PubMed
CrossRef
 
Juri H, Palma A, Obeide A, Lacuara J, Yung S, Lapin R. The CO2 laser in the treatment of decubitus ulcer. Journal of Neurological and Orthopaedic Medicine and Surgery. 1986; 7:29-33.
 
Foster RD, Anthony JP, Mathes SJ, Hoffman WY, Young D, Eshima I. Flap selection as a determinant of success in pressure sore coverage. Arch Surg. 1997; 132:868-73.
PubMed
CrossRef
 
Foster RD, Anthony JP, Mathes SJ, Hoffman WY. Ischial pressure sore coverage: a rationale for flap selection. Br J Plast Surg. 1997; 50:374-9.
PubMed
CrossRef
 
Kierney PC, Engrav LH, Isik FF, Esselman PC, Cardenas DD, Rand RP. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine. Plast Reconstr Surg. 1998; 102:765-72.
PubMed
 
Schryvers OI, Stranc MF, Nance PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil. 2000; 81:1556-62.
PubMed
CrossRef
 
Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg. 1997; 100:1212-7.
PubMed
 
Houghton PE, Campbell KE, Fraser CH, Harris C, Keast DH, Potter PJ, et al. Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury. Arch Phys Med Rehabil. 2010; 91:669-78.
PubMed
CrossRef
 
Adunsky A, Ohry A, DDCT Group. Decubitus direct current treatment (DDCT) of pressure ulcers: results of a randomized double-blinded placebo controlled study. Arch Gerontol Geriatr. 2005; 41:261-9.
PubMed
CrossRef
 
Gentzkow GD, Pollack VP, Kloth LC, Stubbs HA. Improved healing of pressure ulcers using Dermapulse, a new electrical stimulation device. Wounds. 1991; 3:158-70.
 
Griffin JW, Tooms RE, Mendius RA, Clifft JK, Vander Zwaag R, el-Zeky F. Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury. Phys Ther. 1991; 71:433-42.
PubMed
 
Kloth LC, Feedar JA. Acceleration of wound healing with high voltage, monophasic, pulsed current. Phys Ther. 1988; 68:503-8.
PubMed
 
Wood JM, Evans PE 3rd, Schallreuter KU, Jacobson WE, Sufit R, Newman J, et al. A multicenter study on the use of pulsed low-intensity direct current for healing chronic stage II and stage III decubitus ulcers. Arch Dermatol. 1993; 129:999-1009.
PubMed
 
Comorosan S, Vasilco R, Arghiropol M, Paslaru L, Jieanu V, Stelea S. The effect of diapulse therapy on the healing of decubitus ulcer. Rom J Physiol. 1993; 30:41-5.
PubMed
 
Salzberg CA, Cooper-Vastola SA, Perez FJ, Viehbeck MG, Byrne DW. The effects of non-thermal pulsed electromagnetic energy (DIAPULSE) on wound healing of pressure ulcers in spinal cord-injured patients: a randomized, double-blind study. Wounds. 1995; 7:11-6.
 
Ozdemir F, Kasapoglu M, Oymak F, Murat S. Efficiency of magnetic field treatment on pressure sores in bedridden patients. Balkan Medical Journal. 2011; 28:274-8.
 
McDiarmid T, Burns PN, Lewith GT, Machin D. Ultrasound and the treatment of pressure sores. Physiotherapy. 1985; 71:66-70.
 
ter Riet G, Kessels AG, Knipschild P. Randomised clinical trial of ultrasound treatment for pressure ulcers. BMJ. 1995; 310:1040-1.
PubMed
 
Nussbaum EL, Biemann I, Mustard B. Comparison of ultrasound/ultraviolet-C and laser for treatment of pressure ulcers in patients with spinal cord injury. Phys Ther. 1994; 74:812-23.
PubMed
 
Ford CN, Reinhard ER, Yeh D, Syrek D, De Las Morenas A, Bergman SB, et al. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers. Ann Plast Surg. 2002; 49:55-61.
PubMed
CrossRef
 
Dehlin O, Elmståhl S, Gottrup F. Monochromatic phototherapy in elderly patients: a new way of treating chronic pressure ulcers? Aging Clin Exp Res. 2003; 15:259-63.
PubMed
 
Dehlin O, Elmståhl S, Gottrup F. Monochromatic phototherapy: effective treatment for grade II chronic pressure ulcers in elderly patients. Aging Clin Exp Res. 2007; 19:478-83.
PubMed
 
Lucas C, van Gemert MJ, de Haan RJ. Efficacy of low-level laser therapy in the management of stage III decubitus ulcers: a prospective, observer-blinded multicentre randomised clinical trial. Lasers Med Sci. 2003; 18:72-7.
PubMed
CrossRef
 
Taly AB, Sivaraman Nair KP, Murali T, John A. Efficacy of multiwavelength light therapy in the treatment of pressure ulcers in subjects with disorders of the spinal cord: A randomized double-blind controlled trial. Arch Phys Med Rehabil. 2004; 85:1657-61.
PubMed
CrossRef
 
Adegoke BO, Badmos KA. Acceleration of pressure ulcer healing in spinal cord injured patients using interrupted direct current. Afr J Med Med Sci. 2001; 30:195-7.
PubMed
 
Ahmad ET. High-voltage pulsed galvanic stimulation: effect of treatment duration on healing of chronic pressure ulcers. Ann Burns Fire Disasters. 2008; 21:124-8.
PubMed
 
Baker LL, Rubayi S, Villar F, Demuth SK. Effect of electrical stimulation waveform on healing of ulcers in human beings with spinal cord injury. Wound Repair Regen. 1996; 4:21-8.
PubMed
CrossRef
 
Durović A, Marić D, Brdareski Z, Jevtić M, Durdević S. The effects of polarized light therapy in pressure ulcer healing. Vojnosanit Pregl. 2008; 65:906-12.
PubMed
 
Iordanou P, Baltopoulos G, Giannakopoulou M, Bellou P, Ktenas E. Effect of polarized light in the healing process of pressure ulcers. Int J Nurs Pract. 2002; 8:49-55.
PubMed
CrossRef
 
Schubert V. Effects of phototherapy on pressure ulcer healing in elderly patients after a falling trauma. A prospective, randomized, controlled study. Photodermatol Photoimmunol Photomed. 2001; 17:32-8.
PubMed
CrossRef
 
Gupta A, Taly AB, Srivastava A, Kumar S, Thyloth M. Efficacy of pulsed electromagnetic field therapy in healing of pressure ulcers: A randomized control trial. Neurol India. 2009; 57:622-6.
PubMed
 
McGaughey H, Dhamija S, Oliver L, Porter-Armstrong A, McDonough S. Pulsed electromagnetic energy in management of chronic wounds: a systematic review. Phys Ther Rev. 2009; 14:132-46.
CrossRef
 
Wanner MB, Schwarzl F, Strub B, Zaech GA, Pierer G. Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study. Scand J Plast Reconstr Surg Hand Surg. 2003; 37:28-33.
PubMed
 
Ho CH, Bensitel T, Wang X, Bogie KM. Pulsatile lavage for the enhancement of pressure ulcer healing: a randomized controlled trial. Phys Ther. 2012; 92:38-48.
PubMed
CrossRef
 
Lucas C, Coenen CHM, de Haan RJ. The effect of low level laser therapy (LLLT) on stage III decubitus ulcers (pressure sores): a prospective randomised single blind, multicentre pilot study. Lasers Med Sci. 2000; 14:94-100.
 
Burke DT, Ho CH, Saucier MA, Stewart G. Effects of hydrotherapy on pressure ulcer healing. Am J Phys Med Rehabil. 1998; 77:394-8.
PubMed
 
McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011; CD001735.
PubMed
 
Cullum N, Nelson EA, Flemming K, Sheldon T. Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy. Health Technol Assess. 2001; 5:1-221.
PubMed
 
Aziz Z, Flemming K, Cullum , Olyaee Manesh A. Electromagnetic therapy for treating pressure ulcers. Cochrane Database Syst Rev. 2010; CD002930.
PubMed
 
Gardner SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on chronic wound healing: a meta-analysis. Wound Repair Regen. 1999; 7:495-503.
PubMed
CrossRef
 
McGaughey H, Dhamija S, Oliver L, Porter-Armstrong A, McDonough S. Pulsed electromagnetic energy in management of chronic wounds: a systematic review. Phys Ther Rev. 2009; 14: (2) 132-46.
CrossRef
 

Figures

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Figure 1.

National Pressure Ulcer Advisory Panel pressure ulcer stages.

Pressure ulcer stages I to IV and the 2 additional categories of suspected deep-tissue injury and unstageable are defined. National Pressure Ulcer Advisory Panel copyright; photos used with permission. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

* Not pictured.

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Figure 2.

Analytic framework of pressure ulcer treatment strategies.

From reference (5).

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Appendix Figure 1.

Summary of evidence search and selection.

Full-text articles that were reviewed include additional studies identified through other sources, hand-searches of reference lists, peer review and public comment, scientific information packets, and gray literature searches. Quality-of-life outcomes and results related to histologic outcomes are in the full report (5) but not included in this article.

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Tables

Table Jump PlaceholderAppendix Table 1. Stages of Pressure Ulcer Equivalency 
Table Jump PlaceholderTable. Summary of Evidence of Benefits and Harms of Pressure Ulcer Treatment Strategies 
Table Jump PlaceholderAppendix Table 2. Summary of Evidence of Differences of Intervention Effectiveness 

References

Bergstrom N, Allman RM, Alvarez OM, Bennett MA, Carlson CE, Frantz RA, et al.  Pressure Ulcer Treatment. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 15. Rockville, MD: U.S. Department of Health and Human Services; 1994. Accessed at www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/archive.html on 17 May 2013.
 
Graves N, Birrell F, Whitby M. Effect of pressure ulcers on length of hospital stay. Infect Control Hosp Epidemiol. 2005; 26:293-7.
PubMed
CrossRef
 
Lyder CH. Pressure ulcer prevention and management. JAMA. 2003; 289:223-6.
PubMed
CrossRef
 
Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA. Treatment of pressure ulcers: a systematic review. JAMA. 2008; 300:2647-62.
PubMed
CrossRef
 
Saha S, Smith B, Totten A, Fu R, Wasson N, Rahman B, et al.  Pressure Ulcer Treatment Strategies: Comparative Effectiveness. Comparative Effectiveness Review no. 90. (Prepared by Oregon Evidence-based Practice Center under contract no. 290-2007-10057-I.) AHRQ Publication no. 13-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2013. Accessed at www.effectivehealthcare.ahrq.gov/reports/final.cfm on 17 May 2013.
 
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998; 52:377-84.
PubMed
CrossRef
 
Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al, Methods Work Group, Third US Preventive Services Task Force. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001; 20:21-35.
PubMed
CrossRef
 
U.S. Preventive Services Task Force.  Section 4: evidence report development. In: U.S. Preventive Services Task Force Procedure Manual. AHRQ Publication No. 08-05118-EF. Rockville, MD: Agency for Healthcare Research and Quality;2008. Accessed at www.uspreventiveservicestaskforce.org/uspstf08/methods/procmanual.htm on 6 July 2011.
 
Agency for Healthcare Research and Quality.  Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Research and Quality; 2011. Accessed at www.effectivehealthcare.ahrq.gov on 6 July 2011.
 
Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002; 21:1539-58.
PubMed
CrossRef
 
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986; 7:177-88.
PubMed
CrossRef
 
Tissue Viability Society. Laboratory measurement of the interface pressures applied by active therapy support surfaces: a consensus document. J Tissue Viability. 2010; 19:2-6.
PubMed
 
Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum , et al, PRESSURE Trial Group. Pressure relieving support surfaces: a randomised evaluation. Health Technol Assess. 2006; 10:iii-iv, ix-x, 1-163.
PubMed
 
Keogh A, Dealey C. Profiling beds versus standard hospital beds: effects on pressure ulcer incidence outcomes. J Wound Care. 2001; 10:15-9.
PubMed
 
Ferrell BA, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA. 1993; 269:494-7.
PubMed
 
Groen HW, Groenier KH, Schuling J. Comparative study of a foam mattress and a water mattress. J Wound Care. 1999; 8:333-5.
PubMed
 
Mulder G, Taro N, Seeley J, Andrews A. A study of pressure ulcer response to low air loss beds vs. conventional treatment. Journal of Geriatric Dermatology. 1994; 2:87-91.
 
Clark MD, Donald IP.  A randomised controlled trial comparing the healing of pressure sores upon two pressure-redistributing seat cushions. Proceedings of the 7th European Conferences on Advances in Wound Management, Harrogate, UK, 18–20 November 1998:122-5.
 
Valente SA, Greenough Iii WB, DeMarco SL, Andersen RE. More expensive surfaces are not always better. Kuwait Med J. 2012; 44:40-5.
 
Allman RM, Walker JM, Hart MK, Laprade CA, Noel LB, Smith CR. Air-fluidized beds or conventional therapy for pressure sores. A randomized trial. Ann Intern Med. 1987; 107:641-8.
PubMed
CrossRef
 
Munro BH, Brown L, Heitman BB. Pressure ulcers: one bed or another? Geriatr Nurs. 1989; 10:190-2.
PubMed
 
Strauss MJ, Gong J, Gary BD, Kalsbeek WD, Spear S. The cost of home air-fluidized therapy for pressure sores. A randomized controlled trial. J Fam Pract. 1991; 33:52-9.
PubMed
 
Jackson BS, Chagares R, Nee N, Freeman K. The effects of a therapeutic bed on pressure ulcers: an experimental study. J Enterostomal Ther. 1988; 15:220-6.
PubMed
 
Ochs RF, Horn SD, van Rijswijk L, Pietsch C, Smout RJ. Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents. Ostomy Wound Manage. 2005; 51:38-68.
PubMed
 
Russell L, Reynolds TM, Towns A, Worth W, Greenman A, Turner R. Randomized comparison trial of the RIK and the Nimbus 3 mattresses. Br J Nurs. 2003; 12:254, 256-9.
PubMed
 
Izutsu T, Matsui T, Satoh T, Tsuji T, Sasaki H. Effect of rolling bed on decubitus in bedridden nursing home patients. Tohoku J Exp Med. 1998; 184:153-7.
PubMed
CrossRef
 
Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, et al. A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. J Tissue Viability. 2010; 19:7-15.
PubMed
CrossRef
 
Evans D, Land L, Geary A. A clinical evaluation of the Nimbus 3 alternating pressure mattress replacement system. J Wound Care. 2000; 9:181-6.
PubMed
 
Russell L, Reynolds TM, Carr J, Evans A, Holmes M. Randomised controlled trial of two pressure-relieving systems. J Wound Care. 2000; 9:52-5.
PubMed
 
Russell L, Reynolds T, Carr J, Evans A, Holmes M. A comparison of healing rates on two pressure-relieving systems. Br J Nurs. 2000; 9:2270-80.
PubMed
 
Land L, Evans D, Geary A, Taylor C. A clinical evaluation of an alternating-pressure mattress replacement system in hospital and residential care settings. J Tissue Viability. 2000; 10:6-11.
PubMed
 
Makhsous M, Lin F, Knaus E, Zeigler M, Rowles DM, Gittler M, et al. Promote pressure ulcer healing in individuals with spinal cord injury using an individualized cyclic pressure-relief protocol. Adv Skin Wound Care. 2009; 22:514-21.
PubMed
CrossRef
 
Warner DJ. A clinical comparison of two pressure-reducing surfaces in the management of pressure ulcers. Decubitus. 1992; 5:52-5, 58-60, 62-4.
PubMed
 
Day A, Leonard F. Seeking quality care for patients with pressure ulcers. Decubitus. 1993; 6:32-43.
PubMed
 
Caley L, Jones S, Freer J, Miller S.  Randomized prospective trial: treatment outcomes and cost-effectiveness of two types of low-air-loss therapy. Proceedings of the 9th Annual Clinical Symposium on Pressure Ulcer and Wound Management, Nashville, TN. October 1994:1-2.
 
Cereda E, Gini A, Pedrolli C, Vanotti A. Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial. J Am Geriatr Soc. 2009; 57:1395-402.
PubMed
CrossRef
 
ter Riet G, Kessels AG, Knipschild PG. Randomized clinical trial of ascorbic acid in the treatment of pressure ulcers. J Clin Epidemiol. 1995; 48:1453-60.
PubMed
CrossRef
 
Leigh B, Desneves K, Rafferty J, Pearce L, King S, Woodward MC, et al. The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers. J Wound Care. 2012; 21:150-6.
PubMed
 
Meaume S, Kerihuel JC, Constans T, Teot L, Lerebours E, Kern J, et al. Efficacy and safety of ornithine alpha-ketoglutarate in heel pressure ulcers in elderly patients: results of a randomized controlled trial. J Nutr Health Aging. 2009; 13:623-30.
PubMed
CrossRef
 
van Anholt RD, Sobotka L, Meijer EP, Heyman H, Groen HW, Topinková E, et al. Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients. Nutrition. 2010; 26:867-72.
PubMed
CrossRef
 
Chernoff R. The effect of a high protein formula (Replete) on decubitus ulcer healing in long term tube fed institutionalized patients. J Am Diet Assoc. 1990; 90:A130.
 
Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial. Clin Nutr. 2005; 24:979-87.
PubMed
CrossRef
 
Benati G, Delvecchio S, Cilla D, Pedone V. Impact on pressure ulcer healing of an arginine-enriched nutritional solution in patients with severe cognitive impairment. Arch Gerontol Geriatr Suppl. 2001; 7:43-7.
PubMed
 
Lee SK, Posthauer ME, Dorner B, Redovian V, Maloney MJ. Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial. Adv Skin Wound Care. 2006; 19:92-6.
PubMed
CrossRef
 
Myers SA, Takiguchi S, Slavish S, Rose CL. Consistent wound care and nutritional support in treatment. Decubitus. 1990; 3:16-28.
PubMed
 
Ohura T, Nakajo T, Okada S, Omura K, Adachi K. Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states (randomized controlled trial). Wound Repair Regen. 2011; 19:330-6.
PubMed
 
Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc. 1993; 41:357-62.
PubMed
 
Brewer S, Desneves K, Pearce L, Mills K, Dunn L, Brown D, et al. Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients. J Wound Care. 2010; 19:311-6.
PubMed
 
Houston S, Haggard J, Williford J Jr, Meserve L, Shewokis P. Adverse effects of large-dose zinc supplementation in an institutionalized older population with pressure ulcers [Letter]. J Am Geriatr Soc. 2001; 49:1130-2.
PubMed
CrossRef
 
Yamamoto T, Fujioka M, Kitamura R, Yakabe A, Kimura H, Katagiri Y, et al. Evaluation of nutrition in the healing of pressure ulcers: are the EPUAP nutritional guidelines sufficient to heal wounds. European Pressure Ulcer Advisory Panel. Wounds. 2009; 21:153-7.
 
Barnes P Jr, Sauter TE, Zaheri S. Subnormal prealbumin levels and wound healing. Tex Med. 2007; 103:65-8.
PubMed
 
Hollisaz MT, Khedmat H, Yari F. A randomized clinical trial comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers [ISRCTN33429693]. BMC Dermatol. 2004; 4:18.
PubMed
CrossRef
 
Alm A, Hornmark AM, Fall PA, Linder L, Bergstrand B, Ehrnebo M, et al. Care of pressure sores: a controlled study of the use of a hydrocolloid dressing compared with wet saline gauze compresses. Acta Derm Venereol Suppl (Stockh). 1989; 149:1-10.
PubMed
 
Xakellis GC, Chrischilles EA. Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: a cost-effectiveness analysis. Arch Phys Med Rehabil. 1992; 73:463-9.
PubMed
 
Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and cost-effectiveness of two methods of managing pressure ulcers. Decubitus. 1993; 6:28-36.
PubMed
 
Gorse GJ, Messner RL. Improved pressure sore healing with hydrocolloid dressings. Arch Dermatol. 1987; 123:766-71.
PubMed
CrossRef
 
Kim YC, Shin JC, Park CI, Oh SH, Choi SM, Kim YS. Efficacy of hydrocolloid occlusive dressing technique in decubitus ulcer treatment: a comparative study. Yonsei Med J. 1996; 37:181-5.
PubMed
 
Neill K, Conforti C, Kedas A, Burris JF. Pressure sore response to a new hydrocolloid dressing. Wounds. 1989; 1:173-85.
 
Winter A, Hewitt H. Testing a hydrocolloid. Nurs Times. 1990; 86:59-62.
PubMed
 
Matzen S, Peschardt A, Alsbjørn B. A new amorphous hydrocolloid for the treatment of pressure sores: a randomised controlled study. Scand J Plast Reconstr Surg Hand Surg. 1999; 33:13-5.
PubMed
 
Kaya AZ, Turani N, Akyüz M. The effectiveness of a hydrogel dressing compared with standard management of pressure ulcers. J Wound Care. 2005; 14:42-4.
PubMed
 
Thomas DR, Goode PS, LaMaster K, Tennyson T. Acemannan hydrogel dressing versus saline dressing for pressure ulcers. A randomized, controlled trial. Adv Wound Care. 1998; 11:273-6.
PubMed
 
Parnell LK, Ciufi B, Gokoo CF. Preliminary use of a hydrogel containing enzymes in the treatment of stage II and stage III pressure ulcers. Ostomy Wound Manage. 2005; 51:50-60.
PubMed
 
Payne WG, Posnett J, Alvarez O, Brown-Etris M, Jameson G, Wolcott R, et al. A prospective, randomized clinical trial to assess the cost-effectiveness of a modern foam dressing versus a traditional saline gauze dressing in the treatment of stage II pressure ulcers. Ostomy Wound Manage. 2009; 55:50-5.
PubMed
 
Kraft MR, Lawson L, Pohlmann B, Reid-Lokos C, Barder L. A comparison of Epi-Lock and saline dressings in the treatment of pressure ulcers. Decubitus. 1993; 6:42-4, 46, 48.
PubMed
 
Sebern MD. Pressure ulcer management in home health care: efficacy and cost effectiveness of moisture vapor permeable dressing. Arch Phys Med Rehabil. 1986; 67:726-9.
PubMed
CrossRef
 
Kurzuk-Howard G, Simpson L, Palmieri A. Decubitus ulcer care: a comparative study. West J Nurs Res. 1985; 7:58-79.
PubMed
CrossRef
 
Day A, Leonard F. Seeking quality care for patients with pressure ulcers. Decubitus. 1993; 6:32-43.
PubMed
 
Darkovich SL, Brown-Etris M, Spencer M. Biofilm hydrogel dressing: a clinical evaluation in the treatment of pressure sores. Ostomy Wound Manage. 1990; 29:47-60.
PubMed
 
Motta G, Dunham L, Dye T, Mentz J, O'Connell-Gifford E, Smith E. Clinical efficacy and cost-effectiveness of a new synthetic polymer sheet wound dressing. Ostomy Wound Manage. 1999; 45:41, 44-6, 48-49.
PubMed
 
Brown-Etris M, Milne C, Orsted H, Gates JL, Netsch D, Punchello M, et al. A prospective, randomized, multisite clinical evaluation of a transparent absorbent acrylic dressing and a hydrocolloid dressing in the management of Stage II and shallow Stage III pressure ulcers. Adv Skin Wound Care. 2008; 21:169-74.
PubMed
CrossRef
 
Bale S, Squires D, Varnon T, Walker A, Benbow M, Harding KG. A comparison of two dressings in pressure sore management. J Wound Care. 1997; 6:463-6.
PubMed
 
Hondé C, Derks C, Tudor D. Local treatment of pressure sores in the elderly: amino acid copolymer membrane versus hydrocolloid dressing. J Am Geriatr Soc. 1994; 42:1180-3.
PubMed
 
Seeley J, Jensen JL, Hutcherson J. A randomized clinical study comparing a hydrocellular dressing to a hydrocolloid dressing in the management of pressure ulcers. Ostomy Wound Manage. 1999; 45:39-44, 46-7.
PubMed
 
Banks V, Bale SE, Harding KG. Comparing two dressings for exuding pressure sores in community patients. J Wound Care. 1994; 3:175-8.
 
Banks V, Bale S, Harding K. The use of two dressings for moderately exuding pressure sores. J Wound Care. 1994; 3:132-4.
 
Brod M, McHenry E, Plasse TF, Fedorczyk D, Trout JR. A randomized comparison of poly-hema and hydrocolloid dressings for treatment of pressure sores [Letter]. Arch Dermatol. 1990; 126:969-70.
PubMed
CrossRef
 
Bale S, Hagelstein S, Banks V, Harding KG. Costs of dressings in the community. J Wound Care. 1998; 7:327-30.
PubMed
 
Thomas S, Banks V, Bale S, Fear-Price M, Hagelstein S, Harding KG, et al. A comparison of two dressings in the management of chronic wounds. J Wound Care. 1997; 6:383-6.
PubMed
 
Belmin J, Meaume S, Rabus MT, Bohbot S, Investigators of the Sequential Treatment of the Elderly with Pressure Sores (STEPS) Trial. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc. 2002; 50:269-74.
PubMed
CrossRef
 
Maume S, Van De Looverbosch D, Heyman H, Romanelli M, Ciangherotti A, Charpin S. A study to compare a new self-adherent soft silicone dressing with a self-adherent polymer dressing in stage II pressure ulcers. Ostomy Wound Manage. 2003; 49:44-51.
PubMed
 
Viamontes L, Temple D, Wytall D, Walker A. An evaluation of an adhesive hydrocellular foam dressing and a self-adherent soft silicone foam dressing in a nursing home setting. Ostomy Wound Manage. 2003; 49:48-52, 54-6, 58.
PubMed
 
Thomas DR, Diebold MR, Eggemeyer LM. A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3-4 pressure ulcers: a pilot study. J Am Med Dir Assoc. 2005; 6:46-9.
PubMed
 
Price P, Bale S, Crook H, Harding KG. The effect of a radiant heat dressing on pressure ulcers. J Wound Care. 2000; 9:201-5.
PubMed
 
Kloth LC, Berman JE, Nett M, Papanek PE, Dumit-Minkel S. A randomized controlled clinical trial to evaluate the effects of noncontact normothermic wound therapy on chronic full-thickness pressure ulcers. Adv Skin Wound Care. 2002; 15:270-6.
PubMed
 
Whitney JD, Salvadalena G, Higa L, Mich M. Treatment of pressure ulcers with noncontact normothermic wound therapy: healing and warming effects. J Wound Ostomy Continence Nurs. 2001; 28:244-52.
PubMed
 
Bito S, Mizuhara A, Oonishi S, Takeuchi K, Suzuki M, Akiyama K, et al. Randomised controlled trial evaluating the efficacy of wrap therapy for wound healing acceleration in patients with NPUAP stage II and III pressure ulcer. BMJ Open. 2012; 2:000371.
PubMed
CrossRef
 
Small N, Mulder M, Mackenzie MJ, Nel M. A comparative analysis of pressure sore treatment modalities in community settings. Curationis. 2002; 25:74-82.
PubMed
CrossRef
 
Yapucu Güneş U, Eşer I. Effectiveness of a honey dressing for healing pressure ulcers. J Wound Ostomy Continence Nurs. 2007; 34:184-90.
PubMed
CrossRef
 
Burgos A, Gimenez J, Moreno E, Laberto E, Ultrera M, Urraca EM, et al. Collagenase ointment application at 24- versus 48-hour intervals in the treatment of pressure ulcers. A randomised multicentre study. Clin Drug Investig. 2000; 19:399-407.
 
Alvarez OM, Fernandez-Obregon A, Rogers RS, Bergamo L, Masso J, Black M. Chemical debridement of pressure ulcers: a prospective, randomized, comparative trial of collagenase and papain/urea formulations. Wounds. 2000; 12:15-25.
 
Müller E, van Leen MW, Bergemann R. Economic evaluation of collagenase-containing ointment and hydrocolloid dressing in the treatment of pressure ulcers. Pharmacoeconomics. 2001; 19:1209-16.
PubMed
 
Rhodes RS, Heyneman CA, Culbertson VL, Wilson SE, Phatak HM. Topical phenytoin treatment of stage II decubitus ulcers in the elderly. Ann Pharmacother. 2001; 35:675-81.
PubMed
CrossRef
 
Graumlich JF, Blough LS, McLaughlin RG, Milbrandt JC, Calderon CL, Agha SA, et al. Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am Geriatr Soc. 2003; 51:147-54.
PubMed
CrossRef
 
Nisi G, Brandi C, Grimaldi L, Calabrò M, D'Aniello C. Use of a protease-modulating matrix in the treatment of pressure sores. Chir Ital. 2005; 57:465-8.
PubMed
 
Sherman RA. Maggot versus conservative debridement therapy for the treatment of pressure ulcers. Wound Repair Regen. 2002; 10:208-14.
PubMed
CrossRef
 
Wang SY, Wang JN, Lv DC, Diao YP, Zhang Z. Clinical research on the bio-debridement effect of maggot therapy for treatment of chronically infected lesions. Orthop Surg. 2010; 2:201-6.
PubMed
 
Sipponen A, Jokinen JJ, Sipponen P, Papp A, Sarna S, Lohi J. Beneficial effect of resin salve in treatment of severe pressure ulcers: a prospective, randomized and controlled multicentre trial. Br J Dermatol. 2008; 158:1055-62.
PubMed
CrossRef
 
Kuflik A, Stillo JV, Sanders D, Roland K, Sweeney T, Lemke PM. Petrolatum versus Resurfix ointment in the treatment of pressure ulcers. Ostomy Wound Manage. 2001; 47:52-6.
PubMed
 
Hsu YC, Chang HH, Chen MF, Chen JC. Therapeutic effect of sheng-ji-san on pressure ulcers. Am J Chin Med. 2000; 28:391-9.
PubMed
CrossRef
 
Felzani G, Spoletini I, Convento A, Di Lorenzo B, Rossi P, Miceli M, et al. Effect of lysine hyaluronate on the healing of decubitus ulcers in rehabilitation patients. Adv Ther. 2011; 28:439-45.
PubMed
CrossRef
 
Narayanan S, Van Vleet J, Strunk B, Ross RN, Gray M. Comparison of pressure ulcer treatments in long-term care facilities: clinical outcomes and impact on cost. J Wound Ostomy Continence Nurs. 2005; 32:163-70.
PubMed
CrossRef
 
Mustoe TA, Cutler NR, Allman RM, Goode PS, Deuel TF, Prause JA, et al. A phase II study to evaluate recombinant platelet-derived growth factor-BB in the treatment of stage 3 and 4 pressure ulcers. Arch Surg. 1994; 129:213-9.
PubMed
CrossRef
 
Landi F, Aloe L, Russo A, Cesari M, Onder G, Bonini S, et al. Topical treatment of pressure ulcers with nerve growth factor: a randomized clinical trial. Ann Intern Med. 2003; 139:635-41.
PubMed
CrossRef
 
Payne WG, Wright TE, Ochs D, Mannari RJ, Robson MD, The Dermagraft Pressure Ulcer Study Group. An exploratory study of dermal replacement therapy in the treatment of stage III pressure ulcers. J Appl Res. 2004; 4:12-23.
 
Hirshberg J, Coleman J, Marchant B, Rees RS. TGF-beta3 in the treatment of pressure ulcers: a preliminary report. Adv Skin Wound Care. 2001; 14:91-5.
PubMed
CrossRef
 
Robson MC, Phillips LG, Thomason A, Robson LE, Pierce GF. Platelet-derived growth factor BB for the treatment of chronic pressure ulcers. Lancet. 1992; 339:23-5.
PubMed
 
Payne WG, Ochs DE, Meltzer DD, Hill DP, Mannari RJ, Robson LE, et al. Long-term outcome study of growth factor-treated pressure ulcers. Am J Surg. 2001; 181:81-6.
PubMed
CrossRef
 
Zuloff-Shani A, Adunsky A, Even-Zahav A, Semo H, Orenstein A, Tamir J, et al. Hard to heal pressure ulcers (stage III-IV): efficacy of injected activated macrophage suspension (AMS) as compared with standard of care (SOC) treatment controlled trial. Arch Gerontol Geriatr. 2010; 51:268-72.
PubMed
CrossRef
 
Rees RS, Robson MC, Smiell JM, Perry BH. Becaplermin gel in the treatment of pressure ulcers: a phase II randomized, double-blind, placebo-controlled study. Wound Repair Regen. 1999; 7:141-7.
PubMed
CrossRef
 
Danon D, Madjar J, Edinov E, Knyszynski A, Brill S, Diamantshtein L, et al. Treatment of human ulcers by application of macrophages prepared from a blood unit. Exp Gerontol. 1997; 32:633-41.
PubMed
CrossRef
 
Chang KW, Alsagoff S, Ong KT, Sim PH. Pressure ulcers—randomised controlled trial comparing hydrocolloid and saline gauze dressings. Med J Malaysia. 1998; 53:428-31.
PubMed
 
Mulder GD, Altman M, Seeley JE, Tintle T. Prospective randomized study of the efficacy of hydrogel, hydrocolloid, and saline solution-moistened dressings on the management of pressure ulcers. Wound Repair Regen. 1993; 1:213-8.
PubMed
CrossRef
 
Sayag J, Meaume S, Bohbot S. Healing properties of calcium alginate dressings. J Wound Care. 1996; 5:357-62.
PubMed
 
Colin D, Kurring PA, Yvon C. Managing sloughy pressure sores. J Wound Care. 1996; 5:444-6.
PubMed
 
Graumlich JF, Blough LS, McLaughlin RG, Milbrandt JC, Calderon CL, Agha SA, et al. Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am Geriatr Soc. 2003; 51:147-54.
PubMed
CrossRef
 
Zerón HM, Krötzsch Gómez FE, Muñoz RE. Pressure ulcers: a pilot study for treatment with collagen polyvinylpyrrolidone. Int J Dermatol. 2007; 46:314-7.
PubMed
CrossRef
 
Robson MC, Phillips LG, Thomason A, Altrock BW, Pence PC, Heggers JP, et al. Recombinant human platelet-derived growth factor-BB for the treatment of chronic pressure ulcers. Ann Plast Surg. 1992; 29:193-201.
PubMed
CrossRef
 
Scevola S, Nicoletti G, Brenta F, Isernia P, Maestri M, Faga A. Allogenic platelet gel in the treatment of pressure sores: a pilot study. Int Wound J. 2010; 7:184-90.
PubMed
CrossRef
 
Juri H, Palma A, Obeide A, Lacuara J, Yung S, Lapin R. The CO2 laser in the treatment of decubitus ulcer. Journal of Neurological and Orthopaedic Medicine and Surgery. 1986; 7:29-33.
 
Foster RD, Anthony JP, Mathes SJ, Hoffman WY, Young D, Eshima I. Flap selection as a determinant of success in pressure sore coverage. Arch Surg. 1997; 132:868-73.
PubMed
CrossRef
 
Foster RD, Anthony JP, Mathes SJ, Hoffman WY. Ischial pressure sore coverage: a rationale for flap selection. Br J Plast Surg. 1997; 50:374-9.
PubMed
CrossRef
 
Kierney PC, Engrav LH, Isik FF, Esselman PC, Cardenas DD, Rand RP. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine. Plast Reconstr Surg. 1998; 102:765-72.
PubMed
 
Schryvers OI, Stranc MF, Nance PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil. 2000; 81:1556-62.
PubMed
CrossRef
 
Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg. 1997; 100:1212-7.
PubMed
 
Houghton PE, Campbell KE, Fraser CH, Harris C, Keast DH, Potter PJ, et al. Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury. Arch Phys Med Rehabil. 2010; 91:669-78.
PubMed
CrossRef
 
Adunsky A, Ohry A, DDCT Group. Decubitus direct current treatment (DDCT) of pressure ulcers: results of a randomized double-blinded placebo controlled study. Arch Gerontol Geriatr. 2005; 41:261-9.
PubMed
CrossRef
 
Gentzkow GD, Pollack VP, Kloth LC, Stubbs HA. Improved healing of pressure ulcers using Dermapulse, a new electrical stimulation device. Wounds. 1991; 3:158-70.
 
Griffin JW, Tooms RE, Mendius RA, Clifft JK, Vander Zwaag R, el-Zeky F. Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury. Phys Ther. 1991; 71:433-42.
PubMed
 
Kloth LC, Feedar JA. Acceleration of wound healing with high voltage, monophasic, pulsed current. Phys Ther. 1988; 68:503-8.
PubMed
 
Wood JM, Evans PE 3rd, Schallreuter KU, Jacobson WE, Sufit R, Newman J, et al. A multicenter study on the use of pulsed low-intensity direct current for healing chronic stage II and stage III decubitus ulcers. Arch Dermatol. 1993; 129:999-1009.
PubMed
 
Comorosan S, Vasilco R, Arghiropol M, Paslaru L, Jieanu V, Stelea S. The effect of diapulse therapy on the healing of decubitus ulcer. Rom J Physiol. 1993; 30:41-5.
PubMed
 
Salzberg CA, Cooper-Vastola SA, Perez FJ, Viehbeck MG, Byrne DW. The effects of non-thermal pulsed electromagnetic energy (DIAPULSE) on wound healing of pressure ulcers in spinal cord-injured patients: a randomized, double-blind study. Wounds. 1995; 7:11-6.
 
Ozdemir F, Kasapoglu M, Oymak F, Murat S. Efficiency of magnetic field treatment on pressure sores in bedridden patients. Balkan Medical Journal. 2011; 28:274-8.
 
McDiarmid T, Burns PN, Lewith GT, Machin D. Ultrasound and the treatment of pressure sores. Physiotherapy. 1985; 71:66-70.
 
ter Riet G, Kessels AG, Knipschild P. Randomised clinical trial of ultrasound treatment for pressure ulcers. BMJ. 1995; 310:1040-1.
PubMed
 
Nussbaum EL, Biemann I, Mustard B. Comparison of ultrasound/ultraviolet-C and laser for treatment of pressure ulcers in patients with spinal cord injury. Phys Ther. 1994; 74:812-23.
PubMed
 
Ford CN, Reinhard ER, Yeh D, Syrek D, De Las Morenas A, Bergman SB, et al. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers. Ann Plast Surg. 2002; 49:55-61.
PubMed
CrossRef
 
Dehlin O, Elmståhl S, Gottrup F. Monochromatic phototherapy in elderly patients: a new way of treating chronic pressure ulcers? Aging Clin Exp Res. 2003; 15:259-63.
PubMed
 
Dehlin O, Elmståhl S, Gottrup F. Monochromatic phototherapy: effective treatment for grade II chronic pressure ulcers in elderly patients. Aging Clin Exp Res. 2007; 19:478-83.
PubMed
 
Lucas C, van Gemert MJ, de Haan RJ. Efficacy of low-level laser therapy in the management of stage III decubitus ulcers: a prospective, observer-blinded multicentre randomised clinical trial. Lasers Med Sci. 2003; 18:72-7.
PubMed
CrossRef
 
Taly AB, Sivaraman Nair KP, Murali T, John A. Efficacy of multiwavelength light therapy in the treatment of pressure ulcers in subjects with disorders of the spinal cord: A randomized double-blind controlled trial. Arch Phys Med Rehabil. 2004; 85:1657-61.
PubMed
CrossRef
 
Adegoke BO, Badmos KA. Acceleration of pressure ulcer healing in spinal cord injured patients using interrupted direct current. Afr J Med Med Sci. 2001; 30:195-7.
PubMed
 
Ahmad ET. High-voltage pulsed galvanic stimulation: effect of treatment duration on healing of chronic pressure ulcers. Ann Burns Fire Disasters. 2008; 21:124-8.
PubMed
 
Baker LL, Rubayi S, Villar F, Demuth SK. Effect of electrical stimulation waveform on healing of ulcers in human beings with spinal cord injury. Wound Repair Regen. 1996; 4:21-8.
PubMed
CrossRef
 
Durović A, Marić D, Brdareski Z, Jevtić M, Durdević S. The effects of polarized light therapy in pressure ulcer healing. Vojnosanit Pregl. 2008; 65:906-12.
PubMed
 
Iordanou P, Baltopoulos G, Giannakopoulou M, Bellou P, Ktenas E. Effect of polarized light in the healing process of pressure ulcers. Int J Nurs Pract. 2002; 8:49-55.
PubMed
CrossRef
 
Schubert V. Effects of phototherapy on pressure ulcer healing in elderly patients after a falling trauma. A prospective, randomized, controlled study. Photodermatol Photoimmunol Photomed. 2001; 17:32-8.
PubMed
CrossRef
 
Gupta A, Taly AB, Srivastava A, Kumar S, Thyloth M. Efficacy of pulsed electromagnetic field therapy in healing of pressure ulcers: A randomized control trial. Neurol India. 2009; 57:622-6.
PubMed
 
McGaughey H, Dhamija S, Oliver L, Porter-Armstrong A, McDonough S. Pulsed electromagnetic energy in management of chronic wounds: a systematic review. Phys Ther Rev. 2009; 14:132-46.
CrossRef
 
Wanner MB, Schwarzl F, Strub B, Zaech GA, Pierer G. Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study. Scand J Plast Reconstr Surg Hand Surg. 2003; 37:28-33.
PubMed
 
Ho CH, Bensitel T, Wang X, Bogie KM. Pulsatile lavage for the enhancement of pressure ulcer healing: a randomized controlled trial. Phys Ther. 2012; 92:38-48.
PubMed
CrossRef
 
Lucas C, Coenen CHM, de Haan RJ. The effect of low level laser therapy (LLLT) on stage III decubitus ulcers (pressure sores): a prospective randomised single blind, multicentre pilot study. Lasers Med Sci. 2000; 14:94-100.
 
Burke DT, Ho CH, Saucier MA, Stewart G. Effects of hydrotherapy on pressure ulcer healing. Am J Phys Med Rehabil. 1998; 77:394-8.
PubMed
 
McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011; CD001735.
PubMed
 
Cullum N, Nelson EA, Flemming K, Sheldon T. Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy. Health Technol Assess. 2001; 5:1-221.
PubMed
 
Aziz Z, Flemming K, Cullum , Olyaee Manesh A. Electromagnetic therapy for treating pressure ulcers. Cochrane Database Syst Rev. 2010; CD002930.
PubMed
 
Gardner SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on chronic wound healing: a meta-analysis. Wound Repair Regen. 1999; 7:495-503.
PubMed
CrossRef
 
McGaughey H, Dhamija S, Oliver L, Porter-Armstrong A, McDonough S. Pulsed electromagnetic energy in management of chronic wounds: a systematic review. Phys Ther Rev. 2009; 14: (2) 132-46.
CrossRef
 

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