Can electrical stimulation (ES) help heal bones?

Electrical Stimulation for Bone Healing: Current Evidence and Recommendations

Electrical stimulation is not recommended for routine bone healing as it shows little to no benefit for patient-important outcomes while adding cost and burden to patients. 1

Evidence Overview

The most recent and highest quality evidence comes from a comprehensive BMJ Rapid Recommendation guideline that provides moderate to high certainty evidence against the use of electrical stimulation for bone healing 1. This guideline specifically evaluated low-intensity pulsed ultrasound (LIPUS), a form of electrical stimulation, and found:

• No significant impact on time to return to work
• No improvement in time to full weight bearing
• No reduction in pain
• No decrease in subsequent operations
• No acceleration of radiographic healing

Efficacy of Different Types of Electrical Stimulation

While the BMJ guideline focused primarily on LIPUS, other forms of electrical stimulation have been studied:

1. Direct Current Stimulation (DCS):

   • Older data from 1980 reported 86% union rates in ununited fractures 2
   • Primarily used for delayed/non-unions rather than fresh fractures

2. Pulsed Electromagnetic Field Therapy (PEMF):

   • Commonly used for delayed/non-unions 3
   • Evidence is inconsistent and of lower quality

3. Electrical Stimulation (General):

   • A 2016 meta-analysis found moderate quality evidence for:
     • Small improvement in pain (7.7mm on 100mm VAS) 4
     • 35% reduction in radiographic non-union 4
     • No difference in functional outcomes 4

Clinical Application Algorithm

1. For Fresh Fractures:

   • Do not use electrical stimulation as an adjunct to standard care 1
   • Standard care alone is sufficient and more cost-effective

2. For Delayed Unions/Non-unions:

   • Consider electrical stimulation only after standard treatments have failed
   • If used, electrical stimulation should be considered a third-line option after:
     • Optimizing standard care (proper fixation, nutrition)
     • Surgical intervention with bone grafting when appropriate

3. For Patients with Nutritional Deficiencies:

   • Address nutritional status first with protein or amino acid supplementation 1
   • This has been shown to reduce wound size in pressure ulcers and may benefit bone healing

Practical Considerations

• Cost: Electrical stimulation devices are expensive ($1,300-$5,000) 1
• Compliance: Devices can be cumbersome, requiring 15-20 minutes of daily use for weeks to months 1
• Clinical Adoption: Despite awareness of the literature, only 32% of surveyed orthopedic surgeons use electrical stimulation 3
• Patient Burden: The treatment adds time and inconvenience with minimal benefit 1

Common Pitfalls and Caveats

1. Misinterpreting Radiographic vs. Functional Outcomes: While some studies show improved radiographic appearance, this doesn't necessarily translate to functional improvement or patient-important outcomes 1, 4

2. Overreliance on Older Studies: Many positive studies are older and of lower methodological quality 5

3. Confusing Different Types of Electrical Stimulation: Various modalities (LIPUS, PEMF, direct current) have different evidence bases but are often conflated 3

4. Ignoring Cost-Effectiveness: Even with potential small benefits, the high cost makes electrical stimulation a poor use of healthcare resources 1

5. Emerging Technology: Newer approaches like self-powered stimulators responsive to rehabilitation exercises show promise in animal models but lack clinical validation 6

Conclusion

Based on the most recent high-quality evidence, electrical stimulation should not be routinely used for bone healing. The BMJ Rapid Recommendations panel unanimously agreed that informed patients would elect not to use electrical stimulation given its minimal benefits, costs, and inconvenience 1. Future research should focus on other interventions with greater probability to speed healing, such as surgical application of adjuvant biomaterials or extracorporeal shock wave therapy 1.