title: Electrical stimulation in bone healing: critical analysis by evaluating levels of evidence.
abstract: OBJECTIVE
  Direct current, capacitive coupling, and inductive coupling are modes of electrical stimulation (ES) used to enhance bone healing. It is important to assess the effectiveness of ES for bone healing to ensure optimization for clinical practice. This review aims to examine the level of evidence (LOE) for the application of ES to enhance bone healing and investigate the proposed mechanism for its stimulatory effect.
  
  
  METHODS
  MEDLINE and EMBASE searches were conducted to identify clinical and in vitro studies utilizing ES for bone healing since 1959. A total of 105 clinical studies and 35 in vitro studies were evaluated. Clinical studies were assigned LOE according to Oxford Centre for Evidence Based Medicine (LOE-1, highest; LOE-5, lowest).
  
  
  RESULTS
  Direct current was found to be effective in enhancing bone healing in spinal fusion but only LOE-4 supported its use for nonunions. Eleven studies were retrieved for capacitive coupling with LOE-1 demonstrating its effectiveness for treating nonunions. The majority of studies utilized inductive coupling with LOE-1 supporting its application for healing osteotomies and nonunions. In vitro studies demonstrate that ES enhances bone healing by changes in growth factors and transmembrane signaling although no clear mechanism has been defined.
  
  
  CONCLUSIONS
  Overall, the studies, although in favor of ES application in bone repair, displayed variability in treatment regime, primary outcome measures, follow-up times, and study design, making critical evaluation and assessment difficult. Electrical stimulation shows promise in enhancement of bone healing; however, better-designed clinical studies will enable the optimization for clinical practice.
authors.forename: Michelle
authors.initials: M
authors.lastname: Griffin
authors.forename: Ardeshir
authors.initials: A
authors.lastname: Bayat