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1 Independent clinical evaluation of Stimulite cushions conducted on behalf of Gerald Simonds Healthcare by Wounds Healing Centres UK Ltd. and Dr Steve Young. April 2013

2 Report on a Clinical Evaluation of the Stimulite Classic XS Cushion Fiona Collins MSc DipCOT HPC Registered 9 th April

3 Executive Summary The Stimulite Cushion was evaluated by 5 Subjects in a Registered Nursing Home for Elderly Mentally Ill (EMI) People over a 2 week period, in order to examine its effect on contributing to the prevention and reversal of pressure injuries in vulnerable adults. The average age of the Subjects was 86 years, with the oldest Subject being 90 years and the youngest 83 years. The Waterlow Score Range was 19 33, with the average Waterlow Score being 25. One of the Subjects was in a High Risk category with the remaining 4 in a Very High Risk category. All five Subjects had pressure injuries of up to Category 2 (EPUAP / NPUAP, 2005), although only four of the five had visually evident pressure injuries; all Subjects were provided with a Stimulite Cushion to use in their armchair, but other than this their usual pressure injury prevention care plans remained unchanged during the evaluation. The use of the cushion resulted in substantial improvement in the pressure injuries of all of these Subjects. The Nursing Home staff all reported that the Stimulite Classic Cushion appeared to provide significantly more comfort than the cushions that the subjects were using prior to the evaluation. The comments made by the staff with regard to each subject were most powerful and these are included under the profile of each Subject. Introduction Preventing and healing pressure injury is difficult, due to the large number of potential aetiological factors involved, although it is recognised that the largest single causative factor is unrelieved pressure. Concomitant to this are other predisposing factors which may be intrinsic or extrinsic. These include, intrinsically malnutrition, incontinence, altered level of consciousness and altered level of sensation, and extrinsically, friction and shear forces (NICE, 2005). Many of these factors are often involved simultaneously, and for those patients who are extremely immobile, appropriate 2

4 pressure redistributing equipment needs to be considered. Pressure injuries occur across the age spectrum from pre-term infants through to the very old (Benbow, 2008). The vast majority of people at risk of pressure injury are provided with a suitable profiling bed frame and pressure relieving mattress appropriate to their needs. However many of these people, particularly if they sit in armchairs, are left vulnerable to pressure injury due to inadequate provision of suitable pressure relieving cushions (Collins 2008). Evaluating the contribution of pressure reducing cushions to preventing and remedying pressure injury is challenging due to the complexity of factors involved, such as length of time the person sits for, their sitting posture, their ability to withstand gravitational forces and the reaction of the person s skin to pressure, shear forces and friction. The Stimulite Classic Pressure Redistributing Cushion Stimulite lightweight cushions use a soft, flexible honeycomb form to distribute weight uniformly, giving exceptional comfort and excellent postural stability. A unique ventilation system allows air to circulate horizontally and vertically, creating an ideal micro-climate for long-term sitting comfort and skin protection. Stimulite cushions have had a proven track record among wheelchair users since They are hygienic, safe and offer total comfort and, uniquely, both cushions and covers are machine washable. They are naturally antibacterial, antifungal and allergen free making them long lasting, durable and cost effective in use. There is a full range of Stimulite cushions, including standard, paediatric, sport and bariatric models, specifically designed to accommodate a wide range of disabilities. The Stimulite Classic cushion is designed for people who are at high risk for skin breakdown, providing excellent pressure relief, unsurpassed comfort and exceptional stability. Project Objectives: The primary objectives of the clinical evaluation were to: 1. Formally evaluate efficacy in preventing and healing pressure injury 3

5 2. To evaluate the comfort, patient experience, and ease of use of the Stimulite Classic Cushion in 5 people in the community who were using a pressure redistributing cushion in their armchair, which for various reasons were unsuccessful. Methodology The Subjects for the evaluation were residents in an EMI Nursing Home, all of whom on examination had existing pressure injury and were vulnerable to further development of pressure injury. Prior to the evaluation, the Subjects had been identified by Nursing Home staff as being at very high risk of pressure injury or with existing pressure injury, and were using pressure relieving cushions on top of their existing armchair seats, which they were finding uncomfortable. Subject profile All Subjects had profiling bed bases and replacement deep cell alternating mattresses. One of the Subjects had a privately owned riser recliner chair, one Subject used a bucket style chair and three of the residents used a conventional high seat chair (all of which had the original seat cushions removed and replaced with a memory foam pressure redistributing cushion). Two of the Subjects had been provided with an alternating air cushion, but had rejected this on grounds of discomfort and instability. Two out of the five Subjects required hoisting for their moving and handling needs. Two Subjects could transfer with assistance, but were extremely immobile. One Subject needed assistance with transfers but once standing was ambulant. All of the Subjects were doubly incontinent. Two of the Subjects had a MUST score (Malnutrition Universal Screening Tool) of 1 (medium risk) and the remaining three had a score of 2 (high risk). Day 0 All Subjects remained in bed prior to assessment. Baseline demographic data was collected for each of the Subject. The skin of each Subject was examined for signs of pressure injury. Photographs were taken of any areas of the skin exhibited signs of pressure injury. High definition ultrasound was used to examine firstly normal skin and then the skin of each person s buttocks and sacrum for signs of pressure injury 4

6 Comments were sought from the Subject (where possible) on the comfort of their existing cushion. Comments from staff relating to perceived Subject comfort were also sought. The Subjects were then provided with a Stimulite Classic cushion which was the same size as their armchair seat. This cushion was positioned into the armchairs instead of the existing pressure reducing cushions already in situ. Day 14 The skin of each Subject was examined for signs of pressure injury. Photographs were taken of any areas of the skin exhibited signs of pressure injury. High definition ultrasound was used to examine firstly normal skin and then the skin of each person s buttocks and sacrum for signs of pressure injury Comments were sought from the Subject (where possible) on the comfort of Stimulite Classic Cushion. Comments from staff Comments from staff relating to perceived Subject comfort, and ease of use of the Stimulite Classic Cushion were also sought. Results Visual examination of the skin demonstrated that the Stimulite Classic Cushion had maintained skin integrity in all five Subjects. In the four Subjects with visually evident pressure injury on Day 0 there were significant visible improvements to the skin condition by Day 14. The photographs presented for each Subject at the end of this report demonstrate the positive effect of the Stimulite Classic Cushion on extremely vulnerable individuals. The results of the High Definition Ultrasound Scans obtained on each of the subjects provides substantive quantitative data, which strongly supports the efficacy of the Stimulite cushion in preventing and healing Pressure Injuries up to Category 2, when comparing scans from Day 0 and Day 14. Dr Steve Young has provided a separate report on High Definition Ultrasound Scanning for the Stimulite Evaluation, which will be presented alongside this report. However, the summary graph from his report with associated comments, is presented at the end of this section. The individual case studies, with photographs, are presented at the end of this report. Due to all of the subjects suffering from Dementia, it was not possible to gain verbal feedback on comfort directly from them. However, qualitative summary feedback was provided by the Nursing 5

7 Home Matron on each subject, including feedback on length of time sitting, the subjects posture and perception of comfort. There were many positive comments and these have been recorded in the details on each Subject s profile below. No negative comments were made by the Matron with regard to the Stimulite Classic cushion. Figure 1: Graph showing LEP: TP ratio Figure 1 Interpretation: Using the scanners image analysis software, it was possible to measure the amount of oedema within the dermal tissue of each subject. Each scan of the tissue was analysed using a form of pixel distribution analysis whereby pixels below certain intensity are classed as Low Echogenic Pixels (LEP). The ratio of LEP s to Total Pixel count (TP) has been shown to reflect changes in dermal water content. The analysis of the ultrasound images from the uninjured skin of the subjects shows that the mean LEP: TP ratio is This is therefore the level we would wish to get the affected skin to if our therapy (i.e. use of the Stimulite Classic Cushion) works. 6

8 As the graph shows, the damaged skin at time 0 is 0.58 which is approximately twice the uninjured skin level, which indicates high levels of oedema present. By 14 days, the ratio is almost at normal/uninjured levels. Conclusion The results obtained during the evaluation of the Stimulite Classic Cushion are extremely positive and would suggest that the use of this cushion has a significant role to play in both preventing and healing pressure injuries up to Category 2 (EPUAP / NPUAP, 2005) in extremely vulnerable people. The comments received by the Matron were overwhelmingly positive, particularly relating to visually improved comfort, improved posture and reduced agitation. This evidence and feedback would indicate that the Stimulite Classic Cushion has a very effective part to play in the prevention and management of pressure injuries for vulnerable people who wish to sit in conventional armchairs for controlled periods of time. 7

9 References Benbow, M (2008) Pressure ulcer prevention and pressure relieving surfaces. British Journal of Nursing. 17 (13): Collins F (2008) An essential guide to managing seated patients in the community. Br J Community Nurs. Mar;13(3):S39-40, S42-3, S45-6. EPUAP / NPUAP (2009) Treatment of Pressure Ulcers: Quick Reference Guide National Institute for Health and Clinical Excellence (2005) The Management of Pressure Ulcers in Primary and Secondary Care. A Clinical Practice guideline. CG029 8

10 Subject 1: (AJ) Age: Gender: Waterlow Score: MUST Score: Medical history: Continence: Transfers: Mobility status: Repositioning status: Length of time sitting 83 years Male 20 (very high risk) 1 (medium risk) Dementia, Diabetes Type 2, Hypertension, Angioplasty Doubly incontinent Standing transfers with the assistance of care staff using a patient handling belt Ambulant Can reposition a little in bed, but predominantly relies on staff for assistance Sits for 2-3 hours during the day in a bucket style chair with a memory foam cushion. Staff reported that this gentleman was often agitated when sitting, constantly attempting to slide down in the chair, hence the provision of a bucket style chair in order to try and prevent this Existing bed frame and mattress Subject has a profiling bed with a deep cell alternating mattress replacement Day 0 Observations A full skin assessment was undertaken. There was generalised erythema in the sacral region and three separate broken areas of skin, all of which were defined as Category 2 (EPUAP, 2005) pressure injuries. Day 0 Photograph Day 14 Observations There was visible improvement of this Subject s pressure injuries. Much of the surrounding erythema had dissipated and there was evidence of epithelialisation in the broken areas 9

11 Day 14 Photograph Matron s Comments on Effect of Stimulite Classic Cushion The Matron felt that AJ had made a marvellous improvement since using the Stimulite Classic cushion in his armchair. She reported that his perceived agitation when sitting and sliding up and down in the chair was much reduced. This she felt, had resulted in his posture being improved and had contributed to his skin integrity being improved. 10

12 Subject 2: (WL) Age: Gender: Waterlow Score: MUST Score: Medical history: Continence: Transfers: Mobility status: Repositioning status: Length of time sitting 90 years Male 33 (very high risk) 2 (high risk) Dementia, Arthritis, Diabetes Type 2, Frailty Doubly incontinent Hoisted for all transfers Non weight bearing Unable to reposition independently Sits for 2-3 hours during the day in a high seat armchair with a memory foam cushion. This gentleman had been provided with an alternating seat cushion, which he did not tolerate and which staff reported made no difference to his skin integrity. This gentleman had a tendency to rock forwards and backwards when sitting Existing bed frame and mattress Subject has a profiling bed with a deep cell alternating mattress replacement Day 0 Observations A full skin assessment was undertaken. Some of the redness observed in the photograph below was caused by a skin reaction to the sacral dressing used to cover an abrasion. This dressing had immediately been discontinued. However, there was generalised non blanching erythema in the sacral region and a graze slightly above and to the right of the natal cleft which was defined as a Category 2 (EPUAP, 2005) pressure injury. Day 0 Photograph 11

13 Day 14 Observations There was significant visible improvement of this Subject s pressure injury. The surrounding erythema had dissipated and the graze the above left of the natal cleft had epithelialised Day 14 Photograph Matron s Comments on Effect of Stimulite Classic Cushion The Matron was extremely pleased that the graze on this subject s sacrum had made such progress. She noted that this client had reduced his tendency to rock in the chair and appeared more comfortable. 12

14 Subject 3: (BH) Age: Gender: Waterlow Score: MUST Score: Medical history: Continence: Transfers: Mobility status: Repositioning status: Length of time sitting 85 years Female 24 (very high risk) 2 (high risk) Dementia, Left and Right Cerebrovascular Accidents leading to bilateral hemiparesis, Arthritis, Angina Doubly incontinent Hoisted for all transfers Non weight bearing Unable to reposition independently in the bed or chair This lady has her own riser recliner armchair onto which staff had placed an alternating seat cushion, as they were concerned about her risk of developing a pressure injury (this lady has a history of pressure injuries); however, the lady refused to sit on the alternating seat cushion due to discomfort and feeling unstable. As a consequence, due concerns about her vulnerability, and as she had no alternative cushion to use, the lady had been placed on enforced bed rest in her best interests, despite her preference to be sat out of bed. However, staff felt that provision of a Stimulite cushion offered the lady an opportunity to sit out of bed, in a controlled situation, on an alternative cushion which it was hoped would meet her needs. Existing bed frame and mattress Subject has a profiling bed with a deep cell alternating mattress replacement Day 0 Observations A full skin assessment was undertaken. Visually the skin in the sacral region and between the buttocks was darkened. It was difficult to note any reddening of the skin although there was clear scarring from previous pressure injuries. However the ultrasound scan determined evidence of Category 1 (EPUAP, 2005) pressure injury in the upper left sacral region Day 0 Photograph 13

15 Day 14 Observations Much of the darkening of the skin in the sacral region had dissipated, leaving paler skin, clearly demonstrating the scarring from previous pressure injuries Day 14 Photograph Matron s Comments on Effect of Stimulite Classic Cushion The Matron reported that she had been extremely concerned when allowing the lady to be sat out of bed using the Stimulite Classic cushion, due to her previous history of pressure injury and the inability of the lady to tolerate the alternating seat cushion previously provided. The Matron reported that this lady s posture had not specifically improved throughout the duration of the evaluation due to her fixed kyphosis, which would not necessarily have been affected by the use of the cushion. 14

16 Subject 4: (CM) Age: Gender: Waterlow Score: MUST Score: 87 years Female 19 (high risk) 1 (medium risk) Medical history: Dementia, R hemiarthroplasty 2012, L dynamic hip screw 2011 Continence: Transfers: Mobility status: Repositioning status: Doubly incontinent Assisted by two to undertake standing transfers Unable to take more than 2-3 steps Unable to reposition independently in the bed, but can reposition a little in the chair Length of time sitting This lady sits in a conventional high seat armchair for 2-3 hours with a memory foam cushion, but regularly requires enforced bed rest due to a tendency to develop sacral pressure injuries Existing bed frame and mattress Subject has a profiling bed with a deep cell alternating mattress replacement Day 0 Observations A full skin assessment was undertaken. There was generalised non blanching erythema in the sacral region and between the buttocks. There was a graze at the top of the buttocks on the right hand side which was defined as a Category 2 (EPUAP, 2005) pressure injury. There was a small reddened area to the lower right buttock, but the ultrasound scan determined that this was not a pressure injury. Day 0 Photograph Day 14 Observations There was a substantial improvement visually; the erythema was no longer present and the graze had healed, with a small area only remaining 15

17 Day 14 Photograph Matron s Comments on Effect of Stimulite Classic Cushion The Matron reported that this lady seemed far more comfortable using the Stimulite Classic cushion rather than the original memory foam cushion that she had been using. This she felt was evident in the lady s improved posture, the improvement in skin integrity and her ability to sit out of bed for increased periods of time. 16

18 Subject 5: (SD) Age: Gender: Waterlow Score: MUST Score: Medical history: Continence: Transfers: Mobility status: Repositioning status: 85 years Male 29 (very high risk) 2 (high risk) Dementia, breathlessness, repetitive urinary tract infections, Type 2 Diabetes Doubly incontinent Assisted by two to undertake standing transfers Unable to take more than 1-2 steps Relies on staff for all repositioning in the bed and chair Length of time sitting This gentleman sits in a conventional high seat armchair for 3-4 hours with a memory foam cushion Existing bed frame and mattress Subject has a profiling bed with a deep cell alternating mattress replacement Day 0 Observations A full skin assessment was undertaken. There was no evidence of erythema in the sacral region; however the ultrasound scan confirmed evidence of oedema within the tissues confirming the presence of tissue injury Day 0 Photograph Day 14 Observations The Subject s skin remained intact with no erythema 17

19 Day 14 Photograph Matron s Comments on Effect of Stimulite Classic Cushion The Matron felt that this particular subject s skin had remained in good integrity despite the fact that he had become increasingly frail during the period of the evaluation. She felt that there was no change in terms of postural improvement, but did feel that he seemed more comfortable using the Stimulite Classic cushion. 18

20 Stimulite Cushions Clinical Trial Report Ultrasound Analysis Dr Steve Young Dr Young's experience into wound healing research extends back almost 30 years to 1983 when he joined the Tissue Repair Research Unit in the Department of Anatomy, Guy's Hospital Medical School, now part of King's College London (KCL), as the Deputy Head. As well as carrying out research he was also an honorary senior lecturer in wound healing at the medical school. As part of the Tissue Repair Research Unit he was also responsible for supervising MSc and PhD students. In 1995 Dr Young founded the Tissue Viability Unit at Guy's and was its Director until Since then he has worked as a biomedical consultant and is one of the inventors of a highresolution diagnostic ultrasound scanner which is unique in that it acquire clinical information about the status of skin and wounds prior to it becoming clinically evident. 26 th April 2013

21 Trial Design This pilot study was carried out by WHC in Eastbourne on patients with evidence of sacral pressure damage. 5 Patients were recruited for this trial The trial design was as follows: Visit 1 Patients identified and consented. Ultrasound scanning carried out on the damaged area of the sacrum to establish a baseline. Also, an area of normal skin adjacent to the damaged area was scanned to ascertain what the patient s uninjured skin looked like. Visit 2 14 days after the baseline visit the same areas were again scanned. From the information gained from this it was possible to establish if the area had improved, deteriorated or stagnated. Assessment: Ultrasound Scanning: The benefit of including ultrasound as an assessment tool is that it provides quantitative information about what is happening beneath the skin surface which is not always clinically evident (1-6). The scanner used in this project (figure 1) operated at a frequency of 20MHz (Episcan - Longport Inc.). This frequency gives an axial resolution of 65 m. Figure 1. Ultrasound Scanner

22 The scanning procedure is non-invasive and the affected area was exposed and an aqueous gel applied to it and a scan then taken. Care was taken to carry out subsequent scans in the same area. Scans were also taken of the patient s normal skin adjacent to the affected area to get a profile of what the patient s uninjured skin should look like. Scans of the injured skin was then compared to the scans of the normal skin (fig 2) to give us a measure of how far from normal the tissues were at the start of the study and how they then progressed back towards the normal profile as the study advanced. Scan Analysis Using the scanners image analysis software it was possible to measure the amount of oedema within the dermal tissue. Each scan of the tissue was analysed using a form of pixel distribution analysis whereby pixels below certain intensity are classed as Low Echogenic Pixels (LEP). The ratio of LEP s to Total Pixel count (TP) has been shown to reflect changes in dermal water content (7, 8, 9). Using this technique it was possible to get a quantitative assessment of the level of oedema present in the damaged tissue. Figure 2 scan of normal skin with adjacent histology section indicating zones

23 Results The following section shows the individual patient scans for all time points. Results BH Figure 3. Scans comparing the patient s normal skin with the damaged site. Normal uninjured sacral skin Injured sacral skin time 0 Injured sacral skin 14 days The injured tissue at time 0 has an elevated level of red pixels in the scan, compared to the uninjured skin, indicating the presence of oedema. The scan of the same tissue after 14 days shows the red pixels appear to have decreased and there is an increase in blue pixels.

24 Figure 4 Graph of LEP: TP ratio for BH Analysis The graph above shows that the injury site at time zero has a much larger LEP:TP ratio value than that of the uninjured skin. This is due to the high levels of oedema present in the skin. After 14 days the ratio level has decreased towards the normal levels as the oedema has decreased.

25 Results AJ Figure 5. Scans comparing the patient s normal skin with the damaged site. Normal uninjured sacral skin Injured sacral skin time 0 Injured sacral skin 14 days The injured tissue at time 0 has an elevated level of red pixels in the scan, compared to the uninjured skin, indicating the presence of oedema. The scan of the same tissue after 14 days shows the red pixels appear to have decreased and there is an increase in blue pixels. It can be noticed that there is still a relatively small zone of oedema just below the epidermis at 14 days which should resolve as treatment continues.

26 Figure 6 Graph of LEP: TP ratio for AJ Analysis The graph above shows that the injury site at time zero has a much larger LEP:TP ratio value than that of the uninjured skin. This is due to the high levels of oedema present in the skin. After 14 days the ratio level has decreased towards the normal levels as the oedema has decreased.

27 Results WL Figure 7. Scans comparing the patient s normal skin with the damaged site. Normal uninjured sacral skin Injured sacral skin time 0 Injured sacral skin 14 days The injured tissue at time 0 has an elevated level of red pixels in the scan, compared to the uninjured skin, indicating the presence of oedema. The scan of the same tissue after 14 days shows the red pixels appear to have decreased and there is an increase in blue pixels. It can be noticed that there is still a relatively small zone of oedema just below the epidermis at 14 days which should resolve as treatment continues.

28 Figure 8 Graph of LEP: TP ratio for BL Analysis The graph above shows that the injury site at time zero has a much larger LEP:TP ratio value than that of the uninjured skin. This is due to the high levels of oedema present in the skin. After 14 days the ratio level has decreased towards the normal levels as the oedema has decreased.

29 Results CM Figure 9. Scans comparing the patient s normal skin with the damaged site. Normal uninjured sacral skin Injured sacral skin time 0 Injured sacral skin 14 days The injured tissue at time 0 has an elevated level of red pixels in the scan, compared to the uninjured skin, indicating the presence of oedema. The scan of the same tissue after 14 days shows the red pixels appear to have decreased and there is an increase in blue pixels. It can be noticed that there is still a relatively small zone of oedema just below the epidermis at 14 days which should resolve as treatment continues.

30 Figure 10 Graph of LEP: TP ratio for CM Analysis The graph above shows that the injury site at time zero has a much larger LEP:TP ratio value than that of the uninjured skin. This is due to the high levels of oedema present in the skin. After 14 days the ratio level has decreased towards the normal levels as the oedema has decreased.

31 Results SD Figure 11. Scans comparing the patient s normal skin with the damaged site. Normal uninjured sacral skin Injured sacral skin time 0 Injured sacral skin 14 days The injured tissue at time 0 has an elevated level of red pixels in the scan, compared to the uninjured skin, indicating the presence of oedema. The scan of the same tissue after 14 days shows the red pixels appear to have decreased and there is an increase in blue pixels.

32 Figure 12 Graph of LEP: TP ratio for SD Analysis The graph above shows that the injury site at time zero has a much larger LEP:TP ratio value than that of the uninjured skin. This is due to the high levels of oedema present in the skin. After 14 days the ratio level has decreased towards the normal levels as the oedema has decreased.

33 Mean result data The mean results for the study are shown in the table below and expressed graphically in figure 13. These figures represent the mean data for the 5 patients. Assessment Period Mean LEP/TP ratio ±SD Uninjured skin ± 0.06 Time ± days ± 0.13 Figure 13. Graph showing LEP: TP ratio The analysis of the ultrasound images from the uninjured skin of the patients shows that the mean LEP: TP ratio is This is therefore the level we would wish to get the affected skin to if our therapy works. As the graph shows, the damaged skin at time 0 is 0.58 which is approximately twice the uninjured skin level, which indicates high levels of oedema present. By 14 days the ratio is almost at normal/uninjured levels.

34 Conclusion The results of the ultrasound scan analysis show that the Stimulite cushions appear to be having a measured effect on tissue recovery, with sacral tissues moving towards their pre-injured state within 14 days after commencing treatment. References 1. Young SR, Ballard K. Wound Assessment: Diagnostic and assessment applications Part 2.. In: Electrotherapy-Evidence based practice Pp Churchill-Livingstone (London). 2. Chen L. Dyson M, Rymer J, et.al. The use of high frequency diagnostic ultrasound to investigate the effect of HRT on skin thickness. Skin Research And Technology 2001; 7(2): Mirpuri N, Young SR. The use of diagnostic ultrasound to assess the skin changes that occur during normal and hypertensive pregnancies. Skin Research and Technology 2001; 7: Kerr A, Young S, Hampton S. Has packing sinus wounds become a ritualistic practice? British Journal of Nursing 2006; 15(19): S27-S Quintavalle P, Lyder CH, Mertz PJ, et.al. Use of high-resolution, high frequency diagnostic ultrasound to investigate the pathogenesis of pressure ulcer development. Adv. Skin & Wound Care 2006; 19(9): Young S, Bolton PA, Downie J. Use of high-frequency ultrasound in the assessment of injectable dermal fillers. Skin Research and Technology 2008;1 14: Gniadecka M. Localization of dermal edema in lipodermatosclerosis, lymphedema, and cardiac insufficiency: high-frequency ultrasound examination of intradermal echogenicity. J Am Acad Dermatol. 1996; 35: Gniadecka M, Quistorff B. Assessment of dermal water by high-frequency ultrasound: comparative studies with nuclear magnetic resonance. Br J Dermatol. 1996; 135: Young. S, Hampton. S, and Tadej. M. Study to evaluate the effect of lowintensity pulsed electrical currents on levels of oedema in chronic non-healing wounds. Journal of Wound Care 2011; 20: