Extracorporeal shock wave therapy for management of chronic ulcers in the lower extremities

Does physical therapy and rehabilitation improve outcomes for diabetic foot ulcers?

One of the most common and serious complications of diabetes mellitus is ulceration of the foot. Among persons with diabetes, 12%-25% will present to a healthcare institution for a foot disorder during their lifespan. Despite currently available medical and surgical treatments, these are still the most common diabetes-related cause of hospitalization and of lower extremity amputations. Thus, many adjunctive and complementary treatments have been developed in an attempt to improve outcomes. We herein review the available literature on the effectiveness of several treatments, including superficial and deep heaters, electro-therapy procedures, prophylactic methods, exercise and shoe modifications, on diabetic foot wounds. Overall, although physical therapy modalities seem to be useful in the treatment of diabetic foot wounds, further randomized clinical studies are required.

The effectiveness of extracorporeal shock wave therapy for the treatment of lower limb ulceration: a systematic review

Extracorporeal shock wave therapy has been reported as an effective treatment for lower limb ulceration. The aim of this systematic review was to investigate the effectiveness of extracorporeal shock wave therapy for the treatment of lower limb ulceration.

Five electronic databases (Ovid MEDLINE, CINAHL, Web of Knowledge, Scopus and Ovid AMED) and reference lists from relevant studies were searched in December 2013. All study designs, with the exception of case-reports, were eligible for inclusion in this review. Assessment of each study’s methodological quality was performed using the Quality Index tool. The effectiveness of studies was measured by calculating effect sizes (Cohen’s d) from means and standard deviations.

Five studies, including; three randomised controlled trials, one quasi-experimental study and one case-series design met our inclusion criteria and were reviewed. Quality assessment scores ranged from 38 to 63% (mean 53%). Improvements in wound healing were identified in these studies following extracorporeal shock wave therapy. The majority of wounds assessed were associated with diabetes and the effectiveness of ESWT as an addition to standard care has only been assessed in one randomised controlled trial.

Considering the limited evidence identified, further research is needed to support the use of extracorporeal shock wave therapy in the treatment of lower limb ulceration.

Efficacy of shock wave therapy on chronic diabetic foot ulcer: a single-blinded randomized controlled clinical trial

OBJECTIVE

This study was conducted to evaluate the efficacy of extracorporeal shock wave therapy (ESWT) on the healing rate, wound surface area and wound bed preparation in chronic diabetic foot ulcers (DFU).

METHODS

Thirty eight patients with 45 chronic DFU were randomly assigned into; the ESWT-group (19 patients/24 ulcers) and the control-group (19 patients/21 ulcers). Blinded therapist measured wound surface area (WSA), the percentage of reduction in the WSA, rate of healing and wound bed preparation at baseline, after the end of the interventions (W8), and at 20-week follow-up (W20). The ESWT group received shock wave therapy twice per week for a total of eight treatments. Each ulcer was received ESWT at a frequency of 100 pulse/cm(2), and energy flux density of 0.11mJ/cm(2). All patients received standardized wound care consisting of debridement, blood-glucose control agents, and footwear modification for pressure reduction.

RESULTS

The overall clinical results showed completely healed ulcers in 33.3% and 54% in ESWT-groups and 14.28% and 28.5% in the control group after intervention (W8), and at follow-up (W20) respectively. The average healing time was significantly lower (64.5 ± 8.06 days vs 81.17 ± 4.35 days, p<0.05) in the ESWT-group compared with the control group.

CONCLUSION

ESWT-treated ulcers had a significant reduction in wound size and median time required for ulcer healing, with no adverse reactions. So, the ESWT is advocated as an adjunctive therapy in chronic diabetic wound.

Shock wave treatment enhances cell proliferation and improves wound healing by ATP release-coupled extracellular signal-regulated kinase (ERK) activation

Shock wave treatment accelerates impaired wound healing in diverse clinical situations. However, the mechanisms underlying the beneficial effects of shock waves have not yet been fully revealed. Because cell proliferation is a major requirement in the wound healing cascade, we used in vitro studies and an in vivo wound healing model to study whether shock wave treatment influences proliferation by altering major extracellular factors and signaling pathways involved in cell proliferation. We identified extracellular ATP, released in an energy- and pulse number-dependent manner, as a trigger of the biological effects of shock wave treatment. Shock wave treatment induced ATP release, increased Erk1/2 and p38 MAPK activation, and enhanced proliferation in three different cell types (C3H10T1/2 murine mesenchymal progenitor cells, primary human adipose tissue-derived stem cells, and a human Jurkat T cell line) in vitro. Purinergic signaling-induced Erk1/2 activation was found to be essential for this proliferative effect, which was further confirmed by in vivo studies in a rat wound healing model where shock wave treatment induced proliferation and increased wound healing in an Erk1/2-dependent fashion. In summary, this report demonstrates that shock wave treatment triggers release of cellular ATP, which subsequently activates purinergic receptors and finally enhances proliferation in vitro and in vivo via downstream Erk1/2 signaling. In conclusion, our findings shed further light on the molecular mechanisms by which shock wave treatment exerts its beneficial effects. These findings could help to improve the clinical use of shock wave treatment for wound healing.

Original hypothesis: Extracorporeal shockwaves as a homeostatic autoimmune restorative treatment (HART) for Type 1 diabetes mellitus

Mononuclear invasion of Langerhans islet and the ensuing insulitis triggers signal-transduction for the autoimmune mediated pancreatic beta-cell (β-cell) apoptosis that severely disrupts insulin production resulting in hyperglycemia associated with Type-1 diabetes (T1DM). Today extensive global research is being conducted to eliminate the need for insulin, and even prevent or find a cure for T1DM. The multifactorial combination of autoimmune dysfunction, Langerhans islet hypoxia, and bio-chemical disruption are seen to be contributory factors for β-cell destruction and the consequential disruption to insulin production. Regeneration of β-cells back to physiological levels may restore homeostatic insulin levels, reversing T1DM. Evidence suggests that there are still functioning pancreatic β-cells even in long standing T1DM providing the potential for their regeneration. Although the exact mechanism of extracorporeal shockwaves (ESW) is yet to be fully elucidated, it is seen to influence a complex spectrum of bio-chemical, cellular and neuronal functions (i.e. suppression of pro-inflammatory immune response, improved tissue hemodynamics, anti-microbial properties, and the induction of progenitor cell expression including proangiogenic factors and nitric oxide syntheses). The rationale for the use of ESW as a therapeutic modality in this instance is attributed to its restorative properties and safety profile demonstrated in urology, cardiology, chronic wounds, osteogenesis, complex pain syndromes, and tendinopathies. ESW may restore autoimmune homeostasis creating a suitable environment for pancreatic β-cell proliferation which in-turn may significantly increase or normalize endogenous insulin secretion reducing or totally eliminating dependency of exogenous insulin. The devastating complications, morbidity and mortality associated with T1DM warrants the exploration of homeostatic autoimmune restorative treatment (HART) modalities that may partially or fully reverse this disease condition. We present our hypothesis discussing ESW as a potential homeostatic autoimmune restorative treatment (HART) option for T1DM.

Penile low-intensity shock wave therapy: a promising novel modality for erectile dysfunction

Penile extracorporeal low-intensity shock wave therapy (LIST) to the penis has recently emerged as a novel and promising modality in the treatment of erectile dysfunction (ED). LIST has angiogenic properties and stimulates neovascularization. If applied to the corpora cavernosa, LIST can improve penile blood flow and endothelial function. In a series of clinical trials, including randomized double-blind sham-controlled studies, LIST has been shown to have a substantial effect on penile hemodynamics and erectile function in patients with vasculogenic ED. LIST is effective in patients who are responsive to phosphodiesterase 5 inhibitors (PDE5i) and can also convert PDE5i nonresponders to responders. The response to LIST wanes gradually over time, and after 2 years, about half of the patients maintain their function. Extensive research is needed to understand the effect of LIST on erectile tissue, to modify the treatment protocol to maximize its outcomes, and to identify the patients who will benefit the most from this treatment.

Extracorporeal shock wave therapy in musculoskeletal disorders: a review

Regenerative therapy is one of the most challenging and intriguing branches of modern medicine. Basic research has demonstrated the effectiveness of extracorporeal shockwaves (ESWT) in stimulating biological activities that involve intra-cell and cell-matrix interactions. These interactions are at the basis of the current clinical applications, and open the horizons to new applications in tissue regeneration. It is also feasible that shock waves could be used to treat various orthopaedic pathologies, removing the need for surgery. However, suitable translational studies need to be performed before ESWT can become a valid alternative to surgery.

Emerging drugs for the treatment of diabetic ulcers

INTRODUCTION

Diabetic ulcers are chronic nonhealing ulcerations that despite the available medical tools still result in high amputation rates. Growing evidence suggests that alteration of the biochemical milieu of the chronic wound plays a significant role in impaired diabetic wound healing.

AREAS COVERED

The basic pathophysiology and the conventional treatment strategy of diabetic foot ulcers have been reviewed in the first section. In the second part, the most up-to-date bench and translational research in the field are described. The third section focuses on the drugs currently under development and the ongoing clinical trials evaluating their safety and efficacy. Finally, the major drug development issues and the possible scientific approaches to overcome them are analyzed.

EXPERT OPINION

Significant strides in understanding the chronic wound development have led to the development of topical therapies to address aberrant expression of growth factors and overexpression of inflammatory cytokines. Current research in the laboratory suggests that while decreased growth factor expression occurs at the local wound level, increased systemic serum levels of growth factors suggest growth factor resistance.

Long-Term Results of Rehabilitative Management with Extracorporeal Shockwave Therapy in Rotator Cuff Disease with Partial Tears

The purpose of this study is to evaluate the effects of rehabilitative approach using MJS and dynamic antigravity postural system (SPAD) with extracorporeal Shockwave therapy (ESWT) on rotator cuff syndrome associated tendon supraspinatus and infraspinatus medium tear (1–3 cm) of the tendons. In the last few years, ESWT has been proposed as an elective treatment in somatic diseases with encouraging short-term results. For this study the authors enrolled 108 patients who underwent 3 treatments with ESWT associated with 24 rehabilitation sessions over 3 weeks. Outcome measures were the VAS for pain and the Constant Murley Scale. The outcomes were measured pre-training, post-training and at 2, 4, 6 month follow-ups. Additional follow-up evaluation sessions were performed every year for 5 years by a telephone interview to evaluate changes in pain and function and the efficacy of treatment. Our study shows that the therapeutic efficacy of rehabilitative approach with ESWT in the rotator cuff syndrome with medium tears persists over time and significantly improves the patient's quality of life. The results obtained are certainly to be attributed to the biological mechanisms that ESWT are able to engage in tissues of the rotator cuff. The results seen at the conclusion of the treatment were maintained over the following years, thanks to the use of MJS and SPAD. In our opinion a conservative treatment with extracorporeal shock-wave (ESW), dynamic antigravity postural system (SPAD) and multi joint system (MJS) should be considered as an alternative and effective treatment for rotator cuff syndromes with medium tears.

Long-Term Effectiveness of Combined Mechanotransduction Treatment in Jumper's Knee

The aim of the study was to show that the addition of extracorporeal shockwave therapy (ESWT) may significantly improve beneficial effects of eccentric training together with high efficiency focused acoustic waves for jumper's knee. We speculate that such an effect may be due to increased mechanotransduction effects on affected tissues. We assessed changes in pain and function in 42 male football players (aged 1834 years) after a treatment protocol consisting of I session with focused ESWT per week combined with 3 physiotherapy sessions per week, for 3 consecutive weeks. While treatment protocol was administered, ordinary activities, but not playing football were permitted. Their condition was evaluated before treatment, at the end of the rehabilitation period (3 weeks) and at 2 months, 4 months and 6 months after the end of treatment by clinical examination, instrumental analysis and VAS for pain assessment. Functional ability related to symptoms was assessed with VISA score. At the end of 2005,2006,2007,2008 and 2009 we carried out a telephone interview to investigate changes in pain and function and the efficacy of the treatment over time. Follow-up controls showed a reduction of average VAS score; after 6 months, tendons showed a structure closer to normal at ultrasonographic investigation. At the last telephone interview in 2009 many patients reported to consider ESWT as an effective treatment and described a significant improvement in their functional abilities, a significant reduction in drug consumption and 88% of subjects continued to play agonistic football. In conclusion, our results showed that, through the addition of ESWT, the effects of the classic vibration and eccentric training combination were improved compared to those found in our experience without ESWT. Although a control group was not included in the study (vibration and eccentric training without ESWT), results show a promising improvement and justify future prospective studies with a control group and more case series.

Extracorporeal shock wave therapy (ESWT) for wound healing: technology, mechanisms, and clinical efficacy

For almost 30 years, extracorporeal shock wave therapy has been clinically implemented as an effective treatment to disintegrate urinary stones. This technology has also emerged as an effective noninvasive treatment modality for several orthopedic and traumatic indications including problematic soft tissue wounds. Delayed/nonhealing or chronic wounds constitute a burden for each patient affected, significantly impairing quality of life. Intensive wound care is required, and this places an enormous burden on society in terms of lost productivity and healthcare costs. Therefore, cost-effective, noninvasive, and efficacious treatments are imperative to achieve both (accelerated and complete) healing of problematic wounds and reduce treatment-related costs. Several experimental and clinical studies show efficacy for extracorporeal shock wave therapy as means to accelerate tissue repair and regeneration in various wounds. However, the biomolecular mechanism by which this treatment modality exerts its therapeutic effects remains unclear. Potential mechanisms, which are discussed herein, include initial neovascularization with ensuing durable and functional angiogenesis. Furthermore, recruitment of mesenchymal stem cells, stimulated cell proliferation and differentiation, and anti-inflammatory and antimicrobial effects as well as suppression of nociception are considered important facets of the biological responses to therapeutic shock waves. This review aims to provide an overview of shock wave therapy, its history and development as well as its current place in clinical practice. Recent research advances are discussed emphasizing the role of extracorporeal shock wave therapy in soft tissue wound healing.

Extracorporeal shock wave treatment improves incisional wound healing in diabetic rats

Impaired wound healing in surgical patients with diabetes increases the incidence of infection, prolongs hospitalization, and even increases the rate of mortality. Low-energy extracorporeal shock wave treatment (ESWT) was reported to accelerate chronic wound healing by promoting revascularization and tissue regeneration; however, it is not known if ESWT could also improve healing of acute surgical incisional wounds in diabetes. In this study, using a rat model of diabetes, we investigated the effect of low-energy ESWT on collagen content in wound tissues and its efficacy in incisional wound healing. A single dorsal incisional wound was inflicted in streptozotocin-induced diabetic rats, and they received ESWT at different time post-wounding. Rats were sacrificed on days 7 and 14 post-wounding. Wound breaking strength, hydroxyproline content, histological characteristics and the expression of transforming growth factor beta 1 (TGF-β1) were analyzed. As a result, the wound breaking strength was significantly enhanced and the hydroxyproline content in wound tissues was increased at each time point examined. The number of fibroblasts was signicantly increased, and the new collagen fibers were more abundant at the wound site after ESWT. Furthermore, the expression of TGF-β1 was up-regulated after ESWT on day 7 post-wounding. These results suggest that low-energy ESWT can increase collagen content, enhance wound breaking strength and improve the healing of incisional wound in diabetic rats. The increased collagen content may be attributed, at least in part, to the up-regulation of TGF-β1 expression in wound tissues.

Effect of extracorporeal shockwave treatment on the melanogenic activity of cultured melanocytes

In addition to the traditional lithotripsy treatment, extracorporeal shockwaves (ESWs) have been shown to be effective in the treatment of certain musculoskeletal disorders and in enhancing skin flap neovascularization. However, relatively little is known about its effect on melanocytes. To investigate its effect on the melanogenic activity of cultured melanocytes, mouse B16F10 melanocytes were treated with defocused ESWs of different energies (15, 21, and 27 kV) and at different doses (300 and 600 impulses). Cell viability was measured 1 and 24 h after treatment. Melanin content was measured and compared against a standard curve generated with fungal melanin. Cellular tyrosinase activity was calculated with the 3,4-dihydroxyphenylalanine (DOPA) oxidase assay. The results demonstrated that ESW treatment reduced cell viability. Our results also indicated that the overall decrease in cell viability lasted for 6 days. After ESW treatment with 300 or 600 impulses at 21 kV, no significant change in melanin content or tyrosinase activity of the B16F10 melanocytes was noted as compared to those of the control. The present study suggests that ESW treatment does not alter the melanogenic activity of the cultured melanocytes.

Extracorporeal shock wave therapy reverses ischemia-related left ventricular dysfunction and remodeling: molecular-cellular and functional assessment

An optimal treatment for patients with diffuse obstructive arterial disease unsuitable for catheter-based or surgical intervention is still pending. This study tested the hypothesis that extracorporeal shock wave (ECSW) therapy may be a therapeutic alternative under such clinical situation. Myocardial ischemia was induced in male mini-pigs through applying an ameroid constrictor over mid-left anterior descending artery (LAD). Twelve mini-pigs were equally randomized into group 1 (Constrictor over LAD only) and group 2 (Constrictor over LAD plus ECSW [800 impulses at 0.09 mJ/mm²] once 3 months after the procedure). Results showed that the parameters measured by echocardiography did not differ between two groups on days 0 and 90. However, echocardiography and left ventricular (LV) angiography showed higher LV ejection fraction and lower LV end-systolic dimension and volume in group 2 on day 180 (p<0.035). Besides, mRNA and protein expressions of CXCR4 and SDF-1α were increased in group 2 (p<0.04). Immunofluorescence staining also showed higher number of vWF-, CD31-, SDF-1α-, and CXCR4-positive cells in group 2 (all p<0.04). Moreover, immunohistochemical staining showed notably higher vessel density but lower mean fibrosis area, number of CD40-positive cells and apoptotic nuclei in group 2 (all p<0.045). Mitochondrial protein expression of oxidative stress was lower, whereas cytochrome-C was higher in group 2 (all p<0.03). Furthermore, mRNA expressions of MMP-9, Bax and caspase-3 were lower, whereas Bcl-2, eNOS, VEGF and PGC-1α were higher in group 2 (all p<0.01). In conclusion, ECSW therapy effectively reversed ischemia-elicited LV dysfunction and remodeling through enhancing angiogenesis and attenuating inflammation and oxidative stress.

Topical atorvastatin in the treatment of diabetic wounds

BACKGROUND

Currently, it is reported that statins may be useful in the treatment of diabetes mellitus foot ulceration. The aim of this study was to evaluate treatment of the wounds in streptozotocin-induced diabetic rats with local atorvastatin.

METHODS

Two 15 x 15 mm-sized wounds were created in 28 streptozotocin-induced rats. A total of 56 diabetic wounds were studied in 8 groups (n = 7). No treatment was administered in the first and second groups, which lasted for 7 and 14 days, respectively. Third and fourth groups consisted of diabetic rats that were administered 1:1 mixture of lanolin and vaseline therapy for 7 and 14 days, respectively. One percent statin plus 1:1 mixture of lanolin and vaseline was used in the fifth and sixth groups for 7 and 14 days, respectively; and in seventh and eighth groups, 5% statin plus 1:1 mixture of lanolin and vaseline therapy was used for 7 and 14 days, respectively. On the 7th and 14th days, state of the wound healing was observed, and the percent of wound healing was determined by measuring its size and by performing a histopathologic study. The statistical analyses were performed by Mann-Whitney U test, using SPSS 14.0 software.

RESULTS

On the 14th day, the rates of wound healing in the first, second, third, and fourth groups were 14%, 40%, 96.59%, and 96.51%, respectively. This ratio was calculated by the formula healing ratio (%) = 100 x (1-wound area/initial wound area). Accordingly, in the multiple comparisons, the rates of wound healing were found to be significantly higher in the diabetic rat groups administered 1% and 5% atorvastatin compared with those administered a mixture of lanolin-vaseline and the untreated group (for comparison each one P < 0.001).

CONCLUSIONS

Local atorvastatin therapy may be useful for healing the wounds in diabetic rats. Further clinical and experimental studies are needed to confirm these results.

The management of neuropathic ulcers of the foot in diabetes by shock wave therapy

BACKGROUND

Diabetes is becoming one of the most common chronic diseases, and ulcers are its most serious complication. Beginning with neuropathy, the subsequent foot wounds frequently lead to lower extremity amputation, even in the absence of critical limb ischemia. In recent years, some researchers have studied external shock wave therapy (ESWT) as a new approach to soft tissue wound healing. The rationale of this study was to evaluate if ESWT is effective in the management of neuropathic diabetic foot ulcers.

METHODS

We designed a randomized, prospective, controlled study in which we recruited 30 patients affected by neuropathic diabetic foot ulcers and then divided them into two groups based on different management strategies. One group was treated with standard care and shock wave therapy. The other group was treated with only standard care. The healing of the ulcers was evaluated over 20 weeks by the rate of re-epithelization.

RESULTS

After 20 weeks of treatment, 53.33% of the ESWT-treated patients had complete wound closure compared with 33.33% of the control patients, and the healing times were 60.8 and 82.2 days, respectively (p < 0.001). Significant differences in the index of the re-epithelization were observed between the two groups, with values of 2.97 mm2/die in the ESWT-group and 1.30 mm2/die in the control group (p < 0.001).

CONCLUSION

Therefore, ESWT may be a useful adjunct in the management of diabetic foot ulceration.