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De la Corte-Rodríguez H, Román-Belmonte JM, Rodríguez-Damiani BA, Vázquez-Sasot A, Rodríguez-Merchán EC. Extracorporeal Shock Wave Therapy for the Treatment of Musculoskeletal Pain: A Narrative Review. Healthcare (Basel) 2023; 11:2830. [PMID: 37957975 PMCID: PMC10648068 DOI: 10.3390/healthcare11212830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Extracorporeal shock waves are high-intensity mechanical waves (500-1000 bar) of a microsecond duration with a morphology characterized by a rapid positive phase followed by a negative phase. BACKGROUND Extracorporeal shock waves have been used for pain treatment for various sub-acute and chronic musculoskeletal (MSK) problems since 2000. The aim of this article is to update information on the role of extracorporeal shock wave therapy (ESWT) in the treatment of various pathologies that cause MSK pain. METHODS Given that in the last two years, articles of interest (including systematic reviews and meta-analyses) have been published on less known indications, such as low back pain, nerve entrapments, osteoarthritis and bone vascular diseases, a literature search was conducted in PubMed, the Cochrane Database, EMBASE, CINAHL and PEDro, with the aim of developing a narrative review of the current literature on this topic. The purposes of the review were to review possible new mechanisms of action, update the level of evidence for known indications and assess possible new indications that have emerged in recent years. RESULTS Although extracorporeal shock waves have mechanical effects, their main mechanism of action is biological, through a phenomenon called mechanotransduction. There is solid evidence that supports their use to improve pain in many MSK pathologies, such as different tendinopathies (epicondylar, trochanteric, patellar, Achilles or calcific shoulder), plantar fasciitis, axial pain (myofascial, lumbar or coccygodynia), osteoarthritis and bone lesions (delayed union, osteonecrosis of the femoral head, Kienbock's disease, bone marrow edema syndrome of the hip, pubis osteitis or carpal tunnel syndrome). Of the clinical indications mentioned in this review, five have a level of evidence of 1+, eight have a level of evidence of 1-, one indication has a level of evidence of 2- and two indications have a level of evidence of 3. CONCLUSIONS The current literature shows that ESWT is a safe treatment, with hardly any adverse effects reported. Furthermore, it can be used alone or in conjunction with other physical therapies such as eccentric strengthening exercises or static stretching, which can enhance its therapeutic effect.
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Affiliation(s)
- Hortensia De la Corte-Rodríguez
- Department of Physical Medicine and Rehabilitation, La Paz University Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain
- IdiPAZ Institute for Health Research, 28046 Madrid, Spain
| | - Juan M. Román-Belmonte
- Department of Physical Medicine and Rehabilitation, Cruz Roja San José y Santa Adela University Hospital, 28003 Madrid, Spain; (J.M.R.-B.)
- Medical School, Alfonso X El Sabio University, 28691 Madrid, Spain
| | - Beatriz A. Rodríguez-Damiani
- Department of Physical Medicine and Rehabilitation, Cruz Roja San José y Santa Adela University Hospital, 28003 Madrid, Spain; (J.M.R.-B.)
- Medical School, Alfonso X El Sabio University, 28691 Madrid, Spain
| | - Aránzazu Vázquez-Sasot
- Department of Physical Medicine and Rehabilitation, Cruz Roja San José y Santa Adela University Hospital, 28003 Madrid, Spain; (J.M.R.-B.)
- Medical School, Alfonso X El Sabio University, 28691 Madrid, Spain
| | - Emérito Carlos Rodríguez-Merchán
- Department of Orthopedic Surgery, La Paz University Hospital, 28046 Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research—IdiPAZ (La Paz University Hospital—Medical School, Autonomous University of Madrid), 28046 Madrid, Spain
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Abbas A, Khan Z, Veqar Z. Dose dependent effects of extracorporeal shockwave therapy on pain and function in osteonecrosis of femoral head: A systematic review. J Clin Orthop Trauma 2023; 45:102275. [PMID: 37927904 PMCID: PMC10624593 DOI: 10.1016/j.jcot.2023.102275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 09/11/2023] [Accepted: 10/21/2023] [Indexed: 11/07/2023] Open
Abstract
Purpose To investigate the effectiveness of different dosages of extracorporeal shockwave therapy (ESWT) on pain, function and radiographic outcomes in patients with osteonecrosis of femoral head (ONFH). Procedure The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analysis) guidelines were followed to conduct this review. The systematic literature search was done by using six different electronic databases include MEDLINE (assessed by Pubmed) CENTRAL (Cochrane Library Central Register of Controlled Trials), Web of Science, PEDro (Physiotherapy Evidence Database), Scopus and Science Direct. Retrospective and prospective cohort studies; case control study, randomized clinical trials were included. Screening conducted by two independent authors along with inclusion and exclusion criteria of included studies. The methodological quality assessment for cohort studies and randomized clinical trials was done by using Structured Effectiveness Quality Evaluation Scale (SEQES) and Newcastle-Ottawa Scale for case control study. Result Total 1410 articles were found from various databases. After duplicates removed 450 articles remained. Followed by title and abstract screening 53 articles eligible for full text reading, out of them 13 articles met the inclusion criteria and included in this review. Conclusion High energy flux densities of ESWT found to be more effective followed by low and moderate energy flux densities in earlier course of the disease compared to later stages in terms of pain relief, functional improvement and disease progression. Due to high variability among study design, ESWT dosages, patient characteristics and considering the paucity of well conducted studies, the present study cannot be conclusive.
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Affiliation(s)
- Ali Abbas
- Jamia Millia Islamia, Centre for Physiotherapy and Rehabilitation Sciences, New Delhi, 110025, India
| | - Zainy Khan
- Jamia Millia Islamia, Centre for Physiotherapy and Rehabilitation Sciences, New Delhi, 110025, India
| | - Zubia Veqar
- Jamia Millia Islamia, Centre for Physiotherapy and Rehabilitation Sciences, New Delhi, 110025, India
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Li S, Yu H, Long S, Li J, He Y, Zheng X, Yang S, Tang Y, Xie Q, Zheng W. Research advances in the treatment of bone marrow edema syndrome. J Clin Densitom 2023; 26:101367. [PMID: 37005106 DOI: 10.1016/j.jocd.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
Bone marrow edema syndrome (BMES) is a relatively uncommon clinical condition. It has been poorly reported in the literature. Hence, doctors are not sufficiently aware of the disease and are prone to misdiagnosis and mistreatment, which can undoubtedly prolong the course of the disease, reduce the quality of life of patients and even affect their function. This paper reviews the literature and summarizes the treatment options for bone marrow edema syndrome, such as symptomatic treatment, extracorporeal shock waves therapy (ESWT), pulsed electromagnetic fields (PEFs), hyperbaric oxygen (HBO), vitamin D, iloprost, bisphosphonates, denosumab, and surgery, etc. This informs clinicians in treating bone marrow edema syndrome, hopefully improving patients' quality of life and shortening the duration of their disease.
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Affiliation(s)
- Shihong Li
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Huimin Yu
- College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Shiwei Long
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Jian Li
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Yang He
- Chengdu Xindu District Traditional Chinese Medicine Hospital, Chengdu, China
| | - Xiaolong Zheng
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Shuang Yang
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Yingchao Tang
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Qingyun Xie
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China.
| | - Wei Zheng
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China.
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Paraskevopoulos K, Keskinis A, Vasios IS, Makiev KG, Tilkeridis K, Drosos GI, Ververidis AN. Comparison of various treatment modalities for the management of bone marrow edema syndrome/transient osteoporosis in men and non-pregnant women: a systematic review. Osteoporos Int 2023; 34:269-290. [PMID: 36370218 DOI: 10.1007/s00198-022-06584-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/20/2022] [Indexed: 11/13/2022]
Abstract
UNLABELLED Transient osteoporosis (TO) or bone marrow edema syndrome (BMES) is a self-limited clinical condition, which affects middle-aged men and women. It can be treated with miscellaneous conservative and surgical measures, which are analyzed in this systematic review. INTRODUCTION BMES/TO is a transient clinical entity, which can be treated with various therapeutic modalities. The aim of our study was to assess the efficacy of different therapeutic options for the alleviation of pain and reduction of bone marrow edema (BME) in patients with BMES/TO, as well as to propose a therapeutic algorithm. METHODS PubMed, Scopus, Cochrane, and Google Scholar were searched. Eligibility and extraction of studies were conducted by two authors. Methodological quality assessment was carried out with the modified Delphi technique, Methodological Index for Non-Randomized Studies (MINORS) criteria, and Cochrane Collaboration's risk of bias tool. Outcomes that were compared were time of pain resolution, VAS pain scores, and BME regression on magnetic resonance imaging (MRI). RESULTS A total of 36 articles (880 patients) were included. Bisphosphonates had higher efficiency in less than 1-month outcomes on pain resolution compared with core decompression (CD), while iloprost was more efficient at 1-3 months compared with bisphosphonates and CD. At 3-6 months, all three of the aforementioned showed equal results on pain resolution, and at a period of 6-12 months, CD and extracorporeal shockwave therapy (ESWT) showed excellent results followed by bisphosphonates and the conservative group (CG) consisting of non-steroidal anti-inflammatory drugs (NSAIDs) and/or analgesics and/or restricted weight bearing. On MRI at 1-3 months, bisphosphonates, iloprost, and CD had relatively the same outcomes on BME resolution, with the least promising being the CG. At 3-6 months, CD seemed to have achieved the best results on the resolution of BME, followed by ESWT, CG, and bisphosphonates group. At 6-12 months, ESWT had the best outcomes compared with the conservative, bisphosphonates, and iloprost groups. CONCLUSION BMES/TO has been treated with many non-standardized measures due to the low number of highly reliable studies. Current literature shows promising results with regard to the reduction of the clinical course of BMES/TO, but further large multicenter randomized controlled trials, as well as standardized radiological and clinical scores, are warranted to acquire evidence-based recommendations on the therapeutic algorithm.
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Affiliation(s)
- Konstantinos Paraskevopoulos
- Medical Centre of Kato Nevrokopi, Department of Orthopaedic Surgery, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece.
| | - Anthimos Keskinis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Ioannis S Vasios
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Konstantinos G Makiev
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Konstantinos Tilkeridis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Georgios I Drosos
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Athanasios N Ververidis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
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Influence of Vitamin D and C on Bone Marrow Edema Syndrome-A Scoping Review of the Literature. J Clin Med 2022; 11:jcm11226820. [PMID: 36431295 PMCID: PMC9696648 DOI: 10.3390/jcm11226820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Bone marrow edema syndrome (BMES) is a rare disease with a largely unknown etiology. The aim of this scoping review is to systematically evaluate and combine the available evidence about vitamin D and C and BMES. The analysis of the manuscripts was based on country of origin, number of patients, gender, study type, epidemiology, localization, bone mineral density measurements, vitamin status and therapy. Sixty studies were included. The overall number of patients was 823 with a male-to-female ratio of 1.55:1 and a mean age of 40.9 years. Studies were very heterogeneous and of diverging scientific scope with a weak level of evidence. The hip was the most affected joint, followed by the foot and ankle and the knee; 18.3% of patients suffered from multifocal BMES. Sixteen studies reported on vitamin D levels, resulting in a high prevalence of vitamin D deficiency (47%) and insufficiency (17.9%) among BMES patients. Three BME manuscripts were associated with vitamin C deficiency. Current therapeutic interventions include conservative measures (mainly unloading), various osteoactive drugs and iloprost. In summary, data about BMES in association with vitamin status is limited. A causal relationship between vitamin D or vitamin C status, osteopenia, and BMES cannot be determined from the existing literature.
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Evola FR, Compagnoni R, Pieroni A, Tassi A, Menon A, Randelli P. The Efficacy of Conservative Treatment of Bone Marrow Edema Syndrome: A Scoping Review of the Last Ten Years of Literature. J Clin Densitom 2022; 25:506-517. [PMID: 35987803 DOI: 10.1016/j.jocd.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 05/24/2022] [Accepted: 06/23/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE The purpose of this review was to conduct a literature search assessing the efficacy of various conservative treatments of BMES. METHODS According to the PRISMA guidelines, a literature search was conducted in April 2021 in MEDLINE database via PubMed and Embase to identify original articles describing the results of conservative treatments for BMES of hip and knee published in the last ten years. For each study, information regarding study characteristics, description of the treatment, patient's demographic and clinical data, length of follow-up, clinical outcome measure, disability, adverse events, classification, and extent and of edema on MRI, were extracted. RESULTS A total of 12 studies were identified. Two studies described treatment with iloprost, three with hyperbaric oxygen (HBO), two with bisphosphonates, five with extracorporeal shockwave therapy (ESWT). The total number of patients was 351: 34 treated with iloprost, 64 with hyperbaric oxygen, 37 with bisphosphonates, 216 with ESWT. In ESWT studies, treatment with a higher flux density and a higher number of therapy sessions lead to better clinical and radiological scores. In iloprost studies, a more remarkable improvement in the VAS scale was observed in the study on hip patients. CONCLUSIONS The treatment of idiopathic bone marrow edema is currently not standardized, making it difficult to find data that can be compared in a highly reliable way. The studies available in the literature show promising results as for the possibility to cure bone marrow edema efficiently. Standardized radiological scores for evaluating bone marrow edema area are needed in future studies.
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Affiliation(s)
- Francesco Roberto Evola
- Azienda Ospedaliera per L'Emergenza "Cannizzaro", U.O.C Ortopedia e Traumatologia, Catania. Via Messina 829, 95126 Catania
| | - Riccardo Compagnoni
- Department of Biomedical, Surgical and Dental sciences. Università degli Studi di Milano. Via della Commenda 10, 20122, Milan, Italy; 1°Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
| | - Arianna Pieroni
- 1°Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy.
| | - Alberto Tassi
- U.O.C. WEEK SURGERY di Ortopedia e Traumatologia, Azienda Socio-Sanitaria Territoriale Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
| | - Alessandra Menon
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy; 1°Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
| | - Pietro Randelli
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy; 1°Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122 Milan, Italy
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Is bone marrow oedema in patients with labral tear an indicator of hip pain? J Orthop Surg Res 2022; 17:420. [PMID: 36109781 PMCID: PMC9479299 DOI: 10.1186/s13018-022-03243-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/08/2022] [Indexed: 12/04/2022] Open
Abstract
Background Hip labral tear (LT) causes various degrees of hip pain, for which there are few objective measures. Bone marrow oedema (BME), characterized by a diffuse, widely spreading change in the bone marrow, is observed in some patients with LT. However, its pathological role has not been fully understood. The purpose of this study was to investigate the prevalence of BME on hip magnetic resonance imaging (MRI) in patients with LT and to determine whether BME was an objective indicator of hip pain. Methods In total, 84 patients with LT who underwent MRI scanning under the same conditions were included. We determined the presence or absence of BME and its size on MRI and evaluated the relationships between BME and sex, age, and pain and total scores on the modified Harris hip score (MHHS). In addition, we collected data on surgical treatments such as hip arthroscopy within a one-year follow-up period and examined whether the presence of BME affected the course of therapy. Results BME was found in 34.5% of patients. MHHS pain and total scores were significantly lower in patients with BME (MHHS pain score: non-BME vs. BME ≤ 1 cm: p = 0.022, non-BME vs. BME > 1 cm: p < 0.001; MHHS total score: non-BME vs. BME ≤ 1 cm: p = 0.131, non-BME vs. BME > 1 cm: p = 0.027). The presence of BME did not differ between patients who did and did not undergo surgery during follow-up (p = 0.563). Conclusion BME on MRI in patients with LT might be an indicator of hip pain and hip joint dysfunction.
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Sconza C, Coletta F, Magarelli N, D'Agostino MC, Egan CG, Di Matteo B, Respizzi S, Mazziotti G. Multimodal conservative treatment of migrating bone marrow edema associated with early osteonecrosis of the hip. SAGE Open Med Case Rep 2022; 10:2050313X211067617. [PMID: 35186294 PMCID: PMC8855375 DOI: 10.1177/2050313x211067617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
Bone marrow edema syndrome is a severely disabling painful condition without a defined treatment and related to pathogenetic mechanisms not yet clearly recognized. We report the case of a 59-year-old post-menopausal woman, affected by bone marrow edema associated with early osteonecrosis of the femoral head with secondary appearance of a rare migrant bone edema of the hip acetabulum. Clinical evaluation and magnetic resonance imaging were used to monitor the outcome of the patient. Pre-treatment clinical evaluation revealed pain upon stepping with the left limb, reduced range of motion of spine and hip, and hip pain during passive rotation. Magnetic resonance imaging showed diffuse signal alteration of the head and neck of the left femur in relation to bone edema, associated with an unclear small cephalic area of the femoral head suggestive of initial osteonecrosis. A further computed tomography scan was performed that did not reveal any alterations in bone profile, interruption of the cortex, or trabecular bone collapse. We immediately started a multimodal conservative treatment administering neridronate (100 mg, intravenously) combined with calcium and vitamin D supplementation and biophysical therapies (magnetotherapy and extracorporeal shockwave therapy). We also instructed the patient not to bear the load on the affected lower limb during standing and walking, using crutches. After 2 months, a notable regression of pain with improvement in mobility was observed. Magnetic resonance imaging revealed complete regression of edema at the head and neck of the femur; however, the new appearance of acetabular bone edema of the ipsilateral acetabular roof was detected. After 4 months, a third magnetic resonance imaging showed the disappearance of the femoral head and acetabular roof defects as well as the complete clinical recovery of the patient. An early diagnosis and intervention are essential to conservatively treat cases of bone marrow edema syndrome.
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Affiliation(s)
- Cristiano Sconza
- Department of Rehabilitation, IRCCS Humanitas Research Hospital, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Francesco Coletta
- Department of Rehabilitation, IRCCS Humanitas Research Hospital, Milan, Italy.,Physical Medicine and Rehabilitation School, University of Milan, Milan, Italy
| | - Nicola Magarelli
- Department of Radiology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Maria Cristina D'Agostino
- Department of Rehabilitation, IRCCS Humanitas Research Hospital, Milan, Italy.,Ortho-Rehabilitation Department, IRCCS Humanitas Research Hospital, Shock Waves Center, Milan, Italy
| | | | - Berardo Di Matteo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Traumatology, Orthopaedics and Disaster Surgery, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Stefano Respizzi
- Department of Rehabilitation, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Endocrinology, Diabetology and Andrology Unit, Metabolic Bone Diseases and Osteoporosis Section, IRCCS Humanitas Research Hospital, Milan, Italy
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Merin U, Leitner G, Jacoby S, Gilad D. Management of high cows-share-contribution of SCC to the bulk milk tank by acoustic pulse technology (APT). PLoS One 2021; 16:e0255747. [PMID: 34424932 PMCID: PMC8382164 DOI: 10.1371/journal.pone.0255747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/23/2021] [Indexed: 11/18/2022] Open
Abstract
A cow with mastitis has a high somatic cell count (SCC) in its milk. Cow-share-contribution of somatic cells to the bulk milk tank (BMTSCC) refers to the relative addition made by each cow's milk to the bulk tank's SCC. Since bulk milk is graded and priced according to the BMTSCC, high-yielding cows with mastitis are the main contributors to penalizations in milk price. The benefits of acoustic pulse technology (APT) application to tissues are well documented, including its anti-inflammatory effect and restoration of tissue function by triggering natural healing processes. An APT-based device was developed specifically for treating mastitis in dairy cows. It enables rapid and deep penetration of the acoustic pulses over a large area of the udder in a single session. A study was performed on six farms with a total of 3,900 cows. One unit of cow-share-contribution equaled the addition of 1,000 cells to each mL of the bulk milk volume above the mean BMTSCC. A total of 206 cows were selected: 103 were treated with APT and 103 served as controls. All of the cows contributed over 1.5 units to the BMTSCC at the time of treatment. Seventy-five days after APT treatment, 2 of the 103 treated cows (1.9%) were culled, compared to 19 (18.5%) of the 103 control cows, as well as infected quarter dry-off in 5 others (4.85%). Overall success was defined as a decrease of >75% in cow-share-contribution from treatment time in two of the three monthly milk recordings following treatment. Results indicated 57.3% success for the APT-treated cows vs. 14.6% for the untreated control groups. Highest share-contribution provide an additional tool for the farmer's decision of how to control BMTSCC. Because the cow-share-contribution value is relative to herd size and BMTSCC, this study included a similar number of cows, with similar SCC and milk yield from each of the six herds.
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Affiliation(s)
- Uzi Merin
- Emeritus Senior Scientist, Department of Food Quality and Safety, Institute of Postharvest and Food Sciences, The Volcani Center, Bet Dagan, Israel
| | | | - Shamay Jacoby
- Institute of Animal Science, A.R.O., The Volcani Center, Bet Dagan, Israel
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Hu Y, Jia X, Zhu Y, Xu Y, Guo M, Ma L, Su N, Jiangyue M, Zhu Y, Zhang S. The Clinical Value of Extracorporeal Shock Wave Therapy Evaluated by Contrast-Enhanced Ultrasound for Noninfectious Nonunion. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2021. [DOI: 10.1166/jmihi.2021.3652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives: The aim of this study was to investigate the clinical value of Contrast-enhanced ultrasound (CEUS) in evaluating Extracorporeal shock wave therapy (ESWT) for noninfectious nonunion. Methods: Thirty-eight patients with long bone nonunion fractures whose were
treated in our hospital from October 2016 to October 2019 were included (20 males and 18 females). The patients received ESWT once a week for 12 consecutive weeks. CEUS was performed before and after the first ESWT session. According to the ratio of the perfusion area to the callus area, neovascular
blood flow observed in CEUS was divided into 4 grades: grade 0 = 0%, grade 1 = 0–30%, grade 2 = 30–70% and grade 3 = 70–100%. The peak values of microbubbles perfusion in the callus area were recorded before and after ESWT. Each patient was followed up for 12 months to record
the healing time. Nonunion over 12 months was considered a nonhealing fracture. To compare the ultrasonic data before and after ESWT, paired T test was used and the correlation between the ultrasonic data and the nonunion healing time, the pearson analysis was used. Results:
Of the 38 patients, 35 patients achieved nonunion healing. The healing time ranged from 5 months to 12 months. Among the 38 patients, 24 patients had a microvascular health score of 0 points and 14 patients had a score of 1 point before treatment. After therapy, the neovascular health score
was 0, 1, 2 and 3 in 5, 10, 15 and 8 patients, respectively. There was a statistically significant difference before and after treatment (P < 0.05). The peak value of microbubbles perfusion in the fracture site after ESWT was significantly higher than that before ESWT (P <
0.05). The greater of difference, the shorter of healing time. Conclusion: Under the supervision of CEUS, the changes in microvascular perfusion of noninfectious nonunion patients before and after ESWT effectively reflected the therapeutic effect. CEUS could predict the ESWT on bone
nonunion at an early stage. Level of evidence: Level III.
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Affiliation(s)
- Yinfeng Hu
- Department of Ultrasound, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Xuewen Jia
- Department of Orthopaedic Surgery, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Yingchun Zhu
- Department of Orthopaedic Surgery, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Youfeng Xu
- Department of Ultrasound, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Minhua Guo
- Department of Ultrasound, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Ling Ma
- Department of Ultrasound, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Nan Su
- Department of Ultrasound, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Mingming Jiangyue
- Department of Ultrasound, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Yufeng Zhu
- Department of Orthopaedic Surgery, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
| | - Shengmin Zhang
- Department of Ultrasound, Ningbo First Hospital, No. 59, Liuting Street, Haishu District, Ningbo, 315010, China
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Cao J, Zhang C, Huang H, Yang L, Duan X. Bone Marrow Edema Syndrome of the Foot Treated with Extracorporeal Shock Wave Therapy: A Retrospective Case Series. J Foot Ankle Surg 2021; 60:523-528. [PMID: 33573900 DOI: 10.1053/j.jfas.2020.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 09/26/2020] [Accepted: 10/02/2020] [Indexed: 02/07/2023]
Abstract
To determine the validity and safety of extracorporeal shock wave therapy (ESWT) in the treatment of bone marrow edema syndrome (BMES) of the foot. Twenty patients diagnosed as foot BMES in our Center were followed and treated by ESWT for 1 to 2 courses. The target of the ESWT treatment was the most obvious foot tenderness, or the most obvious part of bone edema on magnetic resonance imaging (MRI). One course of ESWT was 1 time/week, 5 times in total, with the shock wave energy flow density 0.18 mJ/mm2. The visual analog scale (VAS) and the American Orthopedic Foot and Ankle Society (AOFAS) scores of the foot were recorded before treatment, at 3 months after treatment and the last follow-up; the areas of BME before treatment and at the last follow-up were measured by the fat suppression MRI. Complications during treatment were also recorded. Twenty follow-up patients were obtained. Compared with the pretreatment, the patients had significant improvement in various indicators at 3 months after treatment (p < 0.01). The sagittal MRI at the last follow-up showed that the BME area decreased significantly (p < 0.01). Two patients developed transient erythema on their skin after treatment and alleviated after 2 days of rest. No serious complications were found during treatment. Our findings show that for patients with foot BMES, the use of ESWT treatment can effectively relieve local pain, improve the motor function of the foot and ankle. Two courses of treatment may be required for some patients.
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Affiliation(s)
- Jin Cao
- Surgeon, Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Changgui Zhang
- Surgeon, Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Heqin Huang
- Nurse, Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Liu Yang
- Professor, Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiaojun Duan
- Associate Professor, Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Häußer J, Wieber J, Catalá-Lehnen P. The use of extracorporeal shock wave therapy for the treatment of bone marrow oedema - a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:369. [PMID: 34107978 PMCID: PMC8188716 DOI: 10.1186/s13018-021-02484-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Extracorporeal shock wave therapy (ESWT) has been used for various pathologies associated with bone marrow oedema (BME). However, it is still not clear whether ESWT may be favourable in the treatment of BME. Therefore, the aim of this systematic review was to assess the efficacy of ESWT for the treatment of BME. METHODS MEDLINE was searched for relevant literature with no time constraints. Both randomized and non-randomized trials were included. Case reports and conference abstracts were excluded. Titles and abstracts were screened and full-text articles of included studies were retrieved. Data on the effect of ESWT on pain, function, and the BME area on magnet resonance imaging were extracted. RESULTS Pain, function, and magnet resonance imaging results all improved across the studies - regardless of whether it was a randomized or non-randomized study. This effect was consistent across multiple pathologies such as osteonecrosis of the femoral head, BME associated with knee osteoarthritis, Kienböck's disease, and osteitis pubis. The meta-analysis showed that pain (after 1 month: weighted mean difference (WMD) = - 2.23, 95% CI - 2.58 to - 1.88, P < 0.0001; after 3-6 month: WMD = - 1.72, 95% CI - 2.52 to - 0.92, P < 0.00001) and function (after 1 month: WMD = - 1.59, 95% CI - 2.04 to - 1.14, P < 0.0001; after 3-6 month: WMD = - 2.06, 95% CI - 3.16 to - 0.96, P = 0.0002; after ≥ 12 month: WMD = - 1.20, 95% CI - 1.83 to - 0.56, P = 0.0002) was reduced in terms of ESWT treatment compared to a control group. CONCLUSIONS Based on the available evidence, ESWT may be an adequate option for conservative therapy in pathologies involving BME. TRIAL REGISTRATION PROSPERO, CRD42021201719 . Registered 23 December 2020.
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Affiliation(s)
- Jonathan Häußer
- LANS Medicum Hamburg — Center for Sports and Regenerative Medicine, Stephansplatz 5, 20354 Hamburg, Germany
| | - Juliane Wieber
- LANS Medicum Hamburg — Center for Sports and Regenerative Medicine, Stephansplatz 5, 20354 Hamburg, Germany
- LANS Medicum Hamburg — Center for Sports and Regenerative Medicine, Hohe Bleichen 24/26, 20354 Hamburg, Germany
| | - Philip Catalá-Lehnen
- LANS Medicum Hamburg — Center for Sports and Regenerative Medicine, Stephansplatz 5, 20354 Hamburg, Germany
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Wang YC, Huang HT, Huang PJ, Liu ZM, Shih CL. Efficacy and Safety of Extracorporeal Shockwave Therapy for Treatment of Knee Osteoarthritis: A Systematic Review and Meta-analysis. PAIN MEDICINE 2021; 21:822-835. [PMID: 31626282 DOI: 10.1093/pm/pnz262] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The objective of this study was to assess the efficacy and safety of extracorporeal shockwave therapy (ESWT) for treatment of knee osteoarthritis (OA) using a systemic review and meta-analysis. METHODS An extensive search of relevant articles from electronic databases Pubmed, Embase, and Cochrane Library from inception to March 2019 was conducted. The treatment outcomes (visual analog scale [VAS] and the Western Ontario and McMaster Universities Arthritis Index [WOMAC]) of the included articles were pooled to calculate effect sizes. The assessment of heterogeneity among articles was evaluated using I2. Statistical analyses were conducted using RevMan software. RESULTS The results showed that the ESWT group had significant improvement in pain relief compared with the control group through 12 months based on WOMAC and VAS scores. Compared with the baseline level, the patients had significant improvement in pain relief at most follow-up points (one week to 12 months) based on WOMAC and VAS scores. The patients showed significant improvement in physical function at six- and 12-month follow-up when compared with the control group and for all follow-up (one to 12 months) when compared with the baseline level. Additionally, only minor complications were observed after ESWT treatment. CONCLUSIONS The use of ESWT for treatment of knee OA had a beneficial effect on pain relief and physical function improvement for up to 12 months, and only minor complications occurred after ESWT treatment. However, there remains a lack of clarity regarding the frequency and dosage levels of ESWT required to achieve the maximum improvement.
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Affiliation(s)
- Ying-Chun Wang
- Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsuan-Ti Huang
- Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Peng-Ju Huang
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Zi-Miao Liu
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Lung Shih
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Zhao W, Gao Y, Zhang S, Liu Z, He L, Zhang D, Li W, Meng Q. Extracorporeal shock wave therapy for bone marrow edema syndrome in patients with osteonecrosis of the femoral head: a retrospective cohort study. J Orthop Surg Res 2021; 16:21. [PMID: 33413520 PMCID: PMC7791851 DOI: 10.1186/s13018-020-02159-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is now ample evidence suggesting that extracorporeal shock wave therapy (ESWT) can improve hip mobility and reduce pain in patients with osteonecrosis of the femoral head (ONFH). The ability of ESWT to cure bone marrow edema syndrome (BMES) in patients with ONFH, 12 weeks after the initial course of ESWT, needs to be verified further and more relevant clinical research-based evidence should be consolidated. This study aimed to evaluate the efficacy of ESWT for BMES caused by ONFH. METHODS This retrospective cohort study included 67 patients with BMES caused by ONFH who were participating in a rehabilitation program as outpatients. Before and after ESWT, the area of femoral bone marrow edema was evaluated by magnetic resonance imaging (MRI), and the Harris score and Charnley score were evaluated as hip pain and function indicators. RESULTS After ESWT, MRI revealed that the area of bone marrow edema decreased from 984.6 ± 433.2 mm2 to 189.7 ± 214.4 mm2 (P < 0.0001). The Harris score increased from 42.2 ± 9.1 to 77.7 ± 10.8 points (P < 0.0001). The Charnley score increased from 7.3 ± 1.4 to 12.0 ± 1.7 (P < 0.0001). ESWT was effective in treating BMES in 98.5% of the cases. CONCLUSIONS This study demonstrated that ESWT can effectively treat BMES caused by ONFH and can aid in pain relief and functional recovery in patients with ONFH. Thus, ESWT should be included in the classic physical therapy regimen for patients with ONFH and BMES.
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Affiliation(s)
- Wenyi Zhao
- Harbin Medical University, Harbin, China.,Bone and Joint Surgery Department, First Hospital of Suihua City, Suihua, China
| | - Yuan Gao
- Bone and Joint Surgery Department, Pinghu Hospital Affiliated to Shenzhen University, Shenzhen, China
| | - Shouxiang Zhang
- Bone and Joint Surgery Department, Harbin City Hospital No. 1 Affiliated to Harbin Technical University, Harbin, China
| | - Zhang Liu
- Bone and Joint Surgery Department, First Hospital of Suihua City, Suihua, China
| | - Lin He
- Bone and Joint Surgery Department, First Hospital of Suihua City, Suihua, China
| | - Dahong Zhang
- Bone and Joint Surgery Department, First Hospital of Suihua City, Suihua, China
| | - Wei Li
- Bone and Joint Surgery Department, Harbin City Hospital No. 1 Affiliated to Harbin Technical University, Harbin, China.
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Abstract
Extracorporeal shock wave therapy (ESWT) is a safe therapy and there are only a few side effects known (such as pain during ESWT and minor haematomata), but no severe complications are to be expected if it is performed as recommended. Contraindications are severe coagulopathy for high-energy ESWT, and ESWT with focus on the foetus or embryo and focus on severe infection. The effect mechanism of ESWT is still a component of diverse studies, but as far as we can summarize today, it is a similar process to a cascade triggered by mechano-transduction: mechanical energy causes changes in the cellular skeleton, which provokes a reaction of the cell core (for example release of mRNA) to influence diverse cell structures such as mitochondria, endoplasmic reticulum, intracellular vesicles, etc., so the enzymatic response leads to the improvement of the healing process. The usage of ESWT should be taught, to improve the outcome. Courses should be organized by national societies, since the legal framework conditions are different from one country to another. In this update the musculoskeletal indications are addressed (mainly bone and tendons): pseudoarthrosis, delayed fracture healing, bone marrow oedema and osteonecrosis in its early stages, insertional tendinopathies such as plantar fasciitis and Achilles tendon fasciitis, calcifying tendonitis of the rotator cuff, tennis elbow, and wound healing problems.
Cite this article: EFORT Open Rev 2020;5:584-592. DOI: 10.1302/2058-5241.5.190067
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Affiliation(s)
- Vinzenz Auersperg
- Department of Orthopaedics, Klinikum Steyr-Kirchdorf, Steyr, Austria
| | - Klemens Trieb
- Department of Orthopaedic and Trauma Surgery, Paracelsus Medical University Salzburg, Salzburg, Austria.,Computed Tomography Research Group, University of Applied Sciences Upper Austria, Wels, Austria
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Al-Abbad H, Allen S, Morris S, Reznik J, Biros E, Paulik B, Wright A. The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression. BMC Musculoskelet Disord 2020; 21:275. [PMID: 32345281 PMCID: PMC7189454 DOI: 10.1186/s12891-020-03270-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Shockwave therapy (SWT) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes. However, the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear. The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT. METHODS A comprehensive search of Medline, Embase, Cochrane Controlled Trials Register, CINAHL and SportDiscus was conducted from inception to October 2018. Prospective clinical trials evaluating the effectiveness of SWT based on changes in imaging outcomes were eligible for inclusion. Articles were evaluated independently for risk of bias using the Cochrane Risk of Bias list and the Methodological Index for Non-Randomized Studies. Random-effects meta-analysis and meta-regression with a priori determined covariates was conducted for each condition to determine potential predictors of SWT effects. RESULTS Sixty-three studies were included, with data from 27 studies available for effect size pooling. Meta-analyses and meta-regression on imaging outcomes were performed for rotator cuff calcific tendinitis (n = 11), plantar fasciitis (n = 7) and osteonecrosis of the femoral head (n = 9). There was an overall reduction in the size of measured lesion following SWT (MD 8.44 mm (95%CI -4.30, 12.57), p < 0.001) for calcium deposit diameter, (MD 0.92 mm (95%CI -0.03, 1.81), p = 0.04) for plantar fascia thickness and (MD 4.84% (95%CI -0.06, 9.75), p = 0.05) for lesion size in femoral head osteonecrosis. Meta-regression showed no influence of SWT dosage parameters, however, baseline lesion size was an independent predictor for changes in imaging outcomes. CONCLUSIONS SWT altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of SWT dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review. Registration number: PROSPERO CRD42018091140.
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Affiliation(s)
- Hani Al-Abbad
- School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA Australia
- Physical Therapy department, Rehabilitation hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sophie Allen
- School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA Australia
| | - Susan Morris
- School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA Australia
| | - Jackie Reznik
- College of Healthcare Science and Division of Tropical Health and Medicine, James Cook University, Townsville, QLD Australia
| | - Erik Biros
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | | | - Anthony Wright
- School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA Australia
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Zhang L, Cui Y, Liang D, Guan J, Liu Y, Chen X. High-energy focused extracorporeal shock wave therapy for bone marrow edema syndrome of the hip: A retrospective study. Medicine (Baltimore) 2020; 99:e19747. [PMID: 32311970 PMCID: PMC7220451 DOI: 10.1097/md.0000000000019747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The objective of this retrospective study was to evaluate the efficacy of high-energy focused extracorporeal shock wave therapy (HF-ESWT) on painful bone marrow edema syndrome (BMES) of the hip and shorten the natural course of disease.Thirty-four consecutive patients with BMES of the hip were treated with HF-ESWT in our department between August 2017and July 2018. The progression and treatment results of BMES were evaluated by imaging examination and clinical outcomes. The clinical outcomes include hip pain and function which were measured using the visual analog scale (VAS) and Harris hip score (HHS), respectively, and the VAS and HHS of all patients were calculated and evaluated before treatment (s0), at 1 month (s1), 3 months (s2), 6 months (s3)post-treatment. Imaging examination including Pelvic radiographs and frog views and double hip magnetic resonance imaging (MRI) were also obtained and scheduled before treatment, at 1, 3, 6, and the final follow-up post-treatment to exclude avascular necrosis and other pathology.All patients successfully completed the treatment and follow-up. Compared with pretherapy, the pain was alleviated to varying degrees and the HHS was significantly improved, and the VAS was significantly reduced at S1-2 (1- and 3-months post-treatment) after therapeutic intervention (P < .05). The mean improvements were strongly statistically significant between S0 and S1 and between S1 andS2 (P < .0001) and less significant between S2 and S3 (P < .01). The mean improvement between 6 months (S3) and final follow-up (more than 12 months) was not statistically significant. The MRI findings demonstrated that the diffuse BMES in the femoral head and neck disappeared completely.HF-ESWT is a safe, effective, reliable, and noninvasive treatment in patients with painful BMES of the hip, and it can accelerate the recovery of BMES of the hip, shorten the treatment time and course of disease, improve hip joint function and the quality of life of patients.
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Sansone V, Maiorano E, Pascale V, Romeo P. Bone marrow lesions of the knee: longitudinal correlation between lesion size changes and pain before and after conservative treatment by extracorporeal shockwave therapy. Eur J Phys Rehabil Med 2019; 55:225-230. [DOI: 10.23736/s1973-9087.18.05036-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bayesian Network Meta-Analysis of the Effectiveness of Various Interventions for Nontraumatic Osteonecrosis of the Femoral Head. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2790163. [PMID: 30175121 PMCID: PMC6106725 DOI: 10.1155/2018/2790163] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 07/26/2018] [Indexed: 12/28/2022]
Abstract
Objective To assess the effectiveness of various therapeutic hip preservation strategies on patients with nontraumatic osteonecrosis of the femoral head (ONFH). Design This is a systematic review of previous literature and in-depth Bayesian network meta-analysis of randomized controlled trials (RCTs) to compare the clinical effect of various operation methods and one physical intervention (extracorporeal shockwave). Data Sources Electronic literature, for studies published up to December 2017, was collected from PubMed, Medline, and the Cochrane Library. Study Selection We selected RCTs on patients with ONFH. Treatment methods included extracorporeal shockwave (ESW), core decompression (CD), multiple drilling decompression (DD), vascularized fibular grafting (VFG), free-vascularized fibular grafting (FVFG), inverted femoral head grafting (IFHG), vascular iliac pedicle bone grafting (VIPBG), osteotomy, and tantalum implantation (TI). Outcome The primary outcome was Harris score; the secondary outcome was Harris hip score (HHS), including total hip arthroplasty requirement (THA) and progression to collapse. Results A total of 14 randomized controlled trials were investigated. ESW had the highest improvement on Harris score (probability best 52%), followed by VFG (probability was 38%). In the meanwhile, VFG also proved to be superior in reducing the failure rates of treatment (probability lowest 59%), followed by ESW (probability lowest 24%). In femoral necrosis stage-II, VFG achieved the highest probability in preventing treatment failures (52%) and showed better performance in reducing treatment failure rates than CD. Conclusion ESW therapy (ESWT) is the most effective intervention to improve HHS, and VFG shows superior effect on reducing treatment failure rates.
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Bone remodeling induced by mechanical forces is regulated by miRNAs. Biosci Rep 2018; 38:BSR20180448. [PMID: 29844019 PMCID: PMC6028748 DOI: 10.1042/bsr20180448] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/13/2018] [Accepted: 05/25/2018] [Indexed: 12/14/2022] Open
Abstract
The relationship between mechanical force and alveolar bone remodeling is an important issue in orthodontics because tooth movement is dependent on the response of bone tissue to the mechanical force induced by the appliances used. Mechanical cyclical stretch (MCS), fluid shear stress (FSS), compression, and microgravity play different roles in the cell differentiation and proliferation involved in bone remodeling. However, the underlying mechanisms are unclear, particularly the molecular pathways regulated by non-coding RNAs (ncRNAs) that play essential roles in bone remodeling. Amongst the various ncRNAs, miRNAs act as post-transcriptional regulators that inhibit the expression of their target genes. miRNAs are considered key regulators of many biologic processes including bone remodeling. Here, we review the role of miRNAs in mechanical force-induced bone metabolism.
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Kang S, Gao F, Han J, Mao T, Sun W, Wang B, Guo W, Cheng L, Li Z. Extracorporeal shock wave treatment can normalize painful bone marrow edema in knee osteoarthritis: A comparative historical cohort study. Medicine (Baltimore) 2018; 97:e9796. [PMID: 29384878 PMCID: PMC5805450 DOI: 10.1097/md.0000000000009796] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Bone marrow edema (BME) represents a reversible but highly painful finding in magnetic resonance imaging (MRI) of patients with knee osteoarthritis. The aim of this retrospective study was to evaluate the efficacy of extracorporeal shock wave treatment (ESWT) on painful BME in osteoarthritis of the knee.This study focuses on people who had early-to-mid stage osteoarthritis with knee pain and MRI findings of BME. Patients who underwent ESWT treatment or prescribed alendronate treatment in our department were analyzed. Knee pain and function were measured using the visual analog scale (VAS) for pain and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), respectively. The degree of BME was measured with MRI scans.A total of 126 patients who received ESWT treatment (Group A, n = 82) or alendronate treatment (Group B, n = 44) were included. All patients were followed up clinically and radiographically for a minimum of 12 months. The mean follow-up was 23.5 months (range, 12-38 months). The VAS and WOMAC score decreased more significantly after treatment in Group A than that in Group B (P <.01) within 3 months. In 6-month MRI follow-ups, there was higher incidence of distinct reduction and complete regression of BME of the affected knee in Group A than that in Group B (P <.01).ESWT is an effective, reliable, and noninvasive treatment in patients with painful BME in osteoarthritis of the knee followed by a rapid normalization of the MRI appearance. It has the potential to shorten the natural course of this disease.
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Affiliation(s)
| | - Fuqiang Gao
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Jun Han
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Tianli Mao
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Wei Sun
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Bailiang Wang
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Wanshou Guo
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Liming Cheng
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Zirong Li
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
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Bone Marrow Edema Syndrome of the Medial Femoral Condyle Treated With Extracorporeal Shock Wave Therapy: A Clinical and MRI Retrospective Comparative Study. Arch Phys Med Rehabil 2017; 99:873-879. [PMID: 29223709 DOI: 10.1016/j.apmr.2017.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/26/2017] [Accepted: 10/26/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the validity of extracorporeal shock wave therapy (ESWT) in the treatment of bone marrow edema (BME) of the medial condyle of the knee. DESIGN Retrospective. SETTING Orthopedic Surgery outpatient clinic. PARTICIPANTS Symptomatic patients (N=56) affected by BME of the medial condyle of the knee. Patients were equally divided into an ESWT-treated group and a control group, which was managed conservatively. INTERVENTIONS ESWT delivery to the medial condyle of the affected knee. MAIN OUTCOME MEASURES Clinical and functional assessment of the knee was performed with the use of the clinical and functional scores of the Knee Society Score (KSS). Pain was measured with the visual analog scale (VAS). BME area was measured with magnetic resonance imaging (MRI) before treatment and at 4 months' follow-up. RESULTS Clinical evaluation of patients at final follow-up of 4 months posttreatment showed a significant improvement (P<.0001) of symptoms and knee functionality, both for range of motion and strength in both groups. VAS values were significantly improved (P<.0001) in both groups, with 3 patients in the ESWT group being pain-free (VAS=0) at 4 months' follow-up. At 4 months, MRI assessments on both sagittal and coronal views showed a significant reduction in BME in the ESWT group compared with the control group. CONCLUSIONS Our findings show that ESWT is a valid nonpharmacologic and noninvasive therapy for spontaneous BME of the medial condyle that improves the affected vascular and metabolic state present in this pathologic disorder through its metabolic mechanisms of action.
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Abstract
Bone marrow oedema (BME) is commonly found in hip MR imaging. BME is a nonspecific finding which can be related to a wide variety of diseases. However, there are cases where its existence or its pattern can narrow the differential or even point to a specific diagnosis. Therefore, deep understanding of its pathophysiology is of utmost importance for clinicians and radiologists in order to avoid diagnostic pitfalls. We hereby present currently established knowledge on BME related to adult hip pathology, aiming to raise physicians' suspicion and to highlight that it is mandatory to combine specific imaging patterns with the history, clinical and laboratory findings in order to achieve accurate diagnosis.
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Denosumab is effective in the treatment of bone marrow oedema syndrome. Injury 2017; 48:874-879. [PMID: 28242067 DOI: 10.1016/j.injury.2017.02.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/30/2017] [Accepted: 02/21/2017] [Indexed: 02/02/2023]
Abstract
Bone marrow oedema (BMO) syndrome describes a painful condition with increase of interstitial fluid within bone and is often lately diagnosed due to unspecific symptoms. The underlying causes are diverse while it is widely assumed that in cases of BMO local bone resorption is increased. Denosumab, a human monoclonal antibody that binds to the receptor activator of nuclear factor kappa-B ligand (RANKL) inhibits osteoclastic bone resorption and is commonly administered in the treatment of osteoporosis. Besides one previous case report, its clinical effectiveness in the treatment of bone marrow oedema has not been elucidated. We treated 14 patients with primary (idiopathic) bone marrow oedema of the lower extremity with single dose denosumab application. Mean time between onset of pain and therapy was 155days. MRI scans were performed for initial diagnosis, and 6-12 weeks after denosumab injection. Vitamin D and calcium homeostasis were strived to be balanced before initiation of therapy. Furthermore bone status was analysed using Dual-energy X-ray absorptiometry (DXA) and extended bone turnover serum markers. After 6-12 weeks, BMO dissolved partly or completely in 93%, while a complete recovery was observed in 50% of the individuals. Visual analogue scale (VAS) evaluation revealed a significant decrease in pain level. Furthermore, bone turnover decreased significantly after treatment. No adverse reactions were reported. In conclusion, our retrospective analysis shows that denosumab is highly effective in the treatment of bone marrow oedema and therefore represents an alternative treatment option.
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Sansone V, Romeo P, Lavanga V. Extracorporeal Shock Wave Therapy Is Effective in the Treatment of Bone Marrow Edema of the Medial Compartment of the Knee: A Comparative Study. Med Princ Pract 2017; 26:23-29. [PMID: 27784022 PMCID: PMC5588340 DOI: 10.1159/000452836] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 10/25/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To test the hypothesis that shock wave therapy can produce a statistically significant improvement in symptoms and imaging features of the knee bone marrow edema syndrome (BMES) within 6 months of treatment. SUBJECTS AND METHODS Eighty-six consecutive patients suffering from BMES of the medial compartment of the knee were prescribed a course of high-energy extracorporeal shock wave therapy (ESWT) and clinically followed up at 3 and 6 months and finally from 14 to approximately 18 months after treatment. Thirty-one patients were unable to undergo ESWT but returned for the 6-month and final follow-up; these were referred to as the conservative (control) group, while the other 55 patients constituted the ESWT group. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Visual Analog Scale (VAS) score of each patient were calculated at every follow-up. The BME area was assessed using magnetic resonance imaging before treatment and at the 6-month follow-up. RESULTS Statistically significant improvements were observed in clinical scores and in the BME area for both the ESWT and the control group (p < 0.05). The improvements in the ESWT group were statistically better in all parameters compared with the control group: the ESWT group had a reduction in the BME area of 86% versus 41% in the control group, the VAS pain score improved by 88% in the ESWT group versus 42% in the control group, and the WOMAC score improved by 65% in the ESWT group versus 22% in the control group. Clinical scores were significantly better for patients with medial tibial lesions in the ESWT group. CONCLUSION In this study, ESWT reduced pain and the BME area in the knee, with significant clinical improvement noticed 3 months after treatment.
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Affiliation(s)
- Valerio Sansone
- Department of Orthopedics, Università degli Studi di Milano, Milan, Italy
- Istituto Ortopedico Galeazzi IRCCS, Milan, Italy
- *Valerio Sansone, MD, Istituto Ortopedico Galeazzi IRCCS, Via Riccardo Galeazzi 4, IT–20161 Milano (Italy), E-Mail
| | - Pietro Romeo
- Istituto Ortopedico Galeazzi IRCCS, Milan, Italy
| | - Vito Lavanga
- Department of Orthopedics, Università degli Studi di Milano, Milan, Italy
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Haugen AJ, Rashid HU, Hasvik E, Gleditsch J, Grøvle L. [A man in his 40s with pain in his right thigh and knee]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1553-1555. [PMID: 27731601 DOI: 10.4045/tidsskr.15.1151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Gao F, Sun W, Li Z, Guo W, Wang W, Cheng L, Yue D, Zhang N, Savarin A. Extracorporeal shock wave therapy in the treatment of primary bone marrow edema syndrome of the knee: a prospective randomised controlled study. BMC Musculoskelet Disord 2015; 16:379. [PMID: 26637992 PMCID: PMC4670725 DOI: 10.1186/s12891-015-0837-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 11/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this prospective study was to evaluate the effectiveness of extracorporeal shock wave therapy (ESWT) in normalizing the symptoms and imaging features of primary bone marrow edema syndrome (BMES) of the knee. METHODS This study compared the outcomes of ESWT (Group A) (n = 20) and intravenously applied prostacyclin and bisphosphonate (Group B) (n = 20) in the treatment of BMES of the knee in our department between 2011 and 2013. The Visual Analog Scale for pain (VAS, 100 mm), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), the SF-36 scores and MRI scans as well as plain radiographs were obtained before and after therapy between two groups. RESULTS Compared with Group B, we found greater improvement in VAS, the WOMAC Osteoarthritis Index and SF-36 score at 1, 3 and 6 months post-treatment in Group A (P < 0.05). Furthermore, MRI scans showed a higher incidence of distinct reduction and complete regression of bone marrow edema at 6 months in Group A (95 vs. 65 %; P = 0.018). The MRI at 1 year follow-up showed complete regression in all patients in Group A. However, two cases in Group B continued to normalize over the subsequent follow-up period. CONCLUSIONS ESWT can produce rapid pain relief and functional improvement. It may be an effective, reliable, and non-invasive technique for rapid treatment of BMES of the knee. TRIAL REGISTRATION Research Registry UIN 528, September 03, 2015.
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Affiliation(s)
- Fuqiang Gao
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China. .,Department of Orthopedic Surgery, China Japan Friendship Hospital, Beijing, 100029, China.
| | - Wei Sun
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China. .,Department of Orthopedic Surgery, China Japan Friendship Hospital, Beijing, 100029, China.
| | - Zirong Li
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Wanshou Guo
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Weiguo Wang
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Liming Cheng
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Debo Yue
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Nianfei Zhang
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Amanda Savarin
- Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Department of Orthopedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China.
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Current concepts of shockwave therapy in stress fractures. Int J Surg 2015; 24:195-200. [DOI: 10.1016/j.ijsu.2015.07.723] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/26/2015] [Indexed: 12/20/2022]
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Shock wave as biological therapeutic tool: From mechanical stimulation to recovery and healing, through mechanotransduction. Int J Surg 2015; 24:147-53. [PMID: 26612525 DOI: 10.1016/j.ijsu.2015.11.030] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/28/2015] [Accepted: 11/09/2015] [Indexed: 02/07/2023]
Abstract
Extracorporeal Shock Wave Therapy (ESWT) is a form of "mechanotherapy", that, from its original applications as urological lithotripsy, gained the field of musculo-skeletal diseases as Orthotripsy (mainly tendinopaties and bone regenerative disorders) and Regenerative Medicine as well. The mechanisms of action of Shock Waves (SW), when applied in non-urological indications, are not related to the direct mechanical effect, but to the different pathways of biological reactions, that derive from that acoustic stimulations, through "mechano-transduction". So, the "mechanical model" of urological lithotripsy has been substituted by a "biological model", also supported by current knowledge in "mechanobiology", the emerging multidisciplinary field of science that investigates how physical forces and changes in cell/tissue mechanics can influence the tissue development, physiology and diseases. Although some details are still under study, it is known that SW are able to relief pain, as well to positively regulate inflammation (probably as immunomodulator), to induce neoangiogenesis and stem cells activities, thus improving tissue regeneration and healing. ESWT can be nowadays considered an effective, safe, versatile, repeatable, noninvasive therapy for the treatment of many musculo-skeletal diseases, and for some pathological conditions where regenerative effects are desirable, especially when some other noninvasive/conservative therapies have failed. Moreover, based on the current knowledge in SW mechanobiology, it seems possible to foresee new interesting and promising applications in the fields of Regenerative Medicine, tissue engineering and cell therapies.
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Eriksen EF. Treatment of bone marrow lesions (bone marrow edema). BONEKEY REPORTS 2015; 4:755. [PMID: 26644910 PMCID: PMC4662576 DOI: 10.1038/bonekey.2015.124] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/07/2015] [Indexed: 11/09/2022]
Abstract
Bone marrow lesions (BMLs) or using older terminology 'Bone marrow edema' is characterised by excessive water signals in the marrow space on magnetic resonance imaging or ultrasound; BMLs constitute a central component of a wide variety of inflammatory and non-inflammatory rheumatologic conditions affecting the musculoskeletal system: BMLs are not only considered significant sources of pain but also linked to increased disease activity in many musculoskeletal conditions (for example, osteoarthritis, rheumatoid arthritis). The purpose of this review is to summarise current knowledge about the treatment of BMLs, with an emphasis on the clinical and histological features of this entity in inflammatory and non-inflammatory disease. We also try to pair this hypothesis with the apparent beneficial effects of various treatment regimens, mainly within the group of bone antiresorptive drugs (calcitonin, bisphosphonates) on symptoms associated with BMLs.
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Affiliation(s)
- Erik F Eriksen
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
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