The Use of Shock Waves in Peripheral Nerve Regeneration

Emerging role of extracellular vesicles and exogenous stimuli in molecular mechanisms of peripheral nerve regeneration

Peripheral nerve injuries lead to significant morbidity and adversely affect quality of life. The peripheral nervous system harbors the unique trait of autonomous regeneration; however, achieving successful regeneration remains uncertain. Research continues to augment and expedite successful peripheral nerve recovery, offering promising strategies for promoting peripheral nerve regeneration (PNR). These include leveraging extracellular vesicle (EV) communication and harnessing cellular activation through electrical and mechanical stimulation. Small extracellular vesicles (sEVs), 30-150 nm in diameter, play a pivotal role in regulating intercellular communication within the regenerative cascade, specifically among nerve cells, Schwann cells, macrophages, and fibroblasts. Furthermore, the utilization of exogenous stimuli, including electrical stimulation (ES), ultrasound stimulation (US), and extracorporeal shock wave therapy (ESWT), offers remarkable advantages in accelerating and augmenting PNR. Moreover, the application of mechanical and electrical stimuli can potentially affect the biogenesis and secretion of sEVs, consequently leading to potential improvements in PNR. In this review article, we comprehensively delve into the intricacies of cell-to-cell communication facilitated by sEVs and the key regulatory signaling pathways governing PNR. Additionally, we investigated the broad-ranging impacts of ES, US, and ESWT on PNR.

Local corticosteroid injection versus physical therapy for the treatment of carpal tunnel syndrome: A systematic review and meta-analysis of randomized controlled trials

The comparative effect of commonly used conservative treatments for carpal tunnel syndrome remained controversial. The purpose of this study was to compare the clinical effect of local corticosteroid injection and physical therapy for the treatment of carpal tunnel syndrome. A systematic literature search of PubMed, EMBASE, and Cochrane library was conducted to identify relevant randomized clinical trials published before 21st Mar 2023. Two independent reviewers assayed quality of included studies using the Cochrane collaboration risk of bias tool. Relevant data were extracted and pooled analyses were conducted. Outcome measurements included Boston Carpal Tunnel Syndrome Questionnaire, visual analogue scale and some electrophysiology tests, while the former two were set as the primary outcomes. Subgroup analysis and sensitive analysis were performed and publication bias was evaluated. Heterogeneity among the included studies was examined using the I2 statistic. After selection, 12 studies were identified eligibility for inclusion. Only one study was found to have a high risk of bias. Pooled data of primary outcomes did not show any differences between treatments, and subgroup analysis supported the results. However, patients treated with local corticosteroid injection showed better improvement in distal motor latency (p = 0.002) and compound muscle action potential (p = 0.04). Some studies failed to pass the sensitive analysis, indicating the related analysis might be not so stable. A slight publication bias was observed in subgroup analysis of function scales, among three publication bias test. In conclusion, compared to physical therapy, local corticosteroid injection might have better treatment effects on carpal tunnel syndrome.

Electrophysiological assessment of radial shock wave therapy for carpal tunnel syndrome

This study presents an electrophysiological assessment of radial extracorporeal shock wave therapy on patients with carpal tunnel syndrome (CTS). Sixteen CTS subjects received radial extracorporeal shock wave therapy once a week for five consecutive weeks. Outcome performance was assessed using the Boston Carpal Tunnel Questionnaire (BCTQ) and electrodiagnostic measurements including a nerve conduction study of the median nerve and a compound muscle action potential (CMAP) scan of the abductor pollicis brevis muscle. The BCTQ and the sensory conduction test measurements were all statistically improved after the treatment. However, the motor conduction test measurements were not significantly different before and after the treatment. The CMAP scan examination revealed MScanFit motor unit number estimation (MUNE) was significantly higher after the treatment, while no significant change was found in StairFit MUNE and step index. These results confirmed the effectiveness of shock wave therapy for treating CTS symptoms and the associated sensory property changes. The reasons for the inconsistencies from different CMAP scan processing methods are worthwhile targets for further investigation.

ESWT Diminishes Axonal Regeneration following Repair of the Rat Median Nerve with Muscle-In-Vein Conduits but Not after Autologous Nerve Grafting

Investigations reporting positive effects of extracorporeal shockwave therapy (ESWT) on nerve regeneration are limited to the rat sciatic nerve model. The effects of ESWT on muscle-in-vein conduits (MVCs) have also not been investigated yet. This study aimed to evaluate the effects of ESWT after repair of the rat median nerve with either autografts (ANGs) or MVCs. In male Lewis rats, a 7 mm segment of the right median nerve was reconstructed either with an ANG or an MVC. For each reconstructive technique, one group of animals received one application of ESWT while the other rats served as controls. The animals were observed for 12 weeks, and nerve regeneration was assessed using computerized gait analysis, the grasping test, electrophysiological evaluations and histological quantification of axons, blood vessels and lymphatic vasculature. Here, we provide for the first time a comprehensive analysis of ESWT effects on nerve regeneration in a rat model of median nerve injury. Furthermore, this study is among the first reporting the quantification of lymphatic vessels following peripheral nerve injury and reconstruction in vivo. While we found no significant direct positive effects of ESWT on peripheral nerve regeneration, results following nerve repair with MVCs were significantly inferior to those after ANG repair.

Comparison of Radial Extracorporeal Shock Wave Therapy and Local Corticosteroid Injection Effectiveness in Patients With Carpal Tunnel Syndrome: A Randomized Controlled Study

OBJECTIVE

The aim of the study was to compare the effectiveness of radial extracorporeal shock wave therapy and local corticosteroid injection on pain, function, and nerve conduction studies in the treatment of idiopathic carpal tunnel syndrome.

DESIGN

A total of 72 patients who were diagnosed as having carpal tunnel syndrome were included in the study. The radial extracorporeal shock wave therapy group received radial extracorporeal shock wave therapy, the local corticosteroid injection group received local corticosteroid injection, and the control group only used a resting hand splint. The patients were evaluated using a Visual Analog Scale-pain, a Visual Analog Scale-numbness, the Boston Symptom Severity Scale, the Boston Functional Status Scale, and handgrip strength tests before treatment 1 and 12 wks after the treatment.

RESULTS

Both clinical and nerve conduction study parameters improved with all three groups, and this effect continued at the 12th-week follow-up of the patients. The Visual Analog Scale-pain, Visual Analog Scale-numbness, Boston Symptom Severity Scale, and Boston Functional Status Scale scores in the first week after the treatment, as well as Visual Analog Scale-pain and Boston Functional Status Scale scores in the 12th week after the treatment, were significantly lower in the local corticosteroid injection group compared with the other two groups.

CONCLUSIONS

Our study revealed the success of radial extracorporeal shock wave therapy, splint, and local corticosteroid injection, but symptom relief was greater in the first week and 12th week with local corticosteroid injection.

The effect of extracorporeal shock wave therapy in acute traumatic spinal cord injury on motor and sensory function within 6 months post-injury: a study protocol for a two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled clinical trial

Background

The pathological mechanism in acute spinal cord injury (SCI) is dual sequential: the primary mechanical lesion and the secondary injury due to a cascade of biochemical and pathological changes initiated by the primary lesion. Therapeutic approaches have focused on modulating the mechanisms of secondary injury. Despite extensive efforts in the treatment of SCI, there is yet no causal, curative treatment approach available.

Extracorporeal shock wave therapy (ESWT) has been successfully implemented in clinical use. Biological responses to therapeutic shock waves include altered metabolic activity of various cell types due to direct and indirect mechanotransduction leading to improved migration, proliferation, chemotaxis, modulation of the inflammatory response, angiogenesis, and neovascularization, thus inducing rather a regeneration than repair.

The aim of this clinical study is to investigate the effect of ESWT in humans within the first 48 h after an acute traumatic SCI, with the objective to intervene in the secondary injury phase in order to reduce the extent of neuronal loss.

Methods

This two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled study has been initiated in July 2020, and a total of 82 patients with acute traumatic SCI will be recruited for the first stage in 15 participating hospitals as part of a two-armed three-stage adaptive trial design. The focused ESWT (energy flux density: 0.1–0.19 mJ/mm², frequency: 2–5 Hz) is applied once at the level of the lesion, five segments above/below, and on the plantar surface of both feet within the first 48 h after trauma.

The degree of improvement in motor and sensory function after 6 months post-injury is the primary endpoint of the study. Secondary endpoints include routine blood chemistry parameters, the degree of spasticity, the ability to walk, urological function, quality of life, and the independence in everyday life.

Discussion

The application of ESWT activates the nervous tissue regeneration involving a multitude of various biochemical and cellular events and leads to a decreased neuronal loss. ESWT might contribute to an improvement in the treatment of acute traumatic SCI in future clinical use.

Trial registration

ClinicalTrials.govNCT04474106

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06161-8.

Physical therapy versus radial extracorporeal shock wave therapy in the treatment of carpal tunnel syndrome: A randomized-controlled study

Objectives: This study aims to compare the efficacy of physical therapy (PT) and radial extracorporeal shock wave therapy (rESWT) in the treatment of carpal tunnel syndrome (CTS).

Patients and methods: Between May 2020 and July 2020, a total of 125 wrists of 95 patients (22 males, 73 females; mean age: 54.3±11.3 years; range, 19 to 69 years) with mild-to-moderate CTS were allocated into three groups and evaluated. The control group (Group 1, n=42) was treated with splinting and an exercise program. Group 2 (n=42) was treated with a total of three sessions of rESWT, splinting and an exercise program. Group 3 (n=41) was treated with a total of 15 sessions of PT modalities, splinting, and an exercise program. Each patient was evaluated before, three weeks and 12 weeks after treatment using a Visual Analog Scale (VAS), the Boston Carpal Tunnel Questionnaire (BCTQ), the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale, and electrodiagnostic testing.

Results: The reduction in VAS, BCTQ, LANSS, and improvement in sensory nerve conduction velocity were significantly greater at three and 12 weeks of follow-up in Groups 2 and 3, compared to Group 1 (p<0.001). A greater improvement was observed in all clinical parameters in Group 2, compared to Group 3 (p<0.001).

Conclusion: This is the first study to compare the treatment outcomes of PT and rESWT in the treatment of CTS. The results of this study show that both PT and rESWT are effective in the treatment of CTS; however, rESWT yields superior treatment effects compared to conventional PT. The practicalities of administering rESWT and its efficacy in the treatment of CTS may make it the treatment of choice.

Update on Efficacy of Conservative Treatments for Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common upper extremity compression neuropathy. Non-operative interventions are usually the first-line treatments, and surgery is reserved for those that do not achieve a satisfactory symptom state by non-operative means. This narrative review summarizes the current evidence regarding the efficacy of orthoses, corticosteroid injections, platelet-rich plasma injections, Kinesio taping, neurodynamic techniques, gabapentin, therapeutic ultrasound, and extracorporeal shockwave therapy in people with CTS. While many trials suggest small short-term benefits, rigorous evidence of long-term patient-important benefits is limited. To improve the utility of healthcare resources, research in this area should focus on establishing efficacy of each treatment instead of comparing various treatments with uncertain benefits.

The effect of radial shockwave on the median nerve pathway in patients with mild-to-moderate carpal tunnel syndrome: a randomized clinical trial

Background

This study aimed to evaluate the short-term effect of radial shockwave on the median nerve pathway as a new model method in patients with mild-to-moderate carpal tunnel syndrome.

Methods

In this randomized clinical trial, 60 patients were randomly allocated into three equal groups. The first group received 1500 shocks on the carpal tunnel, the second group received 1500 shocks on the carpal tunnel and median nerve pathways, and the third group was the control group. In all three groups, patients received conventional physiotherapy for ten sessions. In addition, patients in experimental groups received four sessions of radial shockwave. Pain and paresthesia intensity, sensory and motor distal latency were evaluated as primary outcomes. Boston carpal tunnel Questionnaire scores were evaluated as secondary outcomes. Evaluations were performed at baseline, 1 and 4 weeks after the end of the treatment.

Results

Pain and paresthesia intensity and Boston questionnaire score significantly decreased in all three groups, but the greater improvement was noted in shockwave groups. Sensory and motor distal latency were only improved in shockwave groups. In terms of clinical and electrophysiological parameters, two groups of shockwaves showed similar results.

Conclusions

Radial shockwave combined with conventional physiotherapy is an effective noninvasive treatment for mild-to-moderate carpal tunnel syndrome that produces greater and longer-lasting results than conventional physiotherapy alone. There were no differences observed between utilizing radial shockwave on the carpal tunnel or median nerve pathways on the palmar surface of the hand, in terms of clinical and electrophysiological measurements.

Clinical Trial registration number The study was registered at https://fa.irct.ir/user/trial/49490/view (20200706048028N1) in date of 08/24/2021.

Effects of shock wave therapy in patients with carpal tunnel syndrome: a systematic review and meta-analysis

PURPOSE

To determine whether shock wave therapy could improve symptoms and hand function in patients with carpal tunnel syndrome.

MATERIALS AND METHODS

Medline, Embase, Physiotherapy Evidence Database, the Cochrane Central Register of Controlled Trials, OpenGrey, CNKI, VIP, Wang Fang databases, and China Biological Medicine were searched, from inception to December 2019.

RESULTS

Ten trials involving 433 patients (501 wrists) were included in this systematic review. The shock wave therapy was observed to have a significant effect on pain relief (MD: -0.60, 95% CI: -1.16 to -0.05, p = 0.03), syndrome alleviation (MD: -2.26, 95% CI: -3.24 to -1.27, p < 0.00001) and functional recovery (MD: -1.25 95% CI: -2.08 to -0.43, p = 0.003) among the carpal tunnel syndrome patients. As revealed by the subgroup analysis, radial shock wave therapy made a significant difference in pain relief, syndrome alleviation, and functional recovery (p < 0.05). Focused shock wave had no significant effect on pain relief, syndrome alleviation, and functional recovery (p > 0.05).

CONCLUSION

Shock wave therapy could be conductive to improve syndrome and hand function for carpal tunnel syndrome patients.Implications for rehabilitationShock wave therapy is beneficial for alleviating syndrome and improving hand function of carpal tunnel syndrome patients.Radial shock wave therapy seems superior to focused shock wave therapy on syndrome alleviation and functional recovery of hand in carpal tunnel syndrome patients.

Low-intensity pulsed ultrasound for regenerating peripheral nerves: potential for penile nerve

Peripheral nerve damage, such as that found after surgery or trauma, is a substantial clinical challenge. Much research continues in attempts to improve outcomes after peripheral nerve damage and to promote nerve repair after injury. In recent years, low-intensity pulsed ultrasound (LIPUS) has been studied as a potential method of stimulating peripheral nerve regeneration. In this review, the physiology of peripheral nerve regeneration is reviewed, and the experiments employing LIPUS to improve peripheral nerve regeneration are discussed. Application of LIPUS following nerve surgery may promote nerve regeneration and improve functional outcomes through a variety of proposed mechanisms. These include an increase of neurotrophic factors, Schwann cell (SC) activation, cellular signaling activations, and induction of mitosis. We searched PubMed for articles related to these topics in both in vitro and in vivo animal research models. We found numerous studies, suggesting that LIPUS following nerve surgery promotes nerve regeneration and improves functional outcomes. Based on these findings, LIPUS could be a novel and valuable treatment for nerve injury-induced erectile dysfunction.

Low-Intensity Pulsed Ultrasound Prompts Both Functional and Histologic Improvements While Upregulating the Brain-Derived Neurotrophic Factor Expression after Sciatic Crush Injury in Rats

The aim of this study was to determine that low-intensity pulsed ultrasound (LIPUS) at an intensity of 140 mW/cm² promotes functional and histologic improvements in sciatic nerve crush injury in a rat model and to investigate changes over time in relevant growth factors and receptors, exploring the mechanism of LIPUS in the recovery process after injury. Toe angle in the toe-off phase, regenerative axonal length, myelinated nerve fiber density, diameter of myelinated nerve fiber, axon diameter and myelin sheath thickness were significantly higher in the LIPUS group than in the sham group. Gene and protein expression of brain-derived neurotrophic factor (BDNF) was upregulated in the LIPUS group. In conclusion, LIPUS contributed to rapid functional and histologic improvement and upregulated BDNF expression after sciatic nerve crush injury in rats.

Review on experimental study and clinical application of low-intensity pulsed ultrasound in inflammation

Low-intensity pulsed ultrasound (LIPUS), as physical therapy, is widely used in both research and clinical settings. It induces multiple bioeffects, such as alleviating pain, promoting tissue repair, and shortening disease duration. LIPUS can also mediate inflammation. This paper reviews the application of LIPUS in inflammation and discusses the underlying mechanism. In basic experiments, LIPUS can regulate inflammatory responses at the cellular level by affecting some signaling pathways. In a clinical trial, LIPUS has been shown to alleviate inflammatory responses efficiently. As a cheap, safe, and convenient physical method, LIPUS is promising as anti-inflammatory therapy.

The Acceleration of Diabetic Wound Healing by Low-Intensity Extracorporeal Shockwave Involves in the GSK-3β Pathway

Previous studies have demonstrated that extracorporeal shock wave therapy (ESWT) could accelerate diabetic wound healing and that the inhibition of glycogen synthase kinase-3β (GSK-3β) is involved in epithelial differentiation during wound healing. This study investigated whether the enhancement of diabetic wound healing by ESWT is associated with the GSK-3β-mediated Wnt/β-catenin signaling pathway. A dorsal skin wounding defect model using streptozotocin-induced diabetic rodents was established. Rats were divided into 4 groups: group 1, normal controls without diabetes; group 2, diabetic controls without treatment; group 3, diabetic rats receiving ESWT; and group 4, rats receiving 6-bromoindirubin-3′oxime (BIO), a GSK-3β inhibitor, to trigger Wnt/β-catenin signaling. Tissue samples were collected and analyzed by immunohistochemical (IHC) staining and quantitative RT-PCR. The ESWT and BIO-treated groups both exhibited significant promotion of wound healing compared to the healing in controls without treatment. RT-PCR analysis of Wnt-1, -3a, -4, -5a, and -10 and β-catenin expression showed significantly increased expression in the ESWT group. The IHC staining showed that Wnt-3a and -5a and β-catenin levels were significantly increased in the ESWT and BIO treatment groups compared to the control groups. ESWT enhancement of diabetic wound healing is associated with modulation of the GSK-3β-mediated Wnt/β-catenin signaling pathway.

Effectiveness of focused extracorporeal shock wave therapy in the treatment of carpal tunnel syndrome : A randomized, placebo-controlled pilot study

Background

The carpal tunnel syndrome is the most common entrapment neuropathy in the general population. A conservative treatment should be considered in mild to moderate cases. The aim of this study was to assess the effect of a focused extracorporeal shock wave therapy in the treatment of mild to moderate carpal tunnel syndrome.

Material and Methods

In this study 30 patients were randomly assigned into 2 groups. Subjects in the study group received three sessions of focused extracorporeal shock wave therapy, whereas the control group underwent a sham therapy. Patients were evaluated 3 and 12 weeks after treatment. The primary outcome was the visual analogue scale score. Secondary outcome measurements included hand grip strength, Boston Carpal Tunnel Syndrome Questionnaire, SF-36 Health Survey and electrodiagnostic measurements.

Results

A significant improvement of visual analogue scale at week 3 (p = 0.018) and week 12 (p = 0.007) as well as hand grip strength at week 12 (p = 0.019) could be observed in the study group. The study group showed a significantly better sensory nerve conduction velocity at week 12 than the control group, before correcting for multiple testing, and also a significant improvement in distal motor latency of the median nerve at week 12 (p = 0.009) as well as in both questionnaires (SF-36 subscale bodily pain, p = 0.020 and severity symptom scale, p = 0.003). No such improvement was observed in the control group.

Conclusion

Focused extracorporeal shock wave therapy is an effective and noninvasive treatment method for mild to moderate carpal tunnel syndrome.

Facial Tightening Effects, Following Focused and Radial Acoustic Wave Therapy Assessment, Using a Three-Dimensional Digital Imaging

Background and Objectives

Acoustic wave therapy is a novel facial tightening technique that involves nonthermal penetration of the skin and subcutaneous tissue, affecting cells and their metabolism, and resulting in an increased release of unwanted fat and activation of blood and lymphatic flow in tissues. The objective of this study was to investigate the effectiveness of acoustic wave therapy.

Study Design/Materials and Methods

A total of 333 patients underwent multiple facial tightening treatment sessions using focused and radial acoustic waves. Each patient received 2,000–3,000 pulses of focused acoustic waves at a power of 0.45–0.88 mJ/mm² with a pulse frequency of 3–5 Hz and 4,000 pulses of radial acoustic waves at 4‐bar power at a frequency of 21 Hz. These sessions were performed more than three times, and treatments were repeated at 1‐month intervals. Digital photographs superimposed three‐dimensional volumetric assessments, and three‐dimensional skin surface displacement calculations using vectors were used to evaluate the results 12 months after the last treatment. Patients also evaluated the results using a 5‐point Likert scale.

Results

Improvements in skin texture, clarity, and laxity were observed in digital photographs. Superimposed three‐dimensional color images showed marked volumetric reduction and/or formative modification for even contour toward the lower mid‐face. Most vectors showed three‐dimensional skin surface displacement at the lateral sides of the temples, cheeks, and chin, in an upward direction. These results were obtained and sustained for up to 12 months without edematous reactions. Almost all patients reported improvement, with 79% reporting “good” or “excellent” improvement. Complications were minor and transitory. Persistent side effects were not observed.

Conclusion

Acoustic wave therapy could be used as a standard facial tightening treatment, with skin rejuvenation effects shown on digital photographs and three‐dimensional quantification assessments. This noninvasive acoustic wave approach was found to be a safe, long‐lasting, and effective method for facial tightening. Lasers Surg. Med. 00:00–00, 2020. © 2020 Wiley Periodicals LLC

Exosome Released From Schwann Cells May Be Involved in Microenergy Acoustic Pulse-Associated Cavernous Nerve Regeneration

BACKGROUND

Neurogenic erectile dysfunction (ED) is often refractory to treatment because of insufficient functional nerve recovery after injury or insult. Noninvasive mechano-biological intervention, such as microenergy acoustic pulse (MAP), low-intensity pulsed ultrasound, and low-intensity extracorporeal shockwave treatment, is an optimal approach to stimulate nerve regeneration.

AIM

To establish a new model in vitro to simulate nerve injury in neurogenic ED and to explore the mechanisms of MAP in vitro.

METHODS

Sprague-Dawley rats were used to isolate Schwann cells (SCs), major pelvic ganglion (MPG), and cavernous nerve with MPG (CN/MPG). SCs were then treated with MAP (0.033 mJ/mm², 1 Hz, 100 pulses), and SC exosomes were isolated. The MPG and CN/MPG were treated with MAP (0.033 mJ/mm², 1 Hz) at different dosages (25, 50, 100, 200, or 300 pulses) or exosomes derived from MAP-treated SCs in vitro.

OUTCOMES

Neurite growth from the MPG fragments and CN was photographed and measured. Expression of neurotropic factors (brain-derived neurotrophic factor, nerve growth factor, and neurotrophin-3) was checked.

RESULTS

Neurite outgrowth from MPG and CN/MPG was enhanced by MAP in a dosage response manner, peaking at 100 pulses. MAP promoted SC proliferation, neurotropic factor (brain-derived neurotrophic factor, nerve growth factor, and neurotrophin-3) expression, and exosome secretion. SC-derived exosomes significantly enhanced neurite outgrowth from MPG in vitro.

CLINICAL IMPLICATIONS

MAP may have utility in the treatment of neurogenic ED by SC-derived exosomes.

STRENGTH & LIMITATIONS

We confirmed that MAP enhances penile nerve regeneration through exsomes. Limitations of this study include that our study did not explore the exact mechanisms of how MAP increases SC exosome secretion nor whether MAP modulates the content of exosomes.

CONCLUSION

This study revealed that neurite outgrowth from MPG was enhanced by MAP and by SC-derived exosomes which were isolated after MAP treatment. Our findings indicate that one mechanism by which MAP induces nerve regeneration is by stimulation of SCs to secrete exosomes. Peng D, Reed-Maldonado AB, Zhou F, et al. Exosome Released From Schwann Cells May Be Involved in Microenergy Acoustic Pulse-Associated Cavernous Nerve Regeneration. J Sex Med 2020;17:1618-1628.

Efficacy of extracorporeal shockwave therapy in the treatment of postherpetic neuralgia: A pilot study

Established conventional treatments for postherpetic neuralgia (PHN) and postherpetic itch (PHI) are difficult and often disappointing. In this study, the authors investigated the effect and mechanisms of extracorporeal shockwave therapy (ESWT) on pain and itch associated with PHN and PHI.Thirteen patients, 50 to 80 years of age, with symptoms associated with PHN or PHI (duration of persistent pain >3 months) and complaints of pain or itch rated >4 on a numerical rating scale (NRS), were included. ESWT was administered using a shockwave device (Piezo Shockwave, Richard Wolf GmbH, Knittlingen, Germany) to skin areas affected by pain or itch. An energy flux density of 0.09 to 0.16 mJ/mm at a frequency of 5 Hz and 2000 impulses was administered at 3-day intervals for 6 sessions. The NRS, 5D-Itch Scale, and Patients Global Impression of Change (PGIC) scale were used to evaluate the efficacy of ESWT.NRS scores of pain and itch and 5D-Itch Scale scores decreased significantly compared with before treatment and at the end of the treatment sessions (P < .0001, P = .001, P = .0002, respectively). There was a statistically significant difference between PGIC scores, which were checked every 2 sessions (P < .0001).ESWT is a noninvasive modality that significantly reduced PHN-associated pain and itch.

The greater inflammatory pathway-high clinical potential by innovative predictive, preventive, and personalized medical approach

BACKGROUND AND LIMITATIONS

Impaired wound healing (WH) and chronic inflammation are hallmarks of non-communicable diseases (NCDs). However, despite WH being a recognized player in NCDs, mainstream therapies focus on (un)targeted damping of the inflammatory response, leaving WH largely unaddressed, owing to three main factors. The first is the complexity of the pathway that links inflammation and wound healing; the second is the dual nature, local and systemic, of WH; and the third is the limited acknowledgement of genetic and contingent causes that disrupt physiologic progression of WH.

PROPOSED APPROACH

Here, in the frame of Predictive, Preventive, and Personalized Medicine (PPPM), we integrate and revisit current literature to offer a novel systemic view on the cues that can impact on the fate (acute or chronic inflammation) of WH, beyond the compartmentalization of medical disciplines and with the support of advanced computational biology.

CONCLUSIONS

This shall open to a broader understanding of the causes for WH going awry, offering new operational criteria for patients' stratification (prediction and personalization). While this may also offer improved options for targeted prevention, we will envisage new therapeutic strategies to reboot and/or boost WH, to enable its progression across its physiological phases, the first of which is a transient acute inflammatory response versus the chronic low-grade inflammation characteristic of NCDs.

Low-energy extracorporeal shock wave therapy promotes BDNF expression and improves functional recovery after spinal cord injury in rats

Low-energy extracorporeal shock wave therapy (ESWT) has been used to treat various human diseases. Previous studies have shown that low-energy ESWT promotes the release of various cell growth factors and trophic factors from the cells surrounding the target lesion. The aim of the current study was to determine whether the application of low-energy ESWT upregulates the expression of brain-derived neurotrophic factor (BDNF) and reduces neural tissue damage and functional impairment using a rat model of thoracic spinal cord contusion injury. We found that low-energy ESWT promoted BDNF expression in the damaged neural tissue. The expression of BDNF was increased in various neural cells at the lesion. Additionally, low-energy ESWT increased the area of spared white matter and the number of oligodendrocytes in the injured spinal cord compared with untreated control animals. There were more axonal fibers around the injured site after the application of low-energy ESWT than control. Importantly, low-energy ESWT improved the locomotor functions evaluated by both the BBB scale and ladder rung walking test in addition to the sensory function measured using a von Frey test. Moreover, the electrophysiological assessment confirmed that the conductivity of the central motor pathway in the injured spinal cord was restored by low-energy ESWT. These findings indicate that low-energy ESWT promotes BDNF expression at the lesion site and reduces the neural tissue damage and functional impairment following spinal cord injury. Our results support the potential application of low-energy ESWT as a novel therapeutic strategy for treating spinal cord injury.

Motor and sensory Schwann cell phenotype commitment is diminished by extracorporeal shockwave treatment in vitro

The gold standard for peripheral nerve regeneration uses a sensory autograft to bridge a motor/sensory defect site. For motor nerves to regenerate, Schwann cells (SC) myelinate the newly grown axon. Sensory SCs have a reduced ability to produce myelin, partially explaining low success rates of autografts. This issue is masked in pre-clinical research by the excessive use of the rat sciatic nerve defect model, utilizing a mixed nerve with motor and sensory SCs. Aim of this study was to utilize extracorporeal shockwave treatment as a novel tool to influence SC phenotype. SCs were isolated from motor, sensory and mixed rat nerves and in vitro differences between them were assessed concerning initial cell number, proliferation rate, neurite outgrowth as well as ability to express myelin. We verified the inferior capacity of sensory SCs to promote neurite outgrowth and express myelin-associated proteins. Motor Schwann cells demonstrated low proliferation rates, but strongly reacted to pro-myelination stimuli. It is noteworthy for pre-clinical research that sciatic SCs are a strongly mixed culture, not representing one or the other. Extracorporeal shockwave treatment (ESWT), induced in motor SCs an increased proliferation profile, while sensory SCs gained the ability to promote neurite outgrowth and express myelin-associated markers. We demonstrate a strong phenotype commitment of sciatic, motor, and sensory SCs in vitro, proposing the experimental use of SCs from pure cultures to better mimic clinical situations. Furthermore we provide arguments for using ESWT on autografts to improve the regenerative capacity of sensory SCs.

Effect of extracorporeal shockwave therapy on carpal tunnel syndrome: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although several trials have reported the use of extracorporeal shock wave therapy (ESWT) for mild to moderate carpal tunnel syndrome (CTS), little is known about the efficacy of ESWT. Thus, we performed a meta-analysis to evaluate whether ESWT can improve symptoms, functional outcomes, and electrophysiologic parameters in CTS.

METHODS

Six randomized controlled trials investigating the effect of ESWT on CTS were retrieved from PubMed, Embase, and the Cochrane Library. We performed a pairwise meta-analysis using fixed- or random-effects models.

RESULTS

ESWT showed significant overall effect size compared to the control (overall Hedge g pooled standardized mean difference (SMD) = 1.447; 95% confidence interval [CI], 0.439-2.456; P = .005). Symptoms, functional outcomes, and electrophysiologic parameters all improved with ESWT treatment. However, there was no obvious difference between the efficacy of ESWT and local corticosteroid injection (pooled SMD = 0.418; 95% CI, -0.131 to 0.968; P = .135). A publication bias was not evident in this study.

CONCLUSION

Our meta-analysis revealed that ESWT can improve symptoms, functional outcomes, and electrophysiologic parameters in patients with CTS. Further research is needed to confirm the long-term effects and the optimal ESWT protocol for CTS.

Low-intensity pulsed ultrasound promotes Schwann cell viability and proliferation via the GSK-3β/β-catenin signaling pathway

Background: It has been reported that ultrasound enhances peripheral nerve regeneration, but the mechanism remains elusive. Low-intensity pulsed ultrasound (LIPUS) has been reported to enhance proliferation and alter protein production in various types of cells. In this study, we detected the effects of LIPUS on Schwann cells. Material and methods: Schwann cells were separated from new natal Sprague-Dawley rat sciatic nerves and were cultured and purified. The Schwann cells were treated by LIPUS for 10 minutes every day, with an intensity of 27.37 mW/cm2. After treatment for 5 days, MTT, EdU staining, and flow cytometry were performed to examine cell viability and proliferation. Neurotrophic factors, including FGF, NGF, BDNF, and GDNF, were measured by western blot and real-time PCR. GSK-3β, p-GSK-3β, β-catenin and Cyclin D1 protein levels were detected using a western blot analysis. The expression of Cyclin D1 was also detected by immunofluorescence. Results: MTT and EdU staining showed that LIPUS increased the Schwann cells viability and proliferation. Compared to the control group, LIPUS increased the expression of growth factors and neurotrophic factors, including FGF, NGF, BDNF, GDNF, and Cyclin D1. Meanwhile, GSK-3β activity was inhibited in the LIPUS group as demonstrated by the increased level of p-GSK-3β and the ratio of the p-GSK-3β/GSK-3β level. The mRNA and protein expressions of β-catenin were increased in the LIPUS group. However, SB216763, a GSK-3β inhibitor, reversed the effects of LIPUS on Schwann cells. Conclusion: LIPUS promotes Schwann cell viability and proliferation by increasing Cyclin D1 expression via enhancing the GSK-3β/β-catenin signaling pathway.

Comparison of single-dose radial extracorporeal shock wave and local corticosteroid injection for treatment of carpal tunnel syndrome including mid-term efficacy: a prospective randomized controlled trial

BACKGROUND

Recent studies have reported that radial extracorporeal shock wave therapy (rESWT) reduces pain and improves function in patients with mild to moderately severe carpal tunnel syndrome (CTS) compared to a placebo. However, most of those studies used multi-session rESWT combined with wrist support and evaluation of efficacy was limited to a maximum of 14 weeks.

METHODS

The prospective randomized controlled trial compared efficacy in relieving pain and improving clinical function between single-dose rESWT and local corticosteroid injection (LCsI) over the mid-term (24 weeks). Twenty-five patients with mild to moderately severe CTS were randomized to receive either single-dose rESWT (n = 13) or LCsI (n = 12). Primary outcomes were evaluated using the Boston self-assessment questionnaire (BQ), while secondary outcomes used the Visual analogue scale (VAS) and electrodiagnostic parameters. Evaluations at baseline and at 1, 4, 12 and 24 weeks after treatment were performed.

RESULTS

There was significantly greater improvement in symptom severity scores, functional scores and Boston questionnaire scores at weeks 12 to 24 in the rESWT group compared to the LCsI group. When compared to the baseline, there was significant reduction of VAS and functional score in the rESWT group at weeks 12 and 24. The LCsI group had no statistically significant differences in VAS reduction and functional score of the same period.

CONCLUSIONS

Treatment of CTS using single-dose rESWT has a carry-over effect lasting up to 24 weeks suggesting that single-dose rESWT is appropriate for treatment of mild to moderate CTS and provides longer-lasting benefits than LCsI.

TRIAL REGISTRATION

( TCTR20150709001 ). Registered 9 July 2015.

Low-intensity extracorporeal shock wave therapy for erectile dysfunction after radical prostatectomy: a review of preclinical studies

Low-intensity extracorporeal shock wave therapy (LI-ESWT) is a novel treatment for erectile dysfunction (ED). Its ability to improve erectile function has been shown in patients with vasculogenic ED by many randomized-controlled trials against sham procedures. However, the role of LI-ESWT in ED caused by radical prostatectomy (RP) is still questionable because this type of ED was excluded from nearly all clinical studies; it has been investigated in only a few small single-arm trials. This review summarizes preclinical studies on mechanisms of action of LI-ESWT for ED and neurological diseases to explore the potential of this treatment for nerve-impaired ED after RP.

Efficacy of Low-Intensity Extracorporeal Shock Wave Therapy on Men With Chronic Pelvic Pain Syndrome Refractory to 3-As Therapy

Managing patients with chronic pelvic pain syndrome (CPPS) refractory to the traditional 3-As therapy (antibiotics, alpha-blockers, and anti-inflammatories) is a challenging task. Low-intensity extracorporeal shock wave therapy (LI-ESWT) was recently reported to be able to improve pain, urinary symptoms, and even sexual function by inducing neovascularization and anti-inflammation, reducing muscle tone, and influencing nerve impulses. This study evaluates whether combined treatment with LI-ESWT can restore clinical ability and quality of life (QoL) in patients refractory to 3-As therapy. This was an open-label, single-arm prospective study. Patients with CPPS without more than a 6-point decrease in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score under the maximal dosage of 3-As therapy were enrolled. LI-ESWT treatment consisted of 3,000 shock waves administered once weekly for 4 weeks. The NIH-CPSI, visual analog scale (VAS) score, International Prostate Symptom Score (IPSS), and the five-item version of the International Index of Erectile Function (IIEF-5) were used to evaluate efficacy at 1, 4, and 12 weeks after LI-ESWT. Thirty-three patients were enrolled in this study. After LI-ESWT treatment, 27 of the 33 patients (81.82%) had a successful response to LI-ESWT, with a decrease of 3.29 and 5.97 in the VAS score and total IPSS at the 3-month follow-up. Waist circumference was the only significant predictor of a successful response to LI-ESWT. LI-ESWT can serve as a salvage therapy for patients with CPPS refractory to traditional 3-As therapy. Further studies are needed to determine an adequate therapeutic protocol and important predictors in patients with different CPPS etiologies.

The Effect of Low-Intensity Ultrasound on Brain-Derived Neurotropic Factor Expression in a Rat Sciatic Nerve Crushed Injury Model

Low-intensity ultrasound (LIU) can improve nerve regeneration and functional recovery after peripheral nerve crush injury, but the underlying mechanism is not clear. The objective of this study was to examine the effects of LIU on rat sciatic crush injury and to investigate a possible molecular mechanism. Adult male Sprague-Dawley rats underwent left sciatic nerve crush surgery and were then randomized into two groups: a treatment group that received LIU every other d, and a control group that received sham exposure. Compared with rats in the control group, rats in the treatment group had higher sciatic nerve function indexes, compound muscle action potentials, wet weight ratios of the target muscle and mRNA expression of brain-derived neurotropic factor (BDNF) in the crushed nerve and ipsilateral dorsal root ganglia. Our findings suggest that LIU might promote injured nerve regeneration by stimulating BDNF release.

The Effectiveness of Radial Extracorporeal Shock Waves for Treatment of Carpal Tunnel Syndrome: A Randomized Clinical Trial

This study examined the effectiveness of radial extracorporeal shock wave therapy in the treatment of carpal tunnel syndrome (CTS). Forty patients with mild to moderate CTS were allocated to two groups: (i) shock wave + wrist splint and (ii) wrist splint. Patients used wrist splints followed by three sessions of low-energy shock wave therapy in the intervention group and wrist splints alone in the other group. The QuickDASH Questionnaire, visual analogue scale and nerve conduction studies were used to evaluate the patients before the study and at 3, 8 and 12 wk after the start of the treatment. At the end of the study, both groups saw the same clinical benefits. However, a significantly greater improvement in the median nerve distal sensory latency was noted in the shock wave group compared with the control group. We suggest that application of shock wave with alternative protocols may be effective in the treatment of CTS in future studies.

[Basic research in traumatology and its contribution to routine operation]

Basic research in traumatology supports the clinical outcome of patients in trauma care and tries to find science-based solutions for clinical problems. Furthermore, institutions for basic research in traumatology usually offer training in different skills, such as how to write a scientific paper, or practice in microsurgery or intubation. Two examples of clinically significant research topics are presented.

Shock wave as biological therapeutic tool: From mechanical stimulation to recovery and healing, through mechanotransduction

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.