Extracorporeal shock wave therapy improves motor dysfunction and pain originating from knee osteoarthritis in rats

The Effects of Shock Wave Therapy on the Symptoms and Function of Individuals With Dupuytren Disease: A Systematic Review

OBJECTIVE

To systematically evaluate the effects of extracorporeal shockwave therapy (ESWT) on pain, clinical and functional outcomes, and satisfaction of patients with Dupuytren disease.

DATA SOURCES

A thorough search for all the study types published in English was conducted in PubMed, Scopus, Web of Science, and Embase from inception to August 31, 2022.

STUDY SELECTION

Title and abstract and then full-text screening against eligibility criteria was performed independently by 2 reviewers, and a third reviewer achieved consensus.

DATA EXTRACTION

Reviewers identified 26 studies, of which 6 were included in the analysis (145 cases). The methodological quality was assessed using the National Heart, Lung, and Blood Institute and the Joanna Briggs Institute checklists. The certainty of evidence was evaluated using the Grading of Recommendation Assessment, Development, and Evaluation.

DATA SYNTHESIS

Assessments represented a remarkable improvement in the pain and function through the measurements including the visual analog scale, the Disabilities of Arm Shoulder and Hand Questionnaire, the Michigan Hand Outcome Questionnaire, and Mayo Wrist Score. Patients' satisfaction was also favorable using the Roles and Maudsley score. The hand grip strength improvement was noted in one study measured via a Jamar dynamometer. In addition, the ultrasonographic assessment of the nodules revealed a decrease in the size of the nodules in a patient with multiple bilateral nodules after the treatment. The quality of the included studies was good for all studies except for one that was fair. The certainty of evidence was moderate for pain and function and was low for patients' satisfaction and ultrasonographic findings.

CONCLUSIONS

ESWT can lead to significant pain improvement, functional rehabilitation, and patient satisfaction with no adverse effect in the management of Dupuytren disease. Pain may return over time, but not to that severity before the intervention. ESWT-related characteristics and the need for continuation of treatment remain to be fully elucidated in future large clinical trials.

The efficacy of extracorporeal shock wave therapy for knee osteoarthritis : an umbrella review

BACKGROUND

An umbrella review was conducted to compare the effectiveness of extracorporeal shock wave therapy (ESWT) versus non-ESWT in the treatment of knee osteoarthritis (KOA).

MATERIALS AND METHODS

Three databases including PubMed, Embase and Web of science were searched up to September 2023. Literature screening, quality evaluation, and data extraction were performed according to inclusion and exclusion criteria. Meta-analysis of outcome indicators was performed using Revman 5.4 software.

RESULTS

A total of eight meta-analysis were included in this umbrella review. All meta-analysis were graded against a Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) and scored between 8 and 11. Compared to the sham group, the ESWT group showed better results in WOMAC (Western Ontario and McMaster Universities Arthritis Index) [mean difference (MD)=-2.94, 95% CI: -5.52, -0.37, P=0.03, I²=60%], Visual Analog Scale (VAS) (MD=-2.0, 95% CI: -2.5, -1.5, P<0.01, I²=0%), range of motion (ROM) (MD=17.55, 95% CI: 13.49, 21.61, P<0.00001, I²=0%), and Lequesne index (MD=-2.85, 95% CI: -3.64, -2.07, P<0.00001, I²=48%).

CONCLUSION

Based on the results of our analysis, ESWT is now an effective therapy for improving pain and function in patients with KOA.

Instrumented assisted soft tissue mobilization vs extracorporeal shock wave therapy in treatment of myofascial pain syndrome

BACKGROUND

Active myofascial trigger points (TrPs) often occur in the upper region of the upper trapezius (UT) muscle. These TrPs can be a significant source of neck, shoulder, and upper back pain and headaches. These TrPs and their related pain and disability can adversely affect an individual’s everyday routine functioning, work-related productivity, and general quality of life.

AIM

To investigate the effects of instrument assisted soft tissue mobilization (IASTM) vs extracorporeal shock wave therapy (ESWT) on the TrPs of the UT muscle.

METHODS

A randomized, single-blind, comparative clinical study was conducted at the Medical Center of the Egyptian Railway Station in Cairo. Forty patients (28 females and 12 males), aged between 20-years-old and 40-years-old, with active myofascial TrPs in the UT muscle were randomly assigned to two equal groups (A and B). Group A received IASTM, while group B received ESWT. Each group was treated twice weekly for 2 weeks. Both groups received muscle energy technique for the UT muscle. Patients were evaluated twice (pre- and post-treatment) for pain intensity using the visual analogue scale and for pain pressure threshold (PPT) using a pressure algometer.

RESULTS

Comparing the pre- and post-treatment mean values for all variables for group A, there were significant differences in pain intensity for TrP1 and TrP2 (P = 0.0001) and PPT for TrP1 (P = 0.0002) and TrP2 (P = 0.0001). Also, for group B, there were significant differences between the pre- and post-treatment pain intensity for TrP1 and TrP2 and PPT for TrP1 and TrP2 (P = 0.0001). There were no significant differences between the two groups in the post-treatment mean values of pain intensity for TrP1 (P = 0.9) and TrP2 (P = 0.76) and PPT for TrP1 (P = 0.09) and for TrP2 (P = 0.91).

CONCLUSION

IASTM and ESWT are effective methods for improving pain and PPT in patients with UT muscle TrPs. There is no significant difference between either treatment method.

Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors

In recent years, extracorporeal shock wave therapy (ESWT) has received increasing attention for its potential beneficial effects on various bone and soft-tissue pathologies, yielding promising outcomes for pain relief and functional recovery. In fact, ESWT has emerged as an alternative, non-invasive, and safe treatment for the management of numerous musculoskeletal disorders, including myofascial pain syndrome (MPS). In particular, MPS is a common chronic painful condition, accounting for the largest proportion of patients affected by musculoskeletal problems. Remarkably, sensory innervation and nociceptors of the fascial system are emerging to play a pivotal role as pain generators in MPS. At the same time, increasing evidence demonstrates that application of ESWT results in selective loss of sensory unmyelinated nerve fibers, thereby inducing long-lasting analgesia. The findings discussed in the present review are supposed to add novel viewpoints that may further enrich our knowledge on the complex interactions occurring between disorders of the deep fascia including changes in innervation, sensitization of fascial nociceptors, the pathophysiology of chronic musculoskeletal pain of MPS, and EWST-induced analgesia. Moreover, gaining mechanistic insights into the molecular mechanisms of pain-alleviating effects of ESWT may broaden the fields of shock waves clinical practice far beyond the musculoskeletal system or its original application for lithotripsy.

The Effects of the Exposure of Musculoskeletal Tissue to Extracorporeal Shock Waves

Extracorporeal shock wave therapy (ESWT) is a safe and effective treatment option for various pathologies of the musculoskeletal system. Many studies address the molecular and cellular mechanisms of action of ESWT. However, to date, no uniform concept could be established on this matter. In the present study, we perform a systematic review of the effects of exposure of musculoskeletal tissue to extracorporeal shock waves (ESWs) reported in the literature. The key results are as follows: (i) compared to the effects of many other forms of therapy, the clinical benefit of ESWT does not appear to be based on a single mechanism; (ii) different tissues respond to the same mechanical stimulus in different ways; (iii) just because a mechanism of action of ESWT is described in a study does not automatically mean that this mechanism is relevant to the observed clinical effect; (iv) focused ESWs and radial ESWs seem to act in a similar way; and (v) even the most sophisticated research into the effects of exposure of musculoskeletal tissue to ESWs cannot substitute clinical research in order to determine the optimum intensity, treatment frequency and localization of ESWT.

Comparison of Extracorporeal Shockwave Therapy with Non-Steroid Anti-Inflammatory Drugs and Intra-Articular Hyaluronic Acid Injection for Early Osteoarthritis of the Knees

Conservative treatments for early osteoarthritis (OA) of the knee included the use of non-steroid anti-inflammatory drugs (NSAIDs) and intra-articular hyaluronic acid (HA) injection. Recently, several animal studies reported that extracorporeal shockwave therapy (ESWT) demonstrated chondroprotective effects on knee OA. The present study compared the efficacy of oral NSAIDs, HA injection, and noninvasive ESWT for early OA of the knee. Forty-five patients with early knee OA were randomized into three groups. NSAIDs group received celecoxib 200 mg daily for 3 weeks. HA group received intra-articular injection of HA once a week for 3 weeks. ESWT group received ESWT for 3 sessions at bi-weekly interval. All patients were followed up for one year. Evaluations included the visual analogue scale (VAS) score, serum enzyme-linked immunosorbent assay (ELISA), plain radiography, dual-energy X-ray absorptiometry (DEXA), and magnetic resonance imaging (MRI). In addition, the functional scores were performed including, WOMAC (Western Ontario and McMaster Universities Arthritis Index) score, KOOS (knee injury and osteoarthritis outcome) score, and IKDC (International Knee Documentation Committee) score. All three groups showed significant improvement in VAS and functional scores as well as in the collected one-year follow-up data after treatments. ESWT group had better pain relief than NSAIDs and HA groups. ESWT group had better therapeutic effects in the functional scores than NSAIDs and HA groups. The bone mineral density (BMD) of proximal tibia is significantly increased after ESWT than others. In the serum ELISA, ESWT inhibited the expression of COMP in knee OA patients as compared with NSAIDs and HA groups. The parameters of MRI showed no significant differences between three groups after treatments. ESWT and intra-articular HA injection showed comparable results than NSAIDs. ESWT was superior in pain relief than HA and NSAIDs. The results demonstrated that ESWT was an effective and alternative therapy than HA and NSAIDs for early osteoarthritis of the knees.

Extracorporeal Shockwave Therapy With a Modified Technique on Tendon and Ligament for Knee Osteoarthritis: A Randomized Controlled Trial

BACKGROUND

There have been no definitive guidelines on the treatment method and specific points in the body.

PURPOSE

The aim of the study was to investigate the effects of extracorporeal shockwave therapy on treating the main tendons and ligaments of knee osteoarthritis.

METHOD

A total of 36 patients with knee osteoarthritis were enrolled in trial and organized into two groups: 3-wk extracorporeal shockwave therapy for the intervention group and 3-wk sham extracorporeal shockwave therapy for control group. Both groups received the same physical therapies: (1) transcutaneous electrical nerve stimulation, (2) magnetic field treatment, and (3) quadricep muscle strength training. Evaluation was performed before the start of treatment, at third week after the start of treatment, and 1 wk after the end of treatment. The study used randomized controlled trials (level of evidence, 1).

RESULT

Eextracorporeal shockwave therapy group had significant improvement in WOMAC pain score, physical function, and total score (mean difference = -2.8, P < 0.001; -5.1, P = 0.02; -8.3, P = 0.004, respectively), Visual Analog Scale score (mean difference = -2.3, P < 0.001), and the distance of 6-min walk test (mean difference = 28.7, P = 0.01) in the 1 wk after the end of treatment. Statistical significance in WOMAC pain, physical function, and total scores (mean difference = -3.0, P = 0.001; -5.6, P = 0.02; -9.3, P = 0.004, respectively) and Visual Analog Scale score (mean difference = -1.2, P = 0.027) was observed between the extracorporeal shockwave therapy group and control group.

CONCLUSIONS

Extracorporeal shockwave therapy for the tendons and ligaments has clinical benefits for pain and physical function improvement in knee osteoarthritis. In addition, improvement in physical performance was observed in the short-term follow-up.

Evaluation of Different Intraarticular Injection Therapies with Gait Analysis in a Rat Osteoarthritis Model

OBJECTIVE

Osteoarthritis (OA) is a degenerative disease that causes serious damage to joints, especially in elderly patients. The aim of study was to demonstrate the effectiveness of intraarticular therapies that are currently used or recently popularized in the treatment of OA.

DESIGN

The baseline values were determined by walking the rats on the CatWalk system. Afterwards, a monosodium iodoacetate (MIA)-induced knee OA model was created with intraarticular MIA, and the rats were walked again on the CatWalk system and post-OA values were recorded. At this stage, the rats were divided into 4 groups, and intraarticular astaxanthin, intraarticular corticosteroid, intraarticular hyaluronic acid, and intraarticular astaxanthin + hyaluronic acid were applied to the groups, respectively. The rats were walked once more and posttreatment values were obtained. Nine different dynamic gait parameters were used in the comparison.

RESULTS

Significant changes were measured in 6 of the 9 dynamic gait parameters after the MIA-induced knee OA model. While the best improvement was observed in run duration (P = 0.0022), stride length (P < 0.0001), and swing speed (P = 0.0355) in the astaxanthin group, the results closest to basal values in paw print length (P < 0.0001), paw print width (P = 0.0101), and paw print area (P = 0.0277) were seen in the astaxanthin + hyaluronic acid group.

CONCLUSION

Astaxanthin gave better outcomes than corticosteroid and hyaluronic acid in both dynamic gait parameters and histological examinations. Intraarticular astaxanthin therapy can be a good alternative to corticosteroid and hyaluronic acid currently used in intraarticular therapy to treat OA.

Biophysical Stimulation in Athletes' Joint Degeneration: A Narrative Review

Osteoarthritis (OA) is the most prevalent degenerative joint disease and the main cause of pain and disability in elderly people. OA currently represents a significant social health problem, since it affects 250 million individuals worldwide, mainly adults aged over 65. Although OA is a multifactorial disease, depending on both genetic and environmental factors, it is reported that joint degeneration has a higher prevalence in former athletes. Repetitive impact and loading, joint overuse and recurrent injuries followed by a rapid return to the sport might explain athletes' predisposition to joint articular degeneration. In recent years, however, big efforts have been made to improve the prevention and management of sports injuries and to speed up the athletes' return-to-sport. Biophysics is the study of biological processes and systems using physics-based methods or based on physical principles. Clinical biophysics has recently evolved as a medical branch that investigates the relationship between the human body and non-ionizing physical energy. A physical stimulus triggers a biological response by regulating specific intracellular pathways, thus acting as a drug. Preclinical and clinical trials have shown positive effects of biophysical stimulation on articular cartilage, subchondral bone and synovia. This review aims to assess the role of pulsed electromagnetic fields (PEMFs) and extracorporeal shockwave therapy (ESWT) in the prevention and treatment of joint degeneration in athletes.

Combined Effects of Extracorporeal Shockwave Therapy and Integrated Neuromuscular Inhibition on Myofascial Trigger Points of Upper Trapezius: A Randomized Controlled Trial

Objective

To investigate the combined effect of extracorporeal shockwave therapy (ESWT) and integrated neuromuscular inhibition (INI) on myofascial trigger points in the upper trapezius.

Methods

Sixty subjects aged 18–24 years old with active myofascial trigger points in the upper trapezius were studied. Participants were assigned randomly to either group A who received ESWT one session/week, group B who received INI three sessions/week, or group C who received ESWT in addition to INI. All groups completed 4 weeks of intervention. The following main outcome measures were evaluated at baseline and after 4 weeks of intervention: pain intensity, functional disability, pressure pain threshold (PPT), sympathetic skin response (SSR), and neuromuscular junction response (NMJR).

Results

Within-group analysis revealed a significant decline in visual analog scale (VAS), Arabic neck disability index (ANDI), and NMJR and incline in PPT and SSR latency post-intervention (p<0.001). Multiple comparison analysis showed a substantial difference between the groups, while the major changes favored group C (p<0.05).

Conclusion

Combined treatment with ESWT and INI for treating myofascial trigger points in the upper trapezius is more effective than using only one of the two approaches in terms of clinical, functional, and neurophysiological aspects.

Rehabilitation of the Canine Forelimb

The goal of rehabilitation is to restore function and mobility and reduce pain associated with chronic disease. In human medicine, physical therapy is standard of care for acute and chronic injuries and an integral component of postoperative recovery. Although there is a dearth of evidence-based veterinary medical studies in rehabilitation therapy and modalities for forelimb injuries in dogs, some extrapolation from human medicine can be made and applied. When developing a rehabilitation and therapeutic plan, the biomechanics of the affected limb and timeline of tissue healing of the target tissue and/or joint are important to consider.

Extracorporeal shockwave treatment in knee osteoarthritis: therapeutic effects and possible mechanism

Osteoarthritis (OA), the most common degenerative joint disease, is characterized by the cardinal symptoms of chronic pain and restricted joint activity. The complicated pathological changes associated with OA and unclear mechanistic etiology have rendered existing non-surgical OA management options unsatisfactory. Increasing clinical and experimental evidence suggests that extracorporeal shockwave therapy (ESWT) is beneficial in OA treatment. ESWT is found to have modifying effects on cartilage and subchondral bone alterations in OA progression, as well as the clinical complaints of patients, including chronic pain and limited joint activities. However, the specific treatment strategy regarding the dosage and frequency of ESWT is still underdetermined. This review discusses the existing evidence regarding the therapeutic indications and possible mechanism of ESWT for OA treatment.

Plantar Fasciitis/Fasciosis

Many randomized controlled trials demonstrate the effectiveness of conservative treatment of plantar fasciitis. Patients with acute plantar fasciitis generally respond to treatment more rapidly and more predictably than patients with chronic plantar fasciitis. If conservative treatment fails, endoscopic plantar fasciotomy offers patients a more prompt return to activity compared with open procedures.

Focused electromagnetic high-energetic extracorporeal shockwave (ESWT) reduces pain levels in the nodular state of Dupuytren's disease-a randomized controlled trial (DupuyShock)

Dupuytren’s disease is a progressive fibroproliferative disorder of the hand. In the nodular stage of Dupuytren’s disease, pain might limit daily hand activities and progress to finger contractures. Focused electromagnetic high-energetic extracorporeal shockwave therapy (ESWT) may reduce pain in Dupuytren’s nodules (Tubiana N). In this prospective, randomized, blinded, placebo-controlled single center trial, we enrolled 52 patients (mean age, 58.2 ± 9.2) with painful nodular Dupuytren disease Tubiana N. Randomization was done to either (group A) 3 treatments with focused electromagnetic high-energetic ESWT (2000 shots, 3 Hz, 0.35 mmJ/mm²/hand, Storz Duolith SD1, n = 27) or (group B) placebo ESWT (2000 shots, 3 Hz, 0.01 mJ/mm²/hand, n = 25) in a weekly interval. Primary outcome was the level of pain on a visual analogue scale (VAS 0–10) at 3/6/12/18 months, secondary outcomes were patient-related outcome measures (DASH score, MHQ score, URAM scale), grip strength, patient’s satisfaction, and Dupuytren’s disease progression over 18 months follow-up. Focused ESWT significantly improved outcomes. Pain was reduced from 3.6 ± 1.8 to 1.9 ± 1.2 at three, to 1.4 ± 0.7 at six, to 1.7 ± 1.6 after 12 months and 1.9 ± 0.8 after 18 months in the intervention group (47% reduction, p < 0.05). In the placebo group, pain on VAS increased from 2.2 ± 1.4 to 3.4 ± 1.7 at three, to 3.4 ± 1.8 at six, to 3.4 ± 1.4 at 12 and 3.1 ± 1.1 at 18 months (35% increase, p < 0.05). Quality-of-life score tended to improve in the intervention group (MHQ, 77 ± 19 to 83 ± 12; DASH, 12 ± 18 to 10 ± 9) while it deteriorated in the placebo group as Dupuytren’s disease was progressing (MHQ, 79 ± 15 to 73 ± 17; DASH, 6 ± 10 to 14 ± 13). The strength of the affected hand and fingers did not change significantly in either of the groups. Patients’ satisfaction was higher in the intervention group for symptom improvement (56% vs. 12%) and reduction of disease progression (59% vs. 24%). Any Dupuytren-related intervention was performed in 26% in the intervention group and in 36% in the placebo group within 18 months of follow-up (n.s.). Focused electromagnetic high-energetic ESWT can significantly reduce pain in painful nodules in Dupuytren’s disease in an 18-month perspective. (ClinicalTrials.gov Identifier: NCT01184586).

Extracorporeal shock wave therapy for bone marrow edema syndrome in patients with osteonecrosis of the femoral head: a retrospective cohort study

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.

Comparison of the effects between low- versus medium-energy radial extracorporeal shock wave therapy on knee osteoarthritis: A randomised controlled trial

Objective

This study aimed to compare the effects between low- versus medium-energy radial extracorporeal shock wave therapy on knee osteoarthritis (KOA).

Method

Forty-five patients (26 women and 19 men) aged 45–55 years with grade 2 KOA were randomly assigned into the following three groups (all n = 15): Group A received low-energy radial shock wave therapy (2000 shock/session [10 Hz], energy flux density [EFD] 0.02 mJ/mm²) with strengthening exercises once per week for 4 weeks; Group B received medium-energy radial shock wave therapy (2000 shock/session [10 Hz], EFD 0.178 mJ/mm²) with strengthening exercises once per week for 4 weeks; and Group C (control group) received sham shock wave therapy with strengthening exercises once per week for 4 weeks. Severity of pain was determined using the visual analogue scale, and knee physical function was assessed using the Arabic version of the knee injury and osteoarthritis outcome score physical function short form. Knee proprioception was measured before and after the treatment programme using an isokinetic dynamometer.

Results

The within-group analysis showed significant differences in severity of pain, knee physical function, and knee proprioception in Groups A and B before and after the treatment programme (p < 0.05). The between-group analysis showed significant differences in all variables after treatment, with more significant differences observed in Group B than in Groups A and C (p < 0.05).

Conclusion

Low- and medium-energy radial shock wave therapies are effective modalities for the treatment of KOA, with medium-energy radial shock wave therapy being superior to low-energy radial shock wave therapy.

Clinical Utility of Extracorporeal Shock Wave Therapy on Hypertrophic Scars of the Hand Caused by Burn Injury: A Prospective, Randomized, Double-Blinded Study

Postburn hypertrophic scarring is a common complication in burn injuries to the hands, often associated with impaired hand function. We evaluated the effects of extracorporeal shock wave therapy (ESWT), compared to a sham stimulation therapy, on hypertrophic scars of the hand caused by burn injury and investigated its effects on hand function. This was a double-blinded, randomized, controlled trial of 48 patients with a burn to their dominant right hand. The parameters of ESWT were as follows: energy flux density, 0.05–0.30 mJ/mm²; frequency, 4 Hz; 1000 to 2000 impulses per treatment; four treatments, once a week for four weeks. The outcomes measured were as follows: a 10-point visual analogue scale pain score; Vancouver scar scale for scar vascularity, height, pliability and pigmentation; ultrasound measurement of scar thickness; Jebsen−Taylor hand function test; grip strength; Perdue pegboard test; and the Michigan hand outcomes questionnaire. The change in the score from baseline to post-treatment was compared between the two groups. ESWT improved the pain score (p = 0.001), scar thickness (p = 0.018), scar vascularity (p = 0.0015), and improved hand function (simulated card-turning, p = 0.02; picking up small objects, p = 0.004). The other measured outcomes were not different between the two groups. ESWT is effective in decreasing pain, suppressing hypertrophic scarring, and improving hand function.

Extracorporeal Shock Wave Therapy for the Treatment of Osteoarthritis: A Systematic Review and Meta-Analysis

Background

Osteoarthritis is the most common musculoskeletal disease. Extracorporeal shockwave therapy had shown an effect on osteoarthritis in both some animal experiments and clinical studies, but there was no systematic review to confirm the value of shockwave therapy in the treatment of all types of osteoarthritis and compare it with other traditional therapies (especially traditional Chinese medicine).

Method

PubMed, Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Chinese National Knowledge Infrastructure, WANFANG database, and VIP database were searched up to December 10, 2019, to identify randomized controlled trials comparing shockwave therapy and other treatments for osteoarthritis. Visual analogue scale and the Western Ontario and McMaster Universities Osteoarthritis Index were extracted and analyzed by RevMan and STATA software as outcomes of pain reduction and functional improvement. Adverse reactions were recorded to evaluate the safety of shockwave therapy.

Results

Shockwave therapy had significant improvement in both pain reduction and functional improvement compared with placebo, corticosteroid, hyaluronic acid, medication, and ultrasound (P < 0.05). In functional improvement, shockwave therapy showed statistical improvement compared with kinesiotherapy and moxibustion (P < 0.05) but not with acupotomy surgery (P = 0.24). A significant difference between shockwave therapy and platelet-rich plasma was observed in pain reduction (P < 0.05) but not in functional improvement (P = 0.89). Meanwhile, a statistical difference was found between shockwave therapy and fumigation in functional improvement (P < 0.05) but not in pain reduction (P = 0.26). Additionally, there was no statistically significant difference between shockwave therapy and manipulation in both pain reduction (P = 0.21) and functional improvement (P = 0.45). No serious adverse reaction occurred in all of studies.

Conclusions

Extracorporeal shockwave therapy could be recommended in the treatment of osteoarthritis as a noninvasive therapy with safety and effectiveness, but the grade of recommendations needs to be discussed in a further study.

Extracorporeal shockwave therapy for the treatment of knee osteoarthritis: a meta-analysis

PURPOSE

Extracorporeal shockwave therapy (ESWT) has become a common practice for treating knee osteoarthritis (OA). However, the effectiveness and safety of this treatment are still questionable. This meta-analysis is aimed at determining the degree of pain reduction and functional outcome after ESWT for knee OA.

METHODS

We systematically searched MEDLINE, EMBASE, and other online databases. The articles comparing the outcomes between ESWT and controls were included in the analysis.

RESULTS

Nine studies with 705 patients were included. The pooled data revealed significantly lower pain scores in the ESWT groups than in the control groups within two weeks of treatment and six months after treatment (visual analogue scale, - 1.59, p = 0.0003, 95% confidence interval (CI) - 2.45 to - 0.72 at 2 weeks; - 1.12, p = 0.005, 95% CI - 1.89 to - 0.34 at 6 months). The ESWT group also had better functional outcomes four to six weeks post treatment (Western Ontario and McMaster Universities Osteoarthritis Index, - 11.96, p = 0.003, 95% CI - 19.76 to - 4.15). No rebound pain was noted for up to 12 months.

CONCLUSION

Using ESWT to treat knee OA may reduce pain and improve functional outcomes. The effect may last six months to one year. More prospective studies are needed to investigate the settings for ESWT to optimize treatment results.

Application and efficacy of extracorporeal shockwave treatment for knee osteoarthritis: A systematic review and meta-analysis

The increasing aging of the world population is accompanied by a rise in the incidence of knee osteoarthritis (KOA). There has been a growing interest in shockwave treatment for orthopedic diseases, including KOA. In previous trials, extracorporeal shockwave therapy (ESWT) was compared to physical therapy or placebo in the treatment of KOA. However, the efficacy and safety of ESWT for KOA remains disputed. The present meta-analysis assessed the effects of ESWT in KOA. The PubMed, Medline, Embase, Web of Science, Research Gate and the Cochrane Library were searched to identify comparative studies involving ESWT for patients with KOA. The outcome indicators included the visual analog scale (VAS) score, range of motion (ROM), the Lequesne index (LI) and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC). In the comparison of the ESWT vs. placebo groups, the primary outcomes included the VAS score and ROM, while the LI was the secondary outcome. In the comparison of the ESWT vs. physical therapy groups, the primary outcomes included the pain score and ROM, while the secondary outcome was the WOMAC index. Relevant data were analyzed using RevMan v5.3. The ESWT group had a lower VAS core, larger ROM and a better LI than the placebo group after 1 month of therapy (P<0.05). Furthermore, at 1 month post-therapy, the ESWT group had a lower VAS score, larger ROM and a better WOMAC than the physical therapy group (P<0.05). The outcomes regarding pain, ROM, LI and WOMAC were significantly different between the two different groups (P<0.05). The present meta-analysis suggested that ESWT may achieve a better therapeutic effect for patients with KOA as compared to physical therapy. However, high-quality trials with large sample sizes are essential to substantiate these results.

Hyaluronic Acid (HA), Platelet-Rich Plasm and Extracorporeal Shock Wave Therapy (ESWT) promote human chondrocyte regeneration in vitro and ESWT-mediated increase of CD44 expression enhances their susceptibility to HA treatment

Novel strategies have been proposed for articular cartilage damage occurring during osteoarthritis (OA) and -among these- Extracorporeal Shock Wave Therapy (ESWT), intra-articular injections of Platelet-Rich Plasma (PRP) or Hyaluronic Acid (HA) revealed encouraging results. To investigate the possible mechanisms responsible for those clinical benefits, we established primary cultures of human chondrocytes derived from cartilage explants and measured the in vitro effects of ESW, PRP and HA therapies. After molecular/morphological cell characterization, we assessed those effects on the functional activities of the chondrocyte cell cultures, at the protein and molecular levels. ESWT significantly prevented the progressive dedifferentiation that spontaneously occurs during prolonged chondrocyte culture. We then attested the efficiency of all such treatments to stimulate the expression of markers of chondrogenic potential such as SOX9 and COL2A, to increase the Ki67 proliferation index as well as to antagonize the traditional marker of chondrosenescence p16INK4a (known as Cdkn2a). Furthermore, all our samples showed an ESW- and HA-mediated enhancement of migratory and anti-inflammatory activity onto the cytokine-rich environment characterizing OA. Taken together, those results suggest a regenerative effect of such therapies on primary human chondrocytes in vitro. Moreover, we also show for the first time that ESW treatment induces the surface expression of major hyaluronan cell receptor CD44 allowing the increase of COL2A/COL1A ratio upon HA administration. Therefore, this work suggests that ESW-induced CD44 overexpression enhances the in vitro cell susceptibility of human chondrocytes to HA, presumably favouring the repair of degenerated cartilage.

A Randomized Controlled Trial on the Effects of Low-Dose Extracorporeal Shockwave Therapy in Patients With Knee Osteoarthritis

OBJECTIVE

To test the efficacy of low-dose extracorporeal shockwave therapy (ESWT) on osteoarthritis knee pain, lower limb function, and cartilage alteration for patients with knee osteoarthritis.

DESIGN

Randomized controlled trial with placebo control.

SETTING

Outpatient physical therapy clinics within a hospital network.

PARTICIPANTS

Eligible volunteers (N=63) with knee osteoarthritis (Kellgren-Lawrence grade II or III) were randomly assigned to 2 groups.

INTERVENTIONS

Patients in the experimental group received low-dose ESWT for 4 weeks while those in the placebo group got sham shockwave therapy. Both groups maintained a usual level of home exercise.

MAIN OUTCOME MEASURES

Knee pain and physical function were measured using a visual analog scale (VAS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Lequesne index at baseline, 5 weeks, and 12 weeks. Cartilage alteration was measured analyzing the transverse relaxation time (T2) mapping.

RESULTS

The VAS score, WOMAC, and Lequesne index of the ESWT group were significantly better than those of the placebo group at 5 and 12 weeks (P<.05). Both groups showed improvement in pain and disability scores over the 12-week follow-up period (P<.05). In terms of imaging results, there was no significant difference in T2 values between groups during the trial, although T2 values of the ESWT group at 12 weeks significantly increased compared to those at baseline (P=.004). The number and prevalence of adverse effects were similar between the 2 groups, and no serious side effects were found.

CONCLUSIONS

A 4-week treatment of low-dose ESWT was superior to placebo for pain easement and functional improvement in patients with mild to moderate knee osteoarthritis but had some negative effects on articular cartilage.

The effect of extracorporeal shock wave therapy on the treatment of moderate to severe knee osteoarthritis and cartilage lesion

BACKGROUND

Knee osteoarthritis (KOA) is a major cause leading to chronic bone and muscle pain. Extracorporeal shock wave therapy (ESWT) has been applied in treating KOA in recent years.

METHODS

From April 2016 to April 2017, 82 patients were diagnosed with KOA that received ESWT were selected as the ESWT group. The treatment parameters were as follows, 2.0 bar, 0.25 mJ/mm, and 8 Hz/s for twice a week for 4 weeks continuously. In addition, 104 patients receiving oral administration of nonsteroidal anti-inflammatory drugs (NSAIDs) from April 2015 to April 2016 were also selected as the NSAIDs group. At 4, 8, 12, and 16 weeks upon the completion of treatment, the Visual Analogue Scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were adopted to evaluate the changes in pain and function of patients in both groups. For the ESWT group, the 50-m quick walk time and gait analysis were applied to observe the functional recovery at 4, 8, 12, and 16 weeks upon the completion of treatment; meanwhile, patients were followed up by magnetic resonance imaging (MRI) at 24 weeks upon the completion of treatment, so as to observe the cartilage changes.

RESULTS

Differences in VAS, 4, 8, and 12 weeks after treatment were statistically significant compared with that before treatment (4.59 ± 0.5, P < .05; 2.55 ± 0.5, P < .05; 4.39 ± 0.49, P < .05). Differences in 4, 8, and 12 weeks after treatment were statistically significant compared with that before treatment (90.41 ± 6.64, P < .05; 59.94 ± 3.19, P < .05; 90.49 ± 6.87, P < .05). Gait analysis suggested differences in 50 m walk time, walking speed, swing phase, and stance phase 8 weeks after treatment were statistically significant compared with that before treatment (36.23 ± 4.08, P < .05; 1.25 ± 0.09, P < .05; 58.56 ± 0.87, P < .05; 41.44 ± 0.87, P < .05). Differences in the VAS and WOMAC at 4 and 8 weeks after treatment between ESWT group and NASIDs group were not statistically significant.

CONCLUSIONS

The ESWT has potential in reducing pain and improving knee function, and the therapeutic effects may peak at 8 weeks after the completion of treatment. Further research is needed to arrive at a definitive conclusion.

Radial extracorporeal shock wave therapy promotes osteochondral regeneration of knee joints in rabbits

Radial extracorporeal shock wave therapy (rESWT) has been proven to be effective for nonunion fractures. It was, thus, hypothesized that it may be used as a supplement therapy to promote osteochondral regeneration when combined with a scaffold previously prepared by our research group. In the present study, to verify this hypothesis, New Zealand white adult rabbits were anaesthetized and divided into three groups, as follows: Untreated control group, in which full-thickness cylindrical osteochondral defects were created without repairing; scaffold group, in which rabbits were implanted with the scaffolds; scaffold plus rESWT group, in which rabbits were implanted with scaffolds and then treated with rESWT at 2 weeks post-surgery. At 6 and 12 weeks after surgery, the animals were sacrificed. Nitric oxide (NO) levels in the synovial cavity of the knee joints were measured by the Griess method. In addition, macroscopic observation and the gross score according to the International Cartilage Repair Society (ICRS) histological scoring system were determined. Histological evaluation was also performed by hematoxylin-eosin and Safranin O/fast green staining. The results demonstrated that both the scaffold and scaffold plus rESWT treatments significantly reduced NO levels in the synovial cavity at 6 weeks after surgery (P<0.05), whereas no significant difference was observed at 12 weeks after surgery. The ICRS scores of the scaffold and scaffold plus rESWT groups were significantly higher in comparison with those in the control group (P<0.05), and rESWT further increased these scores at 12 weeks after surgery (P<0.05). Histological results revealed that osteochondral regeneration was improved after treatment with scaffold or scaffold plus rESWT, with the latter displaying better results. These data suggested that rESWT improved the osteochondral regeneration when applied in combination with the scaffold, and that one of the underlying mechanisms may involve the reduction of NO in the synovial fluid. Therefore, rESWT may be a useful treatment for knee osteochondral regeneration.

Extracorporeal shockwave therapy for the treatment of knee osteoarthritis: A retrospective study

This retrospective study investigated the effect and safety of extracorporeal shockwave therapy (ESWT) for treatment of knee osteoarthritis (KOA).In this retrospective study, 105 patients with KOA were included. Of those, 60 patients underwent ESWT, whereas 45 patients received laser therapy. Effect was measured by the Numeric Rating Scale (NRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). In addition, adverse events (AEs) were also recorded in this study. All outcome measurements were evaluated at the end of weeks 1, 6, and 12.Compared with the laser therapy, ESWT showed greater effect in KOA symptoms relief with regard to NRS, WOMAC total, and its subscores at week 6 (P < .05) and week 12 (P < .01) after treatment. No AE, however, occurred in both groups.The results of this retrospective study found that ESWT may be efficacious and safe for the treatment of patients with KOA. It, however, had an intrinsic limitation as a retrospective study. Prospective study with larger sample size is still needed to warrant the result of this study in the future.

A Macaca Fascicularis Knee Osteoarthritis Model Developed by Modified Hulth Combined with Joint Scratches

BACKGROUND Osteoarthritis is a common degenerative disease of joints, and animal models have important significance in the investigation of this disease. The aim of this study was to develop a better method for developing osteoarthritis models in primates by comparing the modified Hulth score combined with joint scratches modeling method with others. MATERIAL AND METHODS We randomly divided 15 young male Macaca fascicularis and 3 old male Macaca fascicularis into 6 groups (n=3). Knee osteoarthritis (KOA) models were developed with different methods: modified Hulth combined with joint scratches (Group A), modified Hulth (Group B), Hulth (Group C), spontaneous models (Group D); sham-operated (Group E), and blank control (Group F). Morphology and pathology of knee joints were observed at the 8th week after surgery. The levels of WBC, IL-1b, and TGF-b1 in synovial fluid were detected by ELISA. The levels of COL-II, ACAN, and MMP-13 in articular cartilage were examined by RT-qPCR and Western blot. RESULTS In Brittberg and modified Mankin score, Group A was higher than B (P<0.05) and lower than C (P<0.05), and there was no statistically significant difference between Group A and D (P>0.05). Except for Group E and F, the differences were statistically significant among others in WBC, IL-1β, and TGF-β1 (P<0.05). COL-II and ACAN decreased and MMP-13 increased, and there was no significant difference between Groups A and D (P>0.05) or between Groups E and F (P>0.05). There were statistically significant differences among other groups (P<0.05). CONCLUSIONS The models developed by modified Hulth combined with joint scratches were the closet to spontaneous models at the 8th week after surgery.

Next-generation sequencing identifies articular cartilage and subchondral bone miRNAs after ESWT on early osteoarthritis knee

Extracorporeal shockwave therapy (ESWT) has shown chondroprotective effects on the initiation of the osteoarthritis (OA) changes of the rat knee. This study evaluated 69 significant expressed profiles of microRNA (miRNA) in the articular cartilage and subchondral bone after ESWT. There were 118 target genes identified for miRNAs of interest in articular cartilage and 214 target genes in subchondral bone by next generation sequencing (NGS). In principal component analysis (PCA), the relationships of miRNA expression in bone and cartilage were improved after ESWT. Global functional annotation showed that predicted targets were involved in cartilage development, inflammatory and immune response, ion binding, angiogenesis, cell adhesion, cell cycle, transcription and translation, gene expression, NTP binding, signal transduction, collagen fibril organization, apoptotic process, chondrocyte differentiation, cell differentiation, bone development as well as cell proliferation. The miRNAs profile and the target genes were comprehensively surveyed and compared in articular cartilage and subchondral bone of early OA knee before and after ESWT. Our study represents the direct assessment to date of miRNA expression profiling in early OA articular cartilage and subchondral bone. The results provide insights that could contribute to the development of new biomarkers and therapeutic strategies for OA changes and the treatment with ESWT.

Comparison Between Extracorporeal Shock Wave Therapy and Intra-articular Hyaluronic Acid Injections in the Treatment of First Carpometacarpal Joint Osteoarthritis

Objective

To compare extracorporeal shockwave therapy (ESWT) with hyaluronic acid (HA) intra-articular injections in terms of pain relief, improvement in hand function, and strength in subjects with first carpometacarpal (CMC) joint osteoarthritis.

Methods

Fifty-eight patients received either focused ESWT or HA injection once a week for 3 consecutive weeks. In the ESWT group, 2,400 consecutive pulses were performed during each treatment session using a frequency of 4 Hz and an energy flux density of 0.09 mJ/mm². The HA group underwent one cycle of three injections of 0.5 cm³ HA. The main outcome measures were pain and hand function as measured by the visual analogue scale (VAS) and Duruoz Hand Index (DHI), respectively. The secondary outcomes were grip and pinch strength. Each assessment was performed at baseline, at the end of treatment, and at 3- and 6-month follow-up visits.

Results

According to VAS and DHI scores, a significant change in test performance was observed over time in both groups (p<0.001), with a greater average improvement in painful symptomatology at the 6-month follow-up in the ESWT group. A significant improvement in strength was observed in both groups, but the ESWT group showed better results on the pinch test starting immediately at the end of treatment.

Conclusion

The use of ESWT in patients with first CMC joint osteoarthritis leads to a reduction in pain, an improvement in pinch test performance that persists for at least 6 months, and a decrease in hand disability up to the 6-month follow-up visit.

A review of the cellular and molecular effects of extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) is a novel therapeutic modality and its use in promoting connective tissue repair and analgesic effect has been advocated in the literature. It is convenient, cost-effective, and has negligible complications; it therefore bypasses many of the problems associated with surgical interventions. This paper reviews the proposed mechanisms of action in promoting tissue repair and regeneration as well as analysing its efficacy providing an analgesic effect in clinical applications. Further research will be required to not only identify the underlying mechanisms more precisely, but will also be critical for ensuring consistency across the literature so that the most beneficial treatment protocol can be developed. Extracorporeal shockwave therapy stands as a promising alternative modality in promoting tissue repair.

Efficacy of nerve growth factor antibody in a knee osteoarthritis pain model in mice

Background

Nerve growth factor (NGF) is not only an important factor in nerve growth but also a major contributor to the production of inflammation. It has been reported that inhibiting NGF could reduce several types of pain in several animal models. Here, we aimed to clarify the efficacy of NGF antibody in a knee osteoarthritis (OA) pain model in mice.

Method

Six-week-old male C57BR/J mice were used (n = 30). Ten mice comprised the control group, which received saline injection into the right knee joints; the other 20 mice comprised the experimental group, which received monoiodoacetate (MIA) injection into the right knee joints. Three weeks after surgery, the 20 experimental mice were randomly placed into treatment groups which received either sterile saline (non-treat group: 10 mg/kg, i.p.) or an anti-NGF antibody (anti-NGF group: 10 mg/kg, i.p.). Simultaneously, all mice received fluorogold (FG) retrograde neurotracer injection into their right joints. In a behavioral study, we evaluated gait using the CatWalk quantitative gait analysis system before surgery, 3 weeks after surgery (before treatment), 4 weeks after surgery (one week after surgery), and 5 weeks after surgery (2 weeks after surgery). In immunohistochemical analysis, the right dorsal root ganglia (DRGs) from the L4–L6 levels were resected 5 weeks after surgery (2 weeks after surgery). They were immunostained for calcitonin gene-related peptide (CGRP), and the number of FG-labeled or CGRP-immunoreactive (IR) DRG neurons was counted.

Results

On gait analysis using the CatWalk system, duty cycle, swing speed, and print area were decreased in non-treat group compared with those in control group and improved in the anti-NGF group compared with those in non-treat group. CGRP expression in DRGs was up-regulated in non-treat group compared with that in control group and suppressed in the anti-NGF group compared with that in non-treat group (both p < 0.05).

Conclusions

MIA injection into the knee joint induced gait impairment and the up-regulation of CGRP in DRG neurons in a knee OA pain model in mice. Intraperitoneal injection of anti-NGF antibody suppressed this impairment of gait and up-regulation of CGRP in DRG neurons. These finding suggest that anti-NGF therapy might be valuable in the treatment of OA pain in the knee.

Effect of Extracorporeal Shockwave Therapy Versus Intra-articular Injections of Hyaluronic Acid for the Treatment of Knee Osteoarthritis

Objective

To evaluate and compare the effects and outcomes of extracorporeal shock wave therapy (ESWT) and intra-articular injections of hyaluronic acid (HA) in patients with knee osteoarthritis (OA).

Methods

Of the 78 patients recruited for the study, 61 patients met the inclusion criteria. The enrolled patients were randomly divided into two groups: the ESWT group and the HA group. The ESWT group underwent 3 sessions of 1,000 shockwave pulses performed on the affected knee with the dosage adjusted to 0.05 mJ/mm² energy. The HA group was administered intra-articular HA once a week for 3 weeks with a 1-week interval between each treatment. The results were measured with the visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequesne index, 40-m fast-paced walk test, and stair-climb test (SCT). A baseline for each test was measured before treatment and then the effects of the treatments were measured by each test at 1 and 3 months after treatment.

Results

In both groups, the scores of the VAS, WOMAC, Lequesne index, 40-m fast-paced walk test, and SCT were significantly improved in a time-dependent manner (p<0.01). There were no statistically significant differences measured at 1 and 3 months after treatment between the two groups (p>0.05).

Conclusion

The ESWT can be an alternative treatment to reduce pain and improve physical functions in patients with knee OA.

Efficacy of extracorporeal shockwave therapy and low-intensity pulsed ultrasound in a rat knee osteoarthritis model: A randomized controlled trial

OBJECTIVE

This study aims to assess the efficacy of extracorporeal shockwave therapy (ESWT) and low-intensity pulsed ultrasound (LIPUS) on osteoarthritic rat knees.

MATERIAL AND METHODS

Twenty-four rats were divided into 3 groups: group 1-control (n=8), group 2-LIPUS (n=8) and group 3-ESWT (n=8). Cartilage degeneration was provided using mono-iodo-asetate (MIA). One milligram of MIA was delivered to the right knees in group 1 and both knees in group 2 and 3. A 0.09% saline solution was delivered to the left knees in group 1 for control. Twenty-four hours after the delivery, ESWT was applied once on the right knees in the group 2 rats to the medial tibia plateu with a 1 Hz frequency and 800 impulses. LIPUS was applied to the right knees in the group 2 rats to the medial tibia plateu with a 3 mHz frequency and 40 mW/cm2 intensity for 20 minutes over a period of 15 days. Pain scores were measured with a knee bend test. Bone mineral density measurements and scintigraphic bone scans were performed. Histopathological examination was done using a modified Mankin scale.

RESULTS

There was no difference among the right knee subchondral bone osteoblastic activities (p>0.05). The left knee osteoblastic activities in the LIPUS and extracorporeal shockwave therapy (ESWT) groups were higher than those in the control group (p<0.05), but there was no difference between the LIPUS and ESWT groups. There was no difference among the groups for both knee subchondral bone BMD values (p>0.05). The modified Mankin scores of both the right and left knees of the ESWT and LIPUS groups were lower than those of the control group (p<0.05), but there was no difference between the ESWT and LIPUS groups. The pain scores of both knees of the ESWT and LIPUS groups at day 7 were higher than those of the control group (p<0.05), but there was no difference between the ESWT and LIPUS groups. There was no difference among the pain scores of the right knees at day 14 (p<0.05).

CONCLUSION

ESWT and LIPUS have systemic proliferative and regenerative effects on cartilage and tissue.

Extracorporeal Shockwave Therapy Enhances Expression of Pdia-3 Which Is a Key Factor of the 1α,25-Dihydroxyvitamin D 3 Rapid Membrane Signaling Pathway in Treatment of Early Osteoarthritis of the Knee

The goal of our research was demonstrated that multiple molecules in microenvironments of the early osteoarthritis (OA) joint tissue may be actively responded to extracorporeal shockwave therapy (ESWT) treatment, which potentially regulated biological function of chondrocytes and synovial cells in early OA knee. We demonstrated that shockwave treatment induced the expression of protein-disulfide isomerase-associated 3 (Pdia-3) which was a significant mediator of the 1α,25-Dihydroxyvitamin D 3 (1α,25(OH)2D3) rapid signaling pathway, using two-dimensional electrophoresis, histological analysis and quantitative polymerase chain reaction (qPCR). We observed that the expression of Pdia-3 at 2 weeks was significantly higher than that of other group at 4, 8, and 12 weeks post-shockwave treatment in early OA rat knee model. The other factors of the rapid membrane signaling pathway, including extracellular signal-regulated protein kinases 1 (ERK1), osteopontin (OPG), alkaline phosphatase (ALP), and matrix metallopeptidase 13 (MMP13) were examined and were found to be significantly increased at 2 weeks post-shockwave treatment by qPCR in early OA of the knee. Our proteomic data revealed significant Pdia-3 expression in microenvironments of OA joint tissue that could be actively responded to ESWT, which may potentially regulate the biological functions of chondrocytes and osteoblasts in the treatment of the early OA of the knee.

Changes of articular cartilage and subchondral bone after extracorporeal shockwave therapy in osteoarthritis of the knee

We assessed the pathological changes of articular cartilage and subchondral bone on different locations of the knee after extracorporeal shockwave therapy (ESWT) in early osteoarthritis (OA). Rat knees under OA model by anterior cruciate ligament transaction (ACLT) and medial meniscectomy (MM) to induce OA changes. Among ESWT groups, ESWT were applied to medial (M) femur (F) and tibia (T) condyles was better than medial tibia condyle, medial femur condyle as well as medial and lateral (L) tibia condyles in gross osteoarthritic areas (p<0.05), osteophyte formation and subchondral sclerotic bone (p<0.05). Using sectional cartilage area, modified Mankin scoring system as well as thickness of calcified and un-calcified cartilage analysis, the results showed that articular cartilage damage was ameliorated and T+F(M) group had the most protection as compared with other locations (p<0.05). Detectable cartilage surface damage and proteoglycan loss were measured and T+F(M) group showed the smallest lesion score among other groups (p<0.05). Micro-CT revealed significantly improved in subchondral bone repair in all ESWT groups compared to OA group (p<0.05). There were no significantly differences in bone remodeling after ESWT groups except F(M) group. In the immunohistochemical analysis, T+F(M) group significant reduced TUNEL activity, promoted cartilage proliferation by observation of PCNA marker and reduced vascular invasion through observation of CD31 marker for angiogenesis compared to OA group (P<0.001). Overall the data suggested that the order of the effective site of ESWT was T+F(M) ≧ T(M) > T(M+L) > F(M) in OA rat knees.

Defocused Shock Wave Therapy for Chronic Soft Tissue Wounds in the Lower Limbs: A Pilot Study

Chronic soft tissue wounds of the lower limbs are debilitating, painful and often unresponsive to advanced dressing treatments. Extracorporeal shock wave therapy (ESWT) could represent an alternative treatment. Ten patients with chronic soft tissue wounds of the legs, unresponsive to advanced dressing treatments for more than 3 mo, underwent three defocused ESWT sessions at 72-h intervals. In every session, the sum of 300 standard pulses + 100 pulses per square centimeter was applied at 0.15 mJ/mm² and 4 Hz over the edge of the wound. The wound size in square centimeters, Bates-Jensen Wound Assessment Tool and visual analogue scale were used as outcome measures. A significant reduction in wound size and Bates-Jensen Wound Assessment Tool and visual analogue scale values from pre-treatment to 90 d was observed. Seven of ten ulcers healed completely and nine of ten patients reported complete pain relief. Defocused ESWT represents a non-invasive, feasible strategy for difficult-to-treat soft tissue wounds of the lower limbs.

Extracorporeal shockwave therapy as a novel and potential treatment for degenerative cartilage and bone disease: Osteoarthritis. A qualitative analysis of the literature

Osteoarthritis (OA) is characterized with pathological changes on articular cartilage and subchondral bone, with clinical symptoms of pain and motor dysfunction in affected joints. A growing number of investigations demonstrated the therapeutic effects of extracorporeal shockwave therapy (ESWT) on joints with OA. While the partial mechanisms of action are based on cellular mechanotransduction through cytoskeleton into nuclei to regulate gene expression and cause biophysical influences, the efficacy and exact mechanisms are still under exploration. At present, a summary of the evidence regarding effectiveness of ESWT on OA is not available. The purpose of this review is thus to offer an overview of ESWT in the management of OA in the aspects of cartilage, subchondral bone, pain sensation and motor function, in hopes of eliciting further multi-disciplinary scientific investigations into this promising application as an adjunct to other modalities or surgery. The optimal frequencies, impulses, energy intensity and protocols of ESWT in the management of OA continue to be elucidated. Further studies are required to reveal its exact mechanisms and biophysical effects on cells, animals and humans prior to the clinical application.

Efficacy of Direct Injection of Etanercept into Knee Joints for Pain in Moderate and Severe Knee Osteoarthritis

PURPOSE

Osteoarthritic (OA) pain is largely considered to be inflammatory pain. However, during the last stage of knee OA, sensory nerve fibers in the knee are shown to be significantly damaged when the subchondral bone junction is destroyed, and this can induce neuropathic pain. Several authors have reported that tumor necrosis factor-α (TNFα) in a knee joint plays a crucial role in pain modulation. The purpose of the current study was to evaluate the efficacy of etanercept, a TNFα inhibitor, for pain in knee OA.

MATERIALS AND METHODS

Thirty-nine patients with knee OA and a 2-4 Kellgren-Lawrence grading were evaluated in this prospective study. Patients were divided into two groups; hyaluronic acid (HA) and etanercept injection. All patients received a single injection into the knee. Pain scores were evaluated before and 4 weeks after injection using a visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and they were compared between the groups.

RESULTS

Before injection, VAS and WOMAC scores were not significantly different between the groups (p>0.05). Significant pain relief was found in the etanercept group at 1 and 2 weeks by VAS, and at 4 weeks by WOMAC score, compared with the HA group (p<0.05). No adverse events were observed in either group.

CONCLUSION

Direct injection of etanercept into OA knee joints was an effective treatment for pain in moderate and severe OA patients. Furthermore, this finding suggests that TNFα is one factor that induces OA pain.

The Dose-Related Effects of Extracorporeal Shock Wave Therapy for Knee Osteoarthritis

Objective

To investigate the dose-related effects of extracorporeal shock wave therapy (ESWT) for knee osteoarthritis.

Methods

Seventy-five subjects were recruited, 60 of which met the inclusion criteria. The patients were randomly classified into two groups: group L, which was a low-energy group (n=30; 1,000 shocks/session; energy flux density [EFD], 0.040 mJ/mm²) and group M, which was a medium-energy group (n=30; 1,000 shocks/session; EFD, 0.093 mJ/mm²). For each group, 1,000 shock waves were delivered to the medial tibial plateau area, once a week, for 3 weeks. The main outcome measures were the visual analogue scale (VAS), the Roles and Maudsley (RM) score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and the Lequesne index. Each assessment was performed at the baseline and at 1, 4, and 12 weeks after ESWT.

Results

In both groups, the VAS, the RM and WOMAC scores, and the Lequesne index were significantly improved over time (p<0.001), and group M showed greater improvement over group L at the 1, 4 and 12 weeks assessments.

Conclusion

In this study, medium-energy group (group M) showed greater improvement in regard to relieving pain and restoring functional outcome than the low-energy group (group L). Therefore, EFD can be considered to have significant influence when treating with ESWT for knee osteoarthritis.

Treatment Outcomes of Corticosteroid Injection and Extracorporeal Shock Wave Therapy as Two Primary Therapeutic Methods for Acute Plantar Fasciitis: A Prospective Randomized Clinical Trial

The outcome of corticosteroid injection (CSI) and extracorporeal shock wave therapy (ESWT) as primary treatment of acute plantar fasciitis has been debated. The purpose of the present study was to evaluate and compare the therapeutic effects of CSI and ESWT in patients with acute (<6-week duration) symptomatic plantar fasciitis. Of the 116 eligible patients, 68 were randomized to 2 equal groups of 34 patients, each undergoing either ESWT or CSI. The ESWT method included 2000 impulses with energy of 0.15 mJ/mm(2) and a total energy flux density of 900 mJ/mm(2) for 3 consecutive sessions at 1-week intervals. In the CSI group, 40 mg of methyl prednisolone acetate plus 1 mL of lidocaine 2% was injected into the maximal tenderness point at the inframedial calcaneal tuberosity. The success and recurrence rates and pain intensity measured using the visual analog scale, were recorded and compared at the 3-month follow-up visit. The pain intensity had reduced significantly in all patients undergoing either technique. However, the value and trend of pain reduction in the CSI group was significantly greater than those in the ESWT group (p < .0001). In the ESWT and CSI groups, 19 (55.9%) and 5 (14.7%) patients experienced treatment failure, respectively. Age, gender, body mass index, and recurrence rate were similar between the 2 groups (p > .05). Both ESWT and CSI can be used as the primary and/or initial treatment option for treating patients with acute plantar fasciitis; however, the CSI technique had better therapeutic outcomes.

Efficacy of combination of meloxicam and pregabalin for pain in knee osteoarthritis

PURPOSE

Osteoarthritic pain is largely considered to be inflammatory pain. Sensory nerve fibers innervating the knee have been shown to be significantly damaged in rat models of knee osteoarthritis (OA) in which the subchondral bone junction is destroyed, and this induces neuropathic pain (NP). Pregabalin was developed as a pain killer for NP; however, there are no reports on pregabalin use in OA patients. The purpose of this study was to investigate the efficacy of pregabalin for pain in OA patients.

MATERIALS AND METHODS

Eighty-nine knee OA patients were evaluated in this randomized prospective study. Patients were divided into meloxicam, pregabalin, and meloxicam+pregabalin groups. Pain scores were evaluated before and 4 weeks after drug application using a visual analogue scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Pain scales among groups were compared using a Kruskal-Wallis test.

RESULTS

Before drug application, there was no significant difference in VAS and WOMAC scores among the three groups (p>0.05). Significant pain relief was seen in the meloxicam+pregabalin group in VAS at 1, 2, and 4 weeks, and WOMAC score at 4 weeks, compared with the other groups (p<0.05). No significant pain relief was seen in the meloxicam only group in VAS during 4 weeks and WOMAC score at 4 weeks compared with the pregabalin only group (p>0.05).

CONCLUSION

Meloxicam+pregabalin was effective for pain in OA patients. This finding suggests that OA pain is a combination of inflammatory and NP.

Extracorporeal shockwave therapy shows site-specific effects in osteoarthritis of the knee in rats

PURPOSE

This study investigated the site-specific effects of extracorporeal shockwave therapy (ESWT) in osteoarthritis of the knee in rats.

METHODS

Sixty SD rats were divided into five groups. Group I was the control and received sham surgery without anterior cruciate ligament transection (ACLT) and medial meniscectomy (MM) and no ESWT. Group II received ACLT + MM, but no ESWT. Group III received ACLT + MM and ESWT at distal femur. Group IV received ACLT + MM and ESWT at proximal tibia. Group V received ACLT + MM and ESWT at distal femur and proximal tibia. Each ESWT session consisted of 800 impulses at 14 kV (= 0.219 mJ/mm(2) energy flux density). The evaluations included radiograph, bone mineral density (BMD), histomorphologic examination, and immunohistochemical analysis.

RESULTS

Radiographic appearance: Group II showed progressive osteoarthritis of the knee at 12 and 24 wk, whereas only subtle changes were noted in Groups I, III, VI, and V. BMD results: Group II showed significant decreases of BMD at 12 and 24 wk. The BMDs of Groups III, IV, and V were comparable to Group I. Cartilage degradation: Group II showed significant increases of Mankin score, Safranin O stain, and matrix metalloproteinase 13 and decrease of collagen II at 12 and 24 wk. The changes of Mankin score, Safranin O stain, matrix metalloproteinase 13, and collagen II in Groups III, IV, and V were comparable to Group I. Subchondral bone remodeling: Group II showed significant decreases of vascular endothelial growth factor, bone morphogenetic protein 2, and osteocalcin at 12 and 24 wk as compared to Group I. The changes of vascular endothelial growth factor, bone morphogenetic protein 2, and osteocalcin in Groups III, IV, and V were comparable to Group I.

CONCLUSION

ESWT shows site-specific effects at distal femur and proximal tibia in osteoarthritis of the knee in rats. The effects of ESWT are consistent at distal femur and proximal tibia, with no additive effects when both areas were simultaneously treated.

Extracorporeal shockwave therapy shows a number of treatment related chondroprotective effect in osteoarthritis of the knee in rats

BACKGROUND

Extracorporeal shockwave therapy (ESWT) shows chondroprotective effect in osteoarthritis of the rat knees. However, the ideal number of ESWT is unknown. This study investigated the effects of different numbers of ESWT in osteoarthritis of the knee in rats.

METHODS

Forty-five male Sprague-Dawley rats were divided into five groups. Group I underwent sham arthrotomy without anterior cruciate ligament transection (ACLT) or medial meniscectomy (MM) and received no ESWT. Group II underwent ACLT + MM and received no ESWT. Group III underwent ACLT + MM, and received ESWT once a week for one treatment. Group IV underwent ACLT + MM and received ESWT twice a week for 2 treatments. Group V underwent ACLT + MM and received ESWT three times a week for 3 treatments. Each treatment consisted of 800 impulses of shockwave at 14 Kv to the medial tibia condyle. The evaluations included radiographs of the knee, histomorphological examination and immunohistochemical analysis at 12 weeks.

RESULTS

At 12 weeks, group II and V showed more radiographic arthritis than groups I, III and IV. On histomorphological examination, the Safranin O matrix staining in groups III and IV are significantly better than in groups II and V, and the Mankin scores in groups III and IV are less than groups II and V. Groups III and IV showed significant decreases of Mankin score and increase of Safranin O stain as compared to group I. Group V showed significant increases of Mankin score and a decrease of Safranin O stain as compared to group II. In articular cartilage, group II showed significant increase of MMP13 and decrease of collagen II as compared to group I. Groups III and IV showed significant decrease of MMP13 and increase of collagen II as compared to group I. Group V showed significant increase of MMP13 and decrease of collagen II as compared to group II. In subchondral bone, vWF, VEGF, BMP-2 and osteocalcin significantly decreased in groups II and V, but increased in groups III and IV relative to group I.

CONCLUSIONS

ESWT shows a number of treatment related chondroproctective effect in osteoarthritis of the knee in rats.

Extracorporeal shock-wave therapy reduces progression of knee osteoarthritis in rabbits by reducing nitric oxide level and chondrocyte apoptosis

INTRODUCTION

The goal for treating osteoarthritis (OA) is finding ways to decrease joint pain and dysfunction and prevent and slow the cartilage degeneration. Extracorporeal shock-wave therapy (ESWT) has been found to improve motor dysfunction and ameliorate pain with OA in animals. However, few studies have found that it can prevent and slow joint degeneration in vivo. The aim of study was to investigate the effect of ESWT on OA in rabbit.

MATERIALS AND METHODS

A total of 30 male New Zealand white rabbits were divided into 3 groups: control, OA induced by anterior cruciate ligament transaction (ACLT), and ALCT plus ESWT. The animals were killed at 4 and 8 weeks. Nitric oxide (NO) level was measured in the synovial cavity of knee joints, and cartilage sections were graded macroscopically by a Mankin scoring system. Chondrocyte apoptosis was investigated by flow cytometry and the expression of active caspase 3 by indirect immunohistochemistry.

RESULTS

ESWT significantly reduced the NO level in the synovial cavity of knee joints (P < 0.05) and chondrocyte apoptosis (P < 0.05) of rabbits with OA. ESWT treatment significantly decreased the severity of cartilage lesions at both times as compared to rabbits with OA alone (P < 0.05).

CONCLUSION

ESWT reduced the progression of OA in rabbits. This effect may be related to decreased level of NO and is likely mediated by reduced chondrocyte apoptosis. ESWT may be a useful treatment for knee OA.

Sensory innervation and inflammatory cytokines in hypertrophic synovia associated with pain transmission in osteoarthritis of the hip: a case-control study

OBJECTIVE

To clarify the sensory innervation and inflammatory cytokines in hypertrophic synovia associated with pain transmission in OA of the hip.

METHODS

A piece of the synovium was extracted during reconstruction surgery in 50 patients with OA of the hip as an inflammatory synovium and in 12 patients with femoral neck fracture as a normal synovium. Each sample was immersed in fixative solution, sectioned on a cryostat, and then processed for immunohistochemistry using antibodies as follows: neuron-specific class III β-tubulin (TuJ-1) as a general marker for nerve fibres, calcitonin gene-related peptide (CGRP) for sensory nerve fibres, nuclear factor κB (NF-κB) for the protein complex controlling the transcription of DNA in cellular responses to painful stimuli, and TNF-α for cytokines involved in acute inflammation. The number of immunopositive cells and fibres were counted using a fluorescence microscope.

RESULTS

In the inflammatory synovium of OA of the hip, TuJ-1 was positive in 46% (23 hips). Of those positive for TuJ-1, 78% (18 hips) were also positive for CGRP, but 22% (5 hips) were negative for CGRP. NF-κB was positive in 68% (34 hips). Of those positive for NF-κB, 76% (26 hips) were also positive for TNF-α, but 24% (8 hips) were negative for TNF-α. In normal synovia, all four substances were negative.

CONCLUSION

We suggest sensory innervation and inflammatory cytokines in hypertrophic synovia are associated with nociception in OA of the hip.

TRIAL REGISTRATION

University Hospital Medical Information Network, www.umin.ac.jp, UMIN000001335.