Selective loss of unmyelinated nerve fibers after extracorporeal shockwave application to the musculoskeletal system

Extracorporeal Shock Wave Therapy and the Handstand-Position Radiography for Proximal Humeral Epiphysiolysis in Elite Gymnasts: A Report of Two Cases

We report two cases of proximal humeral epiphysiolysis in elite gymnasts. Both patients presented with shoulder pain during weight-bearing movements. The patient in case 1, treated with extracorporeal shock wave therapy (ESWT), exhibited rapid bone repair and pain relief, allowing an early return to competition. In the case 2 patient, humeral shortening was identified. Handstand-position radiography revealed compensatory scapular movements, negating the need for surgical intervention. These findings highlight ESWT's potential in promoting bone repair and the utility of handstand-position radiography in assessing humeral length. Both methods provide innovative treatment approaches for proximal humeral epiphysiolysis in gymnasts.

Low-Intensity Extracorporeal Shock Wave Therapy Ameliorates Detrusor Hyperactivity with Impaired Contractility via Transient Potential Vanilloid Channels: A Rat Model for Ovarian Hormone Deficiency

This study explores low-intensity extracorporeal shock wave therapy (LiESWT)'s efficacy in alleviating detrusor hyperactivity with impaired contractility (DHIC) induced by ovarian hormone deficiency (OHD) in ovariectomized rats. The rats were categorized into the following four groups: sham group; OVX group, subjected to bilateral ovariectomy (OVX) for 12 months to induce OHD; OVX + SW4 group, underwent OHD for 12 months followed by 4 weeks of weekly LiESWT; and OVX + SW8 group, underwent OHD for 12 months followed by 8 weeks of weekly LiESWT. Cystometrogram studies and voiding behavior tracing were used to identify the symptoms of DHIC. Muscle strip contractility was evaluated through electrical-field, carbachol, ATP, and KCl stimulations. Western blot and immunofluorescence analyses were performed to assess the expressions of various markers related to bladder dysfunction. The OVX rats exhibited significant bladder deterioration and overactivity, alleviated by LiESWT. LiESWT modified transient receptor potential vanilloid (TRPV) channel expression, regulating calcium concentration and enhancing bladder capacity. It also elevated endoplasmic reticulum (ER) stress proteins, influencing ER-related Ca2+ channels and receptors to modulate detrusor muscle contractility. OHD after 12 months led to neuronal degeneration and reduced TRPV1 and TRPV4 channel activation. LiESWT demonstrated potential in enhancing angiogenic remodeling, neurogenesis, and receptor response, ameliorating DHIC via TRPV channels and cellular signaling in the OHD-induced DHIC rat model.

Efficacy of focused shockwave therapy in patients with moderate-to-severe carpal tunnel syndrome: a preliminary study

OBJECTIVE

To evaluate the efficacy of focused extracorporeal shockwave therapy for symptoms and function in patients with moderate-to-severe carpal tunnel syndrome.

DESIGN

A single-blind randomized controlled trial.

SUBJECTS

Twenty-four outpatients with moderate-to-severe carpal tunnel syndrome.

METHODS

Patients were randomly allocated into 2 groups: a focused extracorporeal shockwave therapy group and a control group. The focused extracorporeal shockwave therapy group received conservative treatment in addition to focused extracorporeal shockwave therapy with an energy flux density ranging from 0.01 to 0.15 mJ/mm2, a frequency of 4-5 Hz, and 1500 pulses per session once a week for a total of 3 sessions. The control group received only conservative treatment, which comprised gliding exercises for carpal tunnel syndrome, a night wrist splint, and lifestyle modification. The Thai version of the Boston Carpal Tunnel Questionnaire (T-BCTQ), a nerve conduction study, and ultrasonography of the median nerve cross-sectional area were performed before treatment and at 3 and 6 weeks after baseline.

RESULTS

The T-BCTQ symptom and function scores had significantly decreased in both groups, favouring focused extracorporeal shockwave therapy at all time-points. In addition, distal sensory and motor latency were significantly different between the groups at 3 weeks from baseline.

CONCLUSION

Focused extracorporeal shockwave therapy plus conservative treatment effectively provided short-term improvement in symptoms, hand function, and nerve conduction in patients with moderate-to-severe carpal tunnel syndrome compared with conservative treatment alone.

Extracorporeal Shock Wave Therapy for the Treatment of Musculoskeletal Pain: A Narrative Review

Extracorporeal shock waves are high-intensity mechanical waves (500-1000 bar) of a microsecond duration with a morphology characterized by a rapid positive phase followed by a negative phase.

BACKGROUND

Extracorporeal shock waves have been used for pain treatment for various sub-acute and chronic musculoskeletal (MSK) problems since 2000. The aim of this article is to update information on the role of extracorporeal shock wave therapy (ESWT) in the treatment of various pathologies that cause MSK pain.

METHODS

Given that in the last two years, articles of interest (including systematic reviews and meta-analyses) have been published on less known indications, such as low back pain, nerve entrapments, osteoarthritis and bone vascular diseases, a literature search was conducted in PubMed, the Cochrane Database, EMBASE, CINAHL and PEDro, with the aim of developing a narrative review of the current literature on this topic. The purposes of the review were to review possible new mechanisms of action, update the level of evidence for known indications and assess possible new indications that have emerged in recent years.

RESULTS

Although extracorporeal shock waves have mechanical effects, their main mechanism of action is biological, through a phenomenon called mechanotransduction. There is solid evidence that supports their use to improve pain in many MSK pathologies, such as different tendinopathies (epicondylar, trochanteric, patellar, Achilles or calcific shoulder), plantar fasciitis, axial pain (myofascial, lumbar or coccygodynia), osteoarthritis and bone lesions (delayed union, osteonecrosis of the femoral head, Kienbock's disease, bone marrow edema syndrome of the hip, pubis osteitis or carpal tunnel syndrome). Of the clinical indications mentioned in this review, five have a level of evidence of 1+, eight have a level of evidence of 1-, one indication has a level of evidence of 2- and two indications have a level of evidence of 3.

CONCLUSIONS

The current literature shows that ESWT is a safe treatment, with hardly any adverse effects reported. Furthermore, it can be used alone or in conjunction with other physical therapies such as eccentric strengthening exercises or static stretching, which can enhance its therapeutic effect.

Shock waves as treatment of mouse myofascial trigger points

INTRODUCTION

An abnormal increase in spontaneous neurotransmission can induce subsynaptic knots in the myocyte called myofascial trigger points. The treatment of choice is to destroy these trigger points by inserting needles. However, 10% of the population has a phobia of needles, blood, or injuries. Therefore, the objective of this study is to verify the usefulness of shock waves in the treatment of myofascial trigger points.

METHODS

Two groups of mice have been developed for this: healthy muscles treated with shock waves; trigger points affected muscles artificially generated with neostigmine and subsequently treated with shock waves. Muscles were stained with methylene blue, PAS-Alcian Blue, and labeling the axons with fluorescein and the acetylcholine receptors with rhodamine. Using intracellular recording the frequency of miniature endplate potentials (mEPPs) was recorded and endplate noise was recorded with electromyography.

RESULTS

No healthy muscles treated with shock waves showed injury. Twitch knots in mice previously treated with neostigmine disappeared after shock wave treatment. Several motor axonal branches were retracted. On the other hand, shock wave treatment reduces the frequency of mEPPs and the number of areas with endplate noise.

DISCUSSION

Shock waves seem to be a suitable treatment for myofascial trigger points. In the present study, with a single session of shock waves, very relevant results have been obtained, both functional (normalization of spontaneous neurotransmission) and morphological (disappearance of myofascial trigger points). Patients with a phobia of needles, blood, or injuries who cannot benefit from dry needling may turn to noninvasive radial shock wave treatment.

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.

Focused Extracorporeal Shock Wave Therapy for Ischial Apophysitis in Young High-Level Gymnasts

OBJECTIVE

We aimed to investigate the effect and safety of extracorporeal shock wave therapy (ESWT) on ischial apophysitis (IA) in young high-level gymnasts. We hypothesized that ESWT would be safe and effective in alleviating pain.

DESIGN

Retrospective case series.

SETTING

Funabashi Orthopedic Hospital.

PATIENTS

The subjects were 18 high-level gymnasts (mean age of 13 years) with a chief complain of chronic buttock pain diagnosed with IA.

INTERVENTIONS

Ten patients received only physiotherapy (PT), whereas 8 received both PT and ESWT to the ischial tuberosity. The basic protocol for ESWT was to use an energy dose of 0.20 mJ/mm 2 or less with 3000 shots per session at 4-week intervals.

MAIN OUTCOME MEASURES

We investigated whether PT and ESWT relieved the pain and allowed the patient to return fully to gymnastics. Based on radiographs at the last observation, we examined whether early closure of the apophyseal line of the ischium and around hip joint on the affected side occurred.

RESULTS

In the PT group, pain was relieved in 2 of 10 patients. In the ESWT group, pain was relieved and full return to gymnastics was possible in all 8 patients. None of the patients showed early closure of the apophyseal line.

CONCLUSIONS

Extracorporeal shock wave therapy can be a safe and effective treatment option for IA in young high-level gymnasts.

The Efficacy of Focused Extracorporeal Shock Wave Therapy and Ultrasound Therapy in the Treatment of Calcar Calcanei: A Randomized Study

The prospective, simple randomized study assesses the effect of focused extracorporeal shock wave therapy (f-ESWT) on pain intensity and calcification size compared to the application of ultrasound physical therapy in treating patients with calcar calcanei. A total of 124 patients diagnosed with calcar calcanei were consecutively included in the study. The patients were divided into two groups: the experimental group (n = 62), which included the patients treated with f-ECWT, and the control group (n = 62), consisting of patients treated with the standard ultrasound therapy method. The experimental group's patients received ten therapy applications spaced seven days apart. The patients in the control group had ten ultrasound treatments on ten consecutive days over two weeks. All patients in both groups were tested using the Visual Analog Scale (VAS) to measure pain intensity before the beginning and at the end of treatment. The size of the calcification was assessed in all patients. The study hypothesizes that f-ESWT reduces the pain and the size of the calcification. Pain intensity reduction was registered in all patients. The calcification size in patients in the experimental group was reduced from the initial range of 2 mm-15 mm, to a content of 0.0 mm-6.2 mm. The calcification size in the control group ranged from 1.2 to 7.5 mm, without any change. None of the patients experienced any adverse reactions to the therapy. Patients treated with standard ultrasound therapy did not have a statistically significant reduction in the calcification size. In contrast, the patients in the experimental group treated with f-ESWT showed a substantial decrease in the calcification size.

Pain Management and Rehabilitation for Central Sensitization in Temporomandibular Disorders: A Comprehensive Review

Temporomandibular disorders (TMD) are a group of musculoskeletal diseases affecting masticatory muscles and temporomandibular joints (TMJ). In this context, the chronic TMD could be considered as a condition with chronic primary orofacial pain, presenting as myofascial TMD pain or TMJ arthralgia. In this context, myogenous TMD may present overlapping features with other disorders, such as fibromyalgia and primary headaches, characterized by chronic primary pain related to dysfunction of the central nervous system (CNS), probably through the central sensitization. This phenomenon could be defined as an amplified response of the CNS to sensory stimuli and peripheral nociceptive, characterized by hyperexcitability in the dorsal horn neurons in the spinal cord, which ascend through the spinothalamic tract. The main objectives of the management of TMD patients are: decreasing pain, increasing TMJ function, and reducing the reflex masticatory muscle spasm/pain. The first-line treatments are physical therapy, pharmacological drugs, occlusal splints, laser therapy, extracorporeal shockwave therapy, transcutaneous electrical nerve stimulation, and oxygen–ozone therapy. Although all these therapeutic approaches were shown to have a positive impact on the central sensitization of TMD pain, there is still no agreement on this topic in the scientific literature. Thus, in this comprehensive review, we aimed at evaluating the evidence on pain management and rehabilitation for the central sensitization in TMD patients.

Efficacy and Effectiveness of Extracorporeal Shockwave Therapy in Patients with Myofascial Pain or Fibromyalgia: A Scoping Review

Myofascial pain syndrome (MPS) and fibromyalgia (FM) are underestimated painful musculoskeletal conditions that could impact function and quality of life. A consensus about the most appropriate therapeutic approach is still not reached. Considering the long course of the diseases, prolonged assumption of drugs, such as NSAIDs and pain killers, could increase the risk of adverse events, often leading affected patients and physicians to prefer non-pharmacological approaches. Among these, radial and focused extracorporeal shock waves therapies (ESWT) are widely used in the management of painful musculoskeletal conditions, despite the fact that the mechanisms of action in the context of pain modulation should be further clarified. We performed a scoping review on PubMed using Mesh terms for analyzing the current evidence about the efficacy and effectiveness of ESWT for patients with MPS or FM. We included 19 clinical studies (randomized controlled trials and observational studies); 12 used radial ESWT, and 7 used focused ESWT for MPS. Qualitative analysis suggests a beneficial role of ESWT for improving clinical and functional outcomes in people with MPS, whereas no evidence was found for FM. Considering this research gap, we finally suggested a therapeutic protocol for this latter condition according to the most recent diagnostic criteria.

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.

Biological response of extracorporeal shock wave therapy to tendinopathy in vivo (review)

Tendinopathy is a degenerative disease of the tendons caused by prolonged overstretching or overuse of the tendons. It accounts for a large proportion of musculoskeletal disorders which can occur in all age groups. The management of tendinopathy is typically conservative. In clinical practice, when other conservative treatments fail, extracorporeal shock wave therapy (ESWT) is normally used as an efficient alternative to surgical management. Several basic studies have shown that ESWT with lower energy flux densities can produce some biological responses in vivo to tendinopathy and may accelerate the initiation of the healing process in injured tendons. ESWT has a positive impact on the interactive chain of biological response, enhancing the signaling pathways of angiogenesis through mechanical conduction, and promoting cell proliferation and collagen formation. Finally, it helps tissue regeneration by controlling inflammation. The purpose of this review is to summarize the biological responses generated by ESWT in tendinopathy through a comprehensive review of the published literature. Although ESWT has been used clinically for the treatment of tendinopathies for nearly decades, less is known about the experimental studies of its biological effects on tendon tissue. Further studies on the biological response of ESWT for tendon injuries in vivo are needed in the future in order to provide better management to patients.

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.

Shock wave lithotripsy and therapy

The biological effects of ultrasound exposure are classified into thermal and mechanical effects. The medical application of shock waves has been explored widely as a technique that exerts a mechanical effect with no thermal effect on the living body. The application of shock waves started in urology as a method to disintegrate calculi by impulsive force. During widespread use in urology, it was confirmed that shock waves could also induce some changes in the bones and soft tissues located in the propagation path, and application of shock waves in the field of orthopedics is currently under intensive investigation. In this brief review, we first discuss the similarities of and differences between shock waves and ultrasound. The characteristics of shock wave sources used to generate therapeutic shock waves are then described, and the mechanisms by which shock waves induce stone fragmentation and other therapeutic effects are discussed.

Focused, radial and combined shock wave therapy in treatment of calcific shoulder tendinopathy

Objective: The aim of this work is to compare the clinical, functional, and ultrasonographic outcomes of focused, radial, and combined extracorporeal shock-wave therapy (ESWT) in the treatment of calcific shoulder tendinopathy.Methods: we enrolled 45 patients with calcific shoulder tendinopathy, their ages ranged from 30 to 68 (50.93 ± 9.44) years, classified according to the line of treatment into three groups, all received four sessions of ESWT 1 week apart.Group I: 15 patients received focused shock waves (F-SW) 1500 shocks.Group II: 15 patients received radial shock waves (R-SW) 2000 shocks.Group III: 15 patients received combined focused and radial shock waves (C-SW). All patients were evaluated by musculoskeletal ultrasound (MSK US) before treatment, at 1 week and at 3 months after the last session.Results: In the three studied groups, there was a significant improvement in shoulder pain, active range of motion (ROM), and shoulder function by shoulder disability questionnaire (SDQ) at 1 week after the end of treatment and after 3 months follow up. Moreover, there was a significant sonographic reduction in calcification size in the three groups. At the end of the study, the best improvement as regards a decrease of calcification size was obtained in group III when compared with group I and group II.Conclusion: These results demonstrated clinical, functional, and sonographic improvement in all groups. The best therapy in calcific shoulder tendinopathy appears to be combined focused and radial ESWT compared to interventions alone. Level 1 Evidence Randomized control study.

Extracorporeal Shockwave Therapy in the Management of Sports Medicine Injuries

ABSTRACT

Treatment of musculoskeletal conditions in athletes with extracorporeal shockwave therapy (ESWT) is gaining popularity as greater evidence supports its use. ESWT protocols (describing energy flux density, number of impulses, type of shockwave (focused or radial), number/frequency/duration of treatment session, area of application, and postprocedural therapy protocols) can be adjusted in the clinical setting. Protocols vary across studies, and optimal protocols for most indications are yet to be determined. ESWT can safely be used to treat various musculoskeletal conditions in athletes, including rotator cuff tendinopathy, lateral elbow epicondlyopathy, greater trochanteric pain syndrome, hamstring tendinopathy, patellar tendinopathy, Achilles tendinopathy, other tendinopathies, plantar fasciopathy, bone stress injuries, and medial tibial stress syndrome. ESWT can be used to treat in-season athletes, as it often requires no/minimal time away from sport and may result in rapid benefits. ESWT should be used in conjunction with physical therapy to facilitate longer-term gains in function and to optimize healing.

Extracorporeal shockwave therapy in spinal cord injury, early to advance to clinical trials? A systematic review and meta-analysis on animal studies

BACKGROUND

As there is no consensus over the efficacy of extracorporeal shockwave therapy in the management of spinal cord injury complications, the current meta-analysis aims to investigate preclinical evidence on the matter.

METHODS

The search strategy was developed based on keywords related to 'spinal cord injury' and 'extracorporeal shockwave therapy'. A primary search was conducted in Medline, Embase, Scopus and Web of Science until the end of 2020. Studies which administered extracorporeal shockwave therapy on spinal cord injury animal models and evaluated motor function and/or histological findings were included. The standardised mean difference with a 95% confidence interval (CI) were calculated.

RESULTS

Seven articles were included. Locomotion was significantly improved in the extracorporeal shockwave therapy treated group (standardised mean difference 1.68, 95% CI 1.05-2.31, P=0.032). It seems that the efficacy of extracorporeal shockwave therapy with an energy flux density of 0.1 mJ/mm² is higher than 0.04 mJ/mm² (P=0.044). Shockwave therapy was found to increase axonal sprouting (standardised mean difference 1.31, 95% CI 0.65, 1.96), vascular endothelial growth factor tissue levels (standardised mean difference 1.36, 95% CI 0.54, 2.18) and cell survival (standardised mean difference 2.49, 95% CI 0.93, 4.04). It also significantly prevents axonal degeneration (standardised mean difference 2.25, 95% CI 1.47, 3.02).

CONCLUSION

Extracorporeal shockwave therapy significantly improves locomotor recovery in spinal cord injury animal models through neural tissue regeneration. Nonetheless, in spite of the promising results and clinical application of extracorporeal shockwave therapy in various conditions, current evidence implies that designing clinical trials on extracorporeal shockwave therapy in the management of spinal cord injury may not be soon. Hence, further preclinical studies with the effort to reach the safest and the most efficient treatment protocol are needed.

Influence of different energy patterns on efficacy of radial shock wave therapy

BACKGROUND

One of the mechanisms of the efficacy of extracorporeal shock wave therapy (ESWT) for impaired muscle coordination of limbs is the destruction of Acetylcholine receptors (AChRs) at neuromuscular junction. The highly increased density of AChRs can change the acoustic impedance, and this change of the acoustic impedance can be the reason that radial shock wave (rESW) destroy AChRs selectively. However, the relationship between applied energy of rESWs and the therapeutic efficacy remains unclear, although some studies compared the clinical efficacy of rESWT between high- and low-energy applications. This study aimed to compare the CMAP change among different energy and pulses of rESW application.

METHODS

Male Sprauger-Dawley rats were used. A device that generates radial shock waves pneumatically, was used to apply the following six patterns of radial extracorporeal shockwaves in different energy flux densities and pulses to the right calf of each rat: 1, 8000 pulses at 0.045 mJ/mm²; 2, 4000 pulses at 0.09 mJ/mm²; 3, 2000 pulses at 0.18 mJ/mm²; 4, 4000 pulses at 0.045 mJ/mm²; 5, 2000 pulses at 0.09 mJ/mm²; 6, 1000 pulses at 0.18 mJ/mm². Left calf muscles were considered controls.

RESULTS

There was a significant reduction in CMAP amplitude between control and rESW-exposed muscles in the group applied 4000 pulses with EFD at 0.09 mJ/mm² and the group applied 2000 pulses with EFD at 0.18 mJ/mm². However, the group applied 8000 pulses with EFD at 0.045 mJ/mm² and all groups which was exposed to total 180 mJ rESW application did not show a significantly decreased CMAP amplitude compared with the untreated side.

CONCLUSIONS

Total energy and energy flux density correlate with a decrease in CMAP amplitude by rESW application. These findings could be availed by clinicians in actual clinical setting for the proper application of rESW.

Comparison of Effectiveness of Density and Number of Sessions of Extracorporeal Shock Wave Therapy in Plantar Fasciitis Patients: A Double-Blind, Randomized-Controlled Study

This study aimed to investigate the effect of density and number of sessions extracorporeal shock wave therapy (ESWT) on pain, fatigue, disability, physical function, and quality of life in patients with plantar fasciitis (PF). Between September 2019 and December 2019, a total of 94 patients with the diagnosis of PF were included in the study. All patients were randomly divided into 3 groups. Group 1 (n = 33) received a total of 7 sessions of high-energy flux density (H-ESWT) (0.26 mJ/mm² ) , group 2 (n = 31) received a total of 3 sessions of H-ESWT (0.26 mJ/mm²), group 3 (n = 30) received total of 7 sessions of low-energy flux density (<0.08 mJ/mm²) with 3 days interval. At baseline and 1 month after the treatment, the Visual Analog Scale (VAS), Short Form-36, Foot Function Index (FFI), Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale, and Six-Minute Walking Test (6MWT) scores were compared among the groups. Of the patients, 69 were females and 25 were males with a mean age of 45.0 ± 8.43 (range, 25-67) years. There were no statistically significant differences in the age, sex, demographic characteristics, and baseline VAS, FFI, 6MWT, and FACIT scores between the groups (p > .05). However, there was a statistically significant decrease in the VAS, FACIT, and FFI scores in all groups after treatment compared to baseline, although only the 6MWT, and Short Form-36 subscale scores were statistically significantly higher (p < .05). There was also a statistically significant difference in the scale scores in Group 1 versus Group 2 and in Group 2 versus Group 3. Our study results suggest that H-ESWT for high number of sessions is more effective than LESWT for low number of sessions on pain, quality of life, physical function, fatigue, and disability in patients with PF.

The Effect of Extracorporeal Shock Wave Therapy on Pain Intensity and Neck Disability for Patients With Myofascial Pain Syndrome in the Neck and Shoulder: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of the study was to investigate the efficacy of extracorporeal shock wave therapy on myofascial pain syndrome in the neck and shoulder compared with that of other treatments.

DATA SOURCES

PubMed, Embase, and Web of Science were systematically searched until May 30, 2019, to select randomized controlled trials.

REVIEW METHODS

The randomized controlled trials comparing extracorporeal shock wave therapy with sham extracorporeal shock wave therapy or other treatments for patients with myofascial pain syndrome in the neck and shoulder patients were included. Two reviewers independently identified eligible studies. The Cochrane Handbook was used to evaluate the methodological quality of the included randomized controlled trials. Main outcomes associated with pain intensity, pressure pain threshold, and neck disability were selected. The study was registered with PROSPERO (Registration Number CRD 42019137459).

RESULTS

A total of 11 randomized controlled trials were finally included. The results indicated that extracorporeal shock wave therapy had a large effect size on improving pain intensity (standardized mean difference [SMD] = 0.67, 95% confidence interval = 0.11 to 1.23, P = 0.02) and pressure pain threshold (SMD = 1.19, 95% confidence interval = 0.27 to l2.12, P = 0.01) at postintervention. However, there was no significant effect on neck disability at postintervention (SMD = 0.03, 95% confidence interval = -0.76 to 0.83, P = 0.93). After the subgroup analyses on the type of extracorporeal shock wave therapy, focused extracorporeal shock wave therapy had a significant effect on improving pain intensity (SMD = 0.75, 95% confidence interval = 0.13 to 1.36, P = 0.02) and pressure pain threshold (SMD = 1.70, 95% confidence interval = 0.21 to 3.18, P = 0.03) at postintervention in comparison with that of other treatments.

CONCLUSIONS

Extracorporeal shock wave therapy is superior to other treatments in terms of alleviating the pain intensity and pressure pain threshold of patients with myofascial pain syndrome in the neck and shoulder at postintervention. In particular, focused extracorporeal shock wave therapy shows significant improvement in pain relief. However, radical extracorporeal shock wave therapy for myofascial pain syndrome treatment still remains unclear.

Meralgia paresthetica treated by injection, decompression, and neurectomy: a systematic review and meta-analysis of pain and operative outcomes

OBJECTIVE

Meralgia paresthetica is caused by entrapment of the lateral femoral cutaneous nerve (LFCN) and often presents with pain. Multiple treatment options targeting the LFCN can be pursued to treat the pain should conservative measures fail, with the most common options being injection, neurolysis, and neurectomy. However, their efficacy in causing pain relief and their clinical outcomes have yet to be directly compared. The aim of this study was to interrogate the contemporary literature and quantitatively define how these options compare.

METHODS

The electronic databases Ovid Embase, PubMed, SCOPUS, and the Cochrane Library were interrogated from inception to May 2020 following the PRISMA guidelines. Candidate articles were screened against prespecified criteria. Outcome data were abstracted and pooled by random-effects meta-analysis of proportions.

RESULTS

There were 25 articles that satisfied all criteria, reporting outcomes for a total of 670 meralgia paresthetica patients, with 78 (12%) treated by injection, 496 (74%) by neurolysis, and 96 (14%) by neurectomy. The incidence of complete pain relief was 85% (95% CI 71%-96%) after neurectomy, 63% (95% CI 56%-71%) after neurolysis, and 22% (95% CI 13%-33%) after injection, which were all statistically different (p < 0.01). The incidence of revision procedures was 12% (95% CI 4%-22%) after neurolysis and 0% (95% CI 0%-2%) after neurectomy, which were significantly lower than 81% (95% CI 64%-94%) after injection (p < 0.01). The incidences of treatment complications were statistically comparable across all three treatments, ranging from 0% to 5% (p = 0.34).

CONCLUSIONS

There are multiple treatment options to target pain in meralgia paresthetica. The incidence of complete pain relief appears to be the greatest among the 3 interventions after neurectomy, accompanied by the lowest incidence of revision procedures. These findings should help inform patient preference and expectations. Greater exploration of the anatomical rationale for incomplete pain relief after surgical intervention will assist in optimizing further surgical treatment for meralgia paresthetica.

Enhanced Spinal Therapy: Extracorporeal Shock Wave Therapy for the Spine

Extracorporeal shock wave therapy (ESWT) is a non-invasive therapeutic method used for pain management and muscle strength improvement through the use of shock waves. In vitro studies have demonstrated that shockwave therapy induces fluctuation in redox reaction regulation and increases in Mitogen-Activated Protein Kinase (MAPK) signal transduction pathways, stimulating increased gene expression in the nucleus. ESWT has also been shown to upregulate angiogenesis and growth factors through activation of endothelial nitric oxide synthase (eNOS) and vascular endothelial growth factor (VEGF). The use of ESWT in the treatment of various musculoskeletal disorders was widely adopted throughout Europe, South America, and Asia before being introduced in the United States in 2000. Within the past 20 years, the clinical application of ESWT in the treatment of musculoskeletal and bone disorders has grown. This paper provides a comprehensive narrative review of applications and outcomes of ESWT in clinical spinal pathology and assesses reported efficacy as it relates to the pathology. A review of the literature yielded studies describing the use of ESWT in degenerative osteoporotic neuro-spinal pathology, heterotopic ossification due to spinal cord injury, cervical spondylosis, scoliosis, sacroiliitis, and coccydynia. The efficacy of ESWT as an adjunct treatment in patients with spinal cord pathologies varied with the specific pathology, however, all pathologies discussed in this review provided evidence of potential benefits with minimal adverse effects. While the use of ESWT for pain management has widely been established, further literature should aim to identify the long-term benefits of ESWT.

Comparison of efficacy of corticosteroid injection versus extracorporeal shock wave therapy on inferior trigger points in the quadratus lumborum muscle: a randomized clinical trial

BACKGROUND

In this study, we aimed to compare the efficacy of corticosteroid trigger point injection (TPI) versus extracorporeal shock wave therapy (ESWT) on inferior trigger points in the quadratus lumborum (QL) muscle.

METHODS

In this single-blind randomized clinical trial, 54 low back pain patients with myofascial trigger points on QL muscle were investigated. Participants were randomly allocated into two groups with A and B pockets. Patients in group A underwent radial ESWT and received 5 treatment sessions (1 per week) and actually were not followed-up. However, patients in group B received corticosteroid TPI and received one session of corticosteroid treatment and followed-up for 4 weeks after injection. Oswestry Disability Index (ODI), visual analogue scale (VAS), pain pressure threshold (PPT) and short form (36) health survey (SF-36) were measured in both groups before, two weeks after and four weeks after intervention.

RESULTS

The between group comparison indicated that corticosteroid TPI leaded to significant higher improvements of ODI (P-value< 0.01), VAS (P value< 0.001), and PPT (P-value = 0.001) scores compared to the ESWT group at two-week follow-up time-point. ESWT group recorded significant higher improvement of ODI (P-value< 0.01) and SF-36 (P-value< 0.001) compared to the corticosteroid TPI at 4th week post treatment evaluation. At four-week follow-up time-point, the patients in the ESWT group were 1.46 times more likely to achieve 30% reduction in VAS, 2.67 times more likely to achieve 30% reduction in ODI, and 2.30 times more likely to achieve 20% improvement in SF-36 compared to the participants in corticosteroid TPI group. These results refer to large effect size for all study outcomes in ESWT group (d = 4.72, d = 1.58, d = 5.48, and d = 7.47 for ODI, PPT, SF-36, and VAS, respectively).

CONCLUSION

Corticosteroid TPI was more effective compared to ESWT in short-term controlling of pain and disability caused by myofascial pain syndrome of QL muscle. However, after 4 weeks treatment, ESWT further improved the quality of life and disability and was related with more probability of achievement the minimal clinically important difference concerning pain, disability and quality of life and large effect size for all study outcomes in treated patients compared to corticosteroid TPI.

TRIAL REGISTRATION

www.irct.ir , IRCT20100827004641N14 , retrospectively registered 2019-01-19.

Efficacy of Extracorporeal Shockwave Therapy on Cervical Myofascial Pain Following Neck Dissection Surgery: A Randomized Controlled Trial

Objective

To investigate the efficacy of extracorporeal shockwave therapy (ESWT) on cervical myofascial pain following neck dissection in reducing pain and improving cervical range of motion (ROM).

Methods

Forty-six patients with cervical myofascial pain following neck dissection surgery were recruited and subdivided at random into two equal groups. The ESWT group received ESWT once a week for 4 weeks (0.25 mL/mm², 1,000 shocks) and a topical non-steroidal anti-inflammatory drug (3 times/day for 4 weeks). The control group received only topical NSAID. The pain assessment was done by using the visual analog scale (VAS) and pressure algometry. A cervical ROM device was used for the assessment of the lateral flexion and rotation of the neck ROM on both sides. All measurements were collected at baseline, 2 weeks, and 4 weeks.

Results

The ESWT group revealed a significant improvement in all parameters at post I and post II than did the control group (p>0.001), that revealed a statistical decrease only in the VAS score at post I without any statistical difference in the pain threshold and neck ROM. However, there were statistical differences in all parameters at post II compared to those at pre-treatment and post I (p<0.001).

Conclusion

As a confirmation of the efficacy of ESWT in cervical myofascial pain control following neck dissection, we observed better results with no side effects in the ESWT group (Clinical Trial Registry No. PACTR202002648274347).

High-energy Flux Density Extracorporeal Shock-wave Therapy Versus Therapeutic Steroid Injection in Costochondritis: A Single-Blind, Randomised Controlled Study

Background This study aims to investigate the effects of extracorporeal shock-wave therapy (ESWT) and intra-articular steroid injection (IASI) on pain, depression, quality of life and pressure pain threshold (PPT) in patients with costochondritis.

Methods A total of 67 patients diagnosed with costochondritis were included. Patients were divided into 2 groups. Group 1 (n=34) received high-energy flux density (H-ESWT) (> 0.28 mJ/mm2) for a total of 7 sessions at 3-day intervals. Group 2 (n=33) received IASI twice at 2-week intervals. At baseline and one month after treatment, Visual Analog Scale (VAS), Short Form-36 (SF-36), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI) scores and PPT values were compared.

Results There was a statistically significant decrease in VAS scores after treatment compared with baseline scores in both groups. The PPT and SF-36 subscale scores were also statistically significantly higher (p<0.05). After treatment, VAS and PPT showed a significantly better improvement in Group 1 compared to Group 2. There was a significant correlation between VAS and SF-36 physical functioning as well as pain subscales in Group 1 and a significant correlation between VAS and SF-36 physical functioning in Group 2.

Conclusions Our data suggest that both treatments H-ESWT and IASI are effective in costochondritis patients. Of note, H-ESWT has a stronger effect on pain and PPT scores.

The Effectiveness of Platelet-Rich Plasma and Radial Extracorporeal Shock Wave Compared with Platelet-Rich Plasma in the Treatment of Moderate Carpal Tunnel Syndrome

OBJECTIVES

To evaluate the combination effect of platelet-rich plasma (PRP) and extracorporeal shock wave therapy (ESWT) for moderate carpal tunnel syndrome (CTS), compared with PRP alone.

DESIGN

A randomized, double-blinded, placebo-controlled trial.

SETTING

A single medical center in Taiwan.

PATIENTS

Patients diagnosed with moderate CTS.

INTERVENTIONS

All subjects were administered one dose of ultrasound-guided PRP injection at baseline. After two weeks, one session of rESWT was completed in the intervention group, whereas the control group received one session of sham rESWT. Evaluations were performed at baseline and one, three, and six months post-PRP injection.

OUTCOME MEASURES

The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was measured as the primary outcome. Electrophysiological study and cross-sectional area (CSA) of the median nerve were used as secondary outcomes.

RESULTS

All 40 enrolled subjects (male/female: 4/36) completed the study, resulting in an analysis of 32 wrists per group (total: N = 64 wrists). Compared with the control group, the intervention group did not show statistically significantly superior outcomes, except in BCTQs at one month (mean change ± SE = -11.47 ± 1.18 vs -7.06 ± 1.26, P = 0.013) and distal motor latency at three months (mean change ± SE = -0.59 ± 0.09 vs -0.30 ± 0.09, P = 0.031).

CONCLUSIONS

Combined PRP and one-session rESWT was not superior to PRP alone in treating moderate CTS. Further studies with multiple sessions of ESWT and longer follow-up periods are needed to verify the clinical efficacy of ESWT.

Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine

Extracorporeal shockwave therapy (ESWT) is a popular non-invasive therapeutic modality in the medical field for the treatment of numerous musculoskeletal disorders. This technique first emerged around the 1980s as extracorporeal shockwave lithotripsy and has been studied since then for its application towards orthopedics and traumatology. ESWT works by the emission of acoustic waves (shockwaves) that carry energy and can propagate through tissues. Shockwaves can generate interstitial and extracellular responses, producing many beneficial effects such as: pain relief, vascularization, protein biosynthesis, cell proliferation, neuro and chondroprotection, and destruction of calcium deposits in musculoskeletal structures. The combination of these effects can lead to tissue regeneration and significant alleviation of pain, improving functional outcomes in injured tissue. Considering these facts, ESWT shows great potential as a useful regenerative medicine technique for the treatment of numerous musculoskeletal injuries.

Extracorporeal Shock Wave Therapy for Achilles Tendinopathy

Extracorporeal shock wave therapy (ESWT) is among the conservative treatments for Achilles tendinopathy. Unfortunately, no optimal application parameters have been determined that would ensure ESWT effectiveness in this condition. The aim of the paper is to use research reports on ESWT in patients with Achilles tendinopathy to help practising physiotherapists establish the most effective intervention parameters. A search was conducted using the following databases: PubMed, Scopus, EBSCOhost, and Web of Science. The papers were checked for relevant content and were included based on the following criteria: full-text article published in English and including comprehensive description of shock wave application. Twenty-two articles met the inclusion criteria. Most studies on the effectiveness of ESWT for Achilles tendinopathy included in this narrative review were randomized controlled trials. Two case-control studies, a case series study, prospective audit, clinical trial protocol, and a pilot study were also considered. The majority were prospective studies. Only a few authors presented the findings from retrospective observations. The two modalities of shock wave therapy used for Achilles tendinopathy are focused shock waves and radial shock waves. The literature contains reports presenting mainly beneficial effects of ESWT in patients with Achilles tendinopathy.

[Extracorporal shock wave therapy for the treatment of pseudarthrosis : New experiences with an old technology]

BACKGROUND

Between 5 and 10 % of all fractures show disturbed healing or nonunion formation. Extracorporeal shock wave therapy (ESWT) has been described as a non-surgical treatment option. Even though the outcome has shown promising results, the procedure is not commonly used in clinical practice. The purpose of this study was to analyze the union rate of pseudarthrosis and the cost savings after ESWT.

METHODS

In this study 42 nonunions were treated with shock waves (LithSpaceOrtho, JenaMedtech). The follow up examinations were performed over a period of six months. Outcome measurement included radiological fracture union and pain (VAS). The study group contained 39 pseudarthrosis in the six-week follow-up (93 %), 41 after three months (98 %) and 41 after six months (98 %).

RESULTS

After six weeks, 13 % of patients showed fracture union. After three months 61 % and after six months 73 % of the fractures were completely healed. The fracture healing was significantly lower in older nonunions. All patients presented significantly lower pain levels six weeks after ESWT. Shock wave treatment of all 42 pseudarthrosis made up less than one quarter of the overall operative costs.

CONCLUSION

We established the ESWT as an important treatment option for fracture nonunion in our clinic. Considering the selection of patients in this study with a high mean time from injury to ESWT and multiple prior operations, the fracture healing rate of 73 % after ESWT is comparable with operative healing rates of nonunions. Further prospective, randomized and controlled studies are needed to show the effectiveness of ESWT in the treatment of nonunions on a higher level of evidence and to identify pseudarthrosis that particularly responds to the EWST.

Extracorporeal shockwave therapy raises mechanical nociceptive threshold in horses with thoracolumbar pain

BACKGROUND

Although extracorporeal shockwave therapy (ESWT) is a common treatment for horses with back pain, effects on mechanical nociceptive threshold (MNT) and multifidus muscle cross sectional area (CSA) in the spine are unknown.

OBJECTIVES

To evaluate effects of ESWT on spinal MNT and multifidus muscle CSA in horses with thoracolumbar pain.

STUDY DESIGN

Non-randomised trial.

METHODS

Thoracolumbar spines of 12 horses with thoracolumbar pain were radiographed to document existing pathology. Each horse received three ESWT treatments, 2 weeks apart (days 0, 14, 28). Palpation scores were documented (days 0, 45 and 65). Ultrasonographic CSA of left and right multifidus muscles was recorded at T12, T14, T16, T18, L3 and L5 (days 0, 45 and 65). MNT was measured at the same spinal sites every 7 days (day 0-56).

RESULTS

Mechanical nociceptive threshold in 10/12 horses (83%) was greater at each time point compared with day 0 (P < 0.05). Mechanical nociceptive threshold increased at all time points at six sites in 2/12 (16%), at five sites in 3/12 (25%), at four sites in 4/12 (33%) and at one site in 1/12 (8%; P < 0.05). Mechanical nociceptive threshold average per cent  increase from day 0 to 56 was 64% for the thoracic region (T12-T18) and 29% for the lumbar region (L3-L5). There was no statistical difference in MNT from day 35 to 56 (P = 0.25). A bimodal analgesic trend was observed following ESWT. Degree of radiographic change was not associated with response to treatment. No significant change in multifidus muscle CSA was observed.

MAIN LIMITATIONS

Small study size and lack of control group.

CONCLUSIONS

Three treatments of ESWT 2 weeks apart raised MNT over a 56-day period in horses with back pain, but did not influence change in CSA of the multifidus muscle. While ESWT appears justifiable for analgesia, physiotherapeutic techniques may be necessary in conjunction for concurrent muscle rehabilitation.

Comparison of radial shockwave and dry needling therapies in the treatment of myofascial pain syndrome

Background/Aims

Myofascial pain syndrome is a frequent problem in the musculoskeletal system. As a method of treatment for myofascial pain syndrome, dry needling therapy is an effective and convenient treatment for patients because they do not need to be treated every day. However, as patients often have post-needle soreness or some patients are afraid of needles, there are limitations to this treatment. The purpose of this study is to compare the effectiveness of radial shockwave therapy with dry needling therapy to treat myofascial pain.

Methods

A total of 42 patients attending the rehabilitation department with at least one myofascial pain trigger point in their upper back muscles, were randomly assigned to receive radial shockwave therapy or dry needling therapy. Treatment was performed once a week for 3 weeks in both groups. Participants' pain pressure threshold, measured using an algometer, and pain levels, measured using a numeric pain scale, were assessed before the designated treatment was applied each week. Each patient also performed upper trapezius, rhomboid and infraspinatus muscle stretches twice a day throughout the study period.

Results

There was no difference in pain pressure threshold at the three trigger points before treatment with the different modalities commenced. At the end of the study, the radial shockwave therapy group had a significant improvement in trapezius pain pressure threshold, increasing from 11.7 at baseline to 14.8 at the end of study. There was no significant between-group difference in pain level (P=3.4 vs P=2.6) at the end of the study. Both treatments significantly reduced pain levels: from 7.2 to 3.4 in the radial shockwave group (P<0.001) and from 6.8 to 2.6 in the dry needling therapy group (P<0.001).

Conclusions

Dry needling and radial shock wave therapies are effective in reducing myofascial pain syndrome originating in the upper back muscles. Participants' pain pressure threshold increased after 3 weeks of treatment with both therapies. Radial shock therapy can be used as an alternative to dry needling in the treatment of myofascial pain syndrome in patients who have trouble attending daily physical therapy or in whom dry needling therapy is contraindicated.

High-Energy Flux Density Extracorporeal Shock Wave Therapy Versus Traditional Physical Therapy Modalities in Myofascial Pain Syndrome: A Randomized-controlled, Single-Blind Trial

Objectives

This study aims to investigate the effects of extracorporeal shock wave therapy (ESWT) on pain, sleep, fatigue, disability, depression, and quality of life (QoL) in patients with myofascial pain syndrome (MPS).

Patients and methods

Between March 2018 and September 2018, a total of 94 patients (16 males, 78 females; mean age 44.2±11.94 years; range, 19 to 74 years) with the diagnosis of MPS were included in the study. The patients were divided into two groups. The treatment group consisted of 49 patients and a total of seven sessions of high-energy flux density ESWT (H-ESWT) (0.26 mJ/mm2) were given with three days interval. The control group consisted of 45 patients and the treatment of hot pack, transcutaneous electrical nerve stimulation, and ultrasound was given for five days for two weeks. At baseline and one month after treatment, the visual analog scale (VAS), Short Form-36 (SF-36), Pittsburgh Sleep Quality Index (PSQI), Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale, Neck Disability Index (NDI), and Beck Depression Inventory (BDI) scores were compared between the groups.

Results

There were no statistically significant differences in the age, sex, demographic characteristics, and baseline VAS, SF-36, NDI, BDI, FACIT, and PSQI scores between the groups (p>0.05). In the ESWT group, there was a statistically significant decrease in the VAS, SF-36, NDI, BDI, FACIT, and PSQI scores after treatment compared to the baseline scores, while only the SF-36 subscale scores were statistically significantly higher (p<0.05). There was a statistically significant correlation between the VAS and SF-36 scores and the BDI, NDI, FACIT and PSQI scores after the treatment.

Conclusion

Our study results suggest that H-ESWT is more effective than traditional physical therapy methods on pain, QoL, sleep, fatigue, depression, and disability in patients with MPS.

High- versus low-energy extracorporeal shock-wave therapy for myofascial pain syndrome of upper trapezius: A prospective randomized single blinded pilot study

BACKGROUND

To compare the efficacy of high- and low-energy extracorporeal shock wave therapy (ESWT) for patients with myofascial pain syndrome (MPS) of the upper trapezius.

METHODS

Thirty patients (3 men, 27 women) were randomly assigned to receive either high-energy ESWT (0.210 mJ/mm) or low-energy ESWT (0.068 mJ/mm). Both groups received 1500 pulses of ESWT once a week, for 2 weeks. Outcome measurement was assessed by verbal numeric pain scale (VNS), neck disability index (NDI), neck range of motion (ROM) (flexion, extension, rotation, lateral bending), and pressure threshold (PT). Statistical analysis was performed with significance level of P < .05.

RESULTS

No statistically significant differences of demographic and clinical characteristics existed between the 2 groups. VNS, NDI, neck ROM (rotation to sound side, lateral bending to affected side, lateral bending to sound side), and PT were improved in both groups. In contrast, statistically significant improvements in neck flexion and neck extension were observed only in the high-energy group. We also found significant differences in post-treatment NDI (4.20 ± 1.78 vs 6.47 ± 2.48) and post-treatment neck flexion ROM (65.47 ± 10.09 vs 55.93 ± 11.07) between high-energy and low-energy group.

CONCLUSION

ESWT effectively improves VNS, NDI, neck ROM, and PT to patients with MPS of the upper trapezius. High-energy ESWT was more effective in improving NDI and neck flexion ROM compared to the low-energy ESWT, suggesting superiority in functional improvement. Further studies are required to specify the effect of ESWT by energy intensity.

Extracorporeal shock wave therapy for sacroiliac joint pain: A prospective, randomized, sham-controlled short-term trial

BACKGROUND

Sacroiliac joint (SIJ) pain can cause lower back pain and pelvic discomfort. However, there is no established standard treatment for SIJ pain. Extracorporeal shock wave therapy (ESWT) is a novel, non-invasive therapeutic modality for musculoskeletal disorders. The mechanism underlying shockwave therapy is not fully understood, but the frequency with which ESWT is applied clinically has increased over the years.

OBJECTIVE

We evaluated the efficacy of using ESWT to treating SIJ pain.

METHODS

Thirty patients with SIJ pain were assigned randomly to ESWT (n = 15) and sham control (n = 15) groups. The ESWT group received 2,000 shockwaves with energy set to the maximum level tolerable by the patient (energy density = 0.09-0.25 mJ/mm2). The probe was oriented perpendicular to the posterior SIJ line, and moved up and down along the joint line. The sham control group received 2,000 shockwaves with the probe oriented parallel to the posterior SIJ line. A 10-cm numeric rating scale (NRS) and the Oswestry Disability Index (ODI) scores were assessed before the intervention, and 1 and 4 weeks post-intervention. Participants were instructed to refrain from using any other conservative treatment, including anti-inflammatory medication and other physical modalities during the study.

RESULTS

In the ESWT group, NRS decreased significantly at post-treatment week 4 (3.64 (95% confidence interval, 2.29-4.99)) compared to baseline (6.42 (5.19-7.66); P < 0.05). ODI improved at 1 and 4 weeks compared to baseline, but not significantly. In the sham group, NRS and ODI did not differ at any post-treatment time point. There was a significant group difference in NRS at week 4 post-treatment (3.64 (2.29-4.99) in the ESWT group vs. 6.18 (5.34-7.02) in the sham control group; P < 0.05), but this was not the case for ODI.

CONCLUSIONS

ESWT represents a potential therapeutic option for decreasing SIJ pain.

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.

Extracorporeal shock wave treatment can selectively destroy end plates in neuromuscular junctions

INTRODUCTION

This study assesses the effect of radial extracorporeal shock wave (rESW) exposure on neuromuscular transmission and neuromuscular junction (NMJ) morphology.

METHODS

We applied 2,000 rESWs at 0.18 mJ/mm² and a frequency of 15 Hz to the right calf of male rats, measured the compound muscle action potential (CMAP), and examined NMJ morphology using electron microscopy. Left calf muscles were used as controls.

RESULTS

rESW exposure significantly reduced CMAP amplitude without delayed latency in exposed muscles compared with controls. All rESW-exposed muscles exhibited NMJs with irregular end plates. Mean interjunctional fold interval was significantly increased compared with controls. However, axon terminals and muscle fibers surrounding NMJs with irregular end plates were unchanged.

DISCUSSION

This localized destruction of end plates may be caused by differences in acoustic impedance induced by the density of acetylcholine receptors. These results provide a possible mechanism for the effectiveness of rESW treatment for spasticity and dystonia. Muscle Nerve 57: 466-472, 2018.

Potential applications of low-energy shock waves in functional urology

A shock wave, which carries energy and can propagate through a medium, is a type of continuous transmitted sonic wave with a frequency of 16 Hz-20 MHz. It is accompanied by processes involving rapid energy transformations. The energy associated with shock waves has been harnessed and used for various applications in medical science. High-energy extracorporeal shock wave therapy is the most successful application of shock waves, and has been used to disintegrate urolithiasis for 30 years. At lower energy levels, however, shock waves have enhanced expression of vascular endothelial growth factor, endothelial nitric oxide synthase, proliferating cell nuclear antigen, chemoattractant factors and recruitment of progenitor cells; shock waves have also improved tissue regeneration. Low-energy shock wave therapy has been used clinically with musculoskeletal disorders, ischemic cardiovascular disorders and erectile dysfunction, through the mechanisms of neovascularization, anti-inflammation and tissue regeneration. Furthermore, low-energy shock waves have been proposed to temporarily increase tissue permeability and facilitate intravesical drug delivery. The present review article provides information on the basics of shock wave physics, mechanisms of action on the biological system and potential applications in functional urology.

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.

Effect of extracorporeal shock wave therapy on scar pain in burn patients: A prospective, randomized, single-blind, placebo-controlled study

BACKGROUND

Extracorporeal shock wave therapy (ESWT) has been used to reduce pain in patients with various musculoskeletal diseases and wounds. We investigated the effect of ESWT on scar pain after complete wound epithelialization in burn patients.

METHODS

A prospective, single-blind, placebo-controlled study was conducted from February 2014 to 2015. Forty patients with burn scar pain despite standard therapy (medication, physical therapy, and burn rehabilitation massage therapy) were randomized into ESWT or control (sham ESWT) groups. ESWT was administered at 100 impulses/cm (0.05-0.15 mJ/mm) once per week for 3 weeks. The treatment effects were assessed using the numerical rating scale (NRS), pain threshold, Nirschl pain phase system, and Roles and Maudsley scores.

RESULTS

The characteristics of patients between the 2 study groups were balanced (P >0.05) for age, sex, and total burn surface area (%). In both groups, the NRS, pain threshold (Ib/cm), and Nirschl pain phase system values significantly improved (P <0.05) after 3 sessions of ESWT or sham therapy, and there were significant differences between the 2 groups in terms of these 3 variables (P <0.001, P <0.001, P = 0.013, respectively). The Roles and Maudsley scores significantly improved; among 20 patients, 17 reported a score of poor (85%) and 3 reported fair (15%) before ESWT, whereas 3 reported poor (15%), 8 reported fair (40%), 5 reported good (25%), and 4 reported excellent (20%) after ESWT (P = 0.004). The scores did not improve in the control group (P = 0.128).

CONCLUSION

ESWT significantly reduced scar pain in burn patients after wound recovery.

Extracorporeal Shockwave Therapy in Patients with Morton's Neuroma A Randomized, Placebo-Controlled Trial

BACKGROUND

The aim of this study was to evaluate the efficacy of extracorporeal shockwave therapy (ESWT) for the treatment of Morton's neuroma by measuring changes in patient pain, function, and neuroma size.

METHODS

Patients with Morton's neuroma were randomly assigned to either the ESWT group or the sham stimulation group. Outcome measures, including visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society lesser toes (AOFAS) scores, were assessed at baseline and 1 and 4 weeks after treatment. The Johnson satisfaction test was also performed 1 and 4 weeks after treatment. The neuroma diameter was measured using ultrasonography at baseline and 4 weeks after treatment.

RESULTS

Patients receiving ESWT exhibited significantly decreased VAS scores 1 and 4 weeks after treatment relative to baseline, and AOFAS scores were significantly improved 4 weeks after treatment relative to baseline. In the sham stimulation group, VAS and AOFAS scores showed no significant changes at any time after treatment. Neither group showed significant changes in Johnson satisfaction test results or neuroma diameter.

CONCLUSIONS

These results suggest that ESWT may reduce pain in patients with Morton's neuroma.

Extracorporeal shock wave therapy in periodontics: A new paradigm

The quest for exploring new frontiers in the field of medical science for efficient and improved treatment modalities has always been on a rise. Extracorporeal shock wave therapy (ESWT) has been enormously used in medical practice, principally, for the management of urolithiasis, cholelithiasis and also in various orthopedic and musculoskeletal disorders. The efficacy of ESWT in the stimulation of osteoblasts, fibroblasts, induction of neovascularization and increased expression of bone morphogenic proteins has been well documented in the literature. However, dentistry is no exception to this trend. The present article enlightens the various applications of ESWT in the field of dentistry and explores its prospective applications in the field of periodontics, and the possibility of incorporating the beneficial properties of shock waves in improving the treatment outcome.