[Molecular repair mechanisms using the Intratissue Percutaneous Electrolysis technique in patellar tendonitis]

Critical review of the evidence for Vojta Therapy: a systematic review and meta-analysis

Introduction

It is essential to link the theoretical framework of any neurophysiotherapy approach with a detailed analysis of the central motor control mechanisms that influence motor behavior. Vojta therapy (VT) falls within interventions aiming to modify neuronal activity. Although it is often mistakenly perceived as exclusively pediatric, its utility spans various functional disorders by acting on central pattern modulation. This study aims to review the existing evidence on the effectiveness of VT across a wide range of conditions, both in the adult population and in pediatrics, and analyze common therapeutic mechanisms, focusing on motor control modulation.

Aim

The goals of this systematic review are to delineate the existing body of evidence concerning the efficacy of Vojta therapy (VT) in treating a broad range of conditions, as well as understand the common therapeutic mechanisms underlying VT with a specific focus on the neuromodulation of motor control parameters.

Methods

PubMed, Cochrane Library, SCOPUS, Web of Science, and Embase databases were searched for eligible studies. The methodological quality of the studies was assessed using the PEDro list and the Risk-Of-Bias Tool to assess the risk of bias in randomized trials. Methodological quality was evaluated using the Risk-Of-Bias Tool for randomized trials. Random-effects meta-analyses with 95% CI were used to quantify the change scores between the VT and control groups. The certainty of our findings (the closeness of the estimated effect to the true effect) was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

Results

Fifty-five studies were included in the qualitative analysis and 18 in the meta-analysis. Significant differences in cortical activity (p = 0.0001) and muscle activity (p = 0.001) were observed in adults undergoing VT compared to the control, as well as in balance in those living with multiple sclerosis (p < 0.03). Non-significant differences were found in the meta-analysis when evaluating gross motor function, oxygen saturation, respiratory rate, height, and head circumference in pediatrics.

Conclusion

Although current evidence supporting VT is limited in quality, there are indications suggesting its potential usefulness for the treatment of respiratory, neurological, and orthopedic pathology. This systematic review and meta-analysis show the robustness of the neurophysiological mechanisms of VT, and that it could be an effective tool for the treatment of balance in adult neurological pathology. Neuromodulation of motor control areas has been confirmed by research focusing on the neurophysiological mechanisms underlying the therapeutic efficacy of VT.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=476848, CRD42023476848.

Effectiveness of different percutaneous electrolysis protocols in the endogenous modulation of pain: A Double-Blinded Randomized Clinical Trial

OBJECTIVE

This randomized clinical trial investigated if the application of percutaneous electrolysis (PE) enhances endogenous pain mechanisms (EPM) when compared with a simple needle application (acting as sham).

METHODS

Forty-six asymptomatic subjects, aged 18-40 years, were randomized into three groups receiving a single ultrasound-guided PE intervention consisting of a needle insertion on the lateral epicondyle: sham (without electrical current), low-intensity (0.3 mA, 90s), or high-intensity (three pulses of 3 mA, 3s) PE. Widespread pressure pain thresholds (PPT), conditioned pain modulation (CPM), and temporal summation (TS) were bilaterally assessed in the lateral epicondyle, bicipital groove, transverse process of C5 and tibialis anterior muscle. Outcomes were obtained by an assessor blinded to the treatment allocation of the subjects.

RESULTS

No significant changes in CPM were observed in either group (omnibus ANOVA all, P > .05). A significant bilateral increase in PPT in the lateral epicondyle in the high intensity group as compared with the sham group was observed (P < .01). A significant decrease of TS in both low (P = .002) and high (P = .049) intensity groups on the right, but not on the left, tibialis anterior was also observed when compared with the sham group.

CONCLUSIONS

One session of PE is able to slightly stimulate modulatory pathways related to nociceptive gain, particularly pressure pain sensitivity and temporal summation but not conditioning pain modulation, when compared with a sham needle intervention, with changes even contralaterally. No significant differences were found between low- and high-intensity doses of percutaneous electrolysis.

Endogenous Pain Modulation in Response to a Single Session of Percutaneous Electrolysis in Healthy Population: A Double-Blinded Randomized Clinical Trial

The purpose of this double-blinded randomized controlled trial was to investigate whether percutaneous electrolysis (PE) is able to activate endogenous pain modulation and whether its effects are dependent on the dosage of the galvanic current. A total of 54 asymptomatic subjects aged 18–40 years were randomized into three groups, receiving a single ultrasound-guided PE intervention that consisted of a needle insertion on the lateral epicondyle tendon: sham (without electrical current), low-intensity (0.3 mA, 90 s), and high-intensity (three pulses of 3 mA, 3 s). Widespread pressure pain thresholds (PPT), conditioned pain modulation (CPM), and temporal summation (TS) were assessed in the elbow, shoulder, and leg before and immediately after the intervention. Both high and low intensity PE protocols produced an increase in PPT in the shoulder compared to sham (p = 0.031 and p = 0.027). The sham group presented a significant decrease in the CPM (p = 0.006), and this finding was prevented in PE groups (p = 0.043 and p = 0.025). In addition, high-intensity PE decreased TS respect to sham in the elbow (p = 0.047) and both PE groups reduced TS in the leg (p = 0.036 and p = 0.020) without significant differences compared to sham (p = 0.512). Consequently, a single PE intervention modulated pain processing in local and widespread areas, implying an endogenous pain modulation. The pain processing effect was independent of the dosage administrated.

Galvanic current dosage and bacterial concentration are determinants of the bactericidal effect of percutaneous needle electrolysis: an in vitro study

Percutaneous needle electrolysis (PNE) is a physiotherapy technique that has been shown to be effective in different pathologies such as tendinopathies or mammary fistula. For many years, theoretical bactericidal and germicidal effects have been attributed to this type of galvanic currents, partly explained by the changes in pH that it generates. However, these effects have not yet been demonstrated. The aim of this study was to evaluate the bactericidal effect and the changes in pH caused by PNE. S. aureus were prepared in two different solutions (TSB and saline solution) and in different concentrations (from 9 to 6 Log₁₀ CFU/mL). Bacteria were treated with three experimental PNE doses to assess bacterial death levels and the changes caused to the pH of the medium. The viable cell count showed that all experimental PNE doses had a bactericidal effect against a high concentration (9 Log₁₀ CFU/mL) of S. aureus in saline solution (p < 0.001). Furthermore, we found that when the concentration of bacteria decreased, a lower dose of galvanic current generated the same effect as a higher dose. Changes in pH were registered only in experiments performed with saline solution. PNE had a bactericidal effect against S. aureus and the level of this effect was mainly modulated by the solution, the bacterial concentration and the dose. Changes affecting pH were modulated by the type of solution and there was no relationship between this and bacterial death.

Effects of Percutaneous Electrolysis on Endogenous Pain Modulation: A Randomized Controlled Trial Study Protocol

Percutaneous electrolysis consists of the application of a galvanic electrical current throughout an acupuncture needle. It has been previously hypothesized that needling procedures' neurophysiological effects may be related to endogenous pain modulation (EPM). This protocol study describes the design of a double-blind (participant, assessor) randomized controlled trial with the aim to investigate whether percutaneous electrolysis is able to enhance EPM and whether the effect is different between two applications depending on the dosage of the galvanic electrical current. Seventy-two asymptomatic subjects not reporting the presence of pain symptoms the previous 6 months before the study, aged 18-40 years, are randomized into one of four groups: a control group who does not receive any intervention, a needling group who receives a needling intervention without electrical current, a low-intensity percutaneous electrolysis group (0.3 mA × 90 s), and a high-intensity percutaneous electrolysis group (three bouts of 3 mA × 3 s). Needling intervention consists of ultrasound-guided insertion of the needle on the common extensor tendon of the lateral epicondyle. The primary outcome is conditioned pain modulation (CPM), and secondary outcomes include widespread pressure pain sensitivity (pressure pain thresholds (PPT) over the lateral epicondyle, the cervical spine, and the tibialis anterior muscle) and temporal summation (TS). We expected that percutaneous electrolysis would have a greater influence on CPM than an isolated needling procedure and no intervention. In addition, we also postulated that there might be differences in outcome measures depending on the intensity of the electrical current during the percutaneous electrolysis application. This study makes a new contribution to the field of neurophysiological effects of percutaneous electrolysis and needling interventions.

Skeletal Muscle Regenerative Engineering

Skeletal muscles have the intrinsic ability to regenerate after minor injury, but under certain circumstances such as severe trauma from accidents, chronic diseases or battlefield injuries the regeneration process is limited. Skeletal muscle regenerative engineering has emerged as a promising approach to address this clinical issue. The regenerative engineering approach involves the convergence of advanced materials science, stem cell science, physical forces, insights from developmental biology, and clinical translation. This article reviews recent studies showing the potential of the convergences of technologies involving biomaterials, stem cells and bioactive factors in concert with clinical translation, in promoting skeletal muscle regeneration. Several types of biomaterials such as electrospun nanofibers, hydrogels, patterned scaffolds, decellularized tissues, and conductive matrices are being investigated. Detailed discussions are given on how these biomaterials can interact with cells and modulate their behavior through physical, chemical and mechanical cues. In addition, the application of physical forces such as mechanical and electrical stimulation are reviewed as strategies that can further enhance muscle contractility and functionality. The review also discusses established animal models to evaluate regeneration in two clinically relevant muscle injuries; volumetric muscle loss (VML) and muscle atrophy upon rotator cuff injury. Regenerative engineering approaches using advanced biomaterials, cells, and physical forces, developmental cues along with insights from immunology, genetics and other aspects of clinical translation hold significant potential to develop promising strategies to support skeletal muscle regeneration.

Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II: treatment options

The treatment of painful chronic tendinopathy is challenging. Multiple non-invasive and tendon-invasive methods are used. When traditional non-invasive treatments fail, the injections of platelet-rich plasma autologous blood or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment. As the last resort, intra- or peritendinous open or endoscopic surgery are employed even though these also show varying results. This ESSKA basic science committee current concepts review follows the first part on the biology, biomechanics and anatomy of tendinopathies, to provide a comprehensive overview of the latest treatment options for tendinopathy as reported in the literature.

Prospective Randomized Trial of Electrolysis for Chronic Plantar Heel Pain

BACKGROUND

Chronic plantar heel pain (CPHP) is a common condition with high prevalence rates and a projected cost of treatment of US$192 to US$376 million. There are several therapeutic approaches and there is increased interest in treatments aimed at the regeneration of tissues with poor healing potential. Our purpose was to investigate the effectiveness of ultrasound-guided percutaneous needle electrolysis in chronic plantar heel pain.

METHODS

A total of 73 patients with a clinical and ultrasonographic diagnosis of plantar heel pain unrelated to systemic inflammatory disease who had not received any other treatment in the previous 6 months on the affected foot were randomly allocated to receive either ultrasound-guided percutaneous needle electrolysis of the fascia (experimental group, n = 39) or placebo puncture (control group, n = 34). The primary outcome was pain scored with an 11-point numeric pain rating scale (0 = no pain, 10 = maximum pain). Secondary outcomes were function and disability measured by the 21-item activities of daily living subscale of the Foot and Ankle Ability Measure questionnaire, and fascia thickness measured by ultrasound. Outcomes were measured at 1, 12, and 24 weeks.

RESULTS

The mixed-model analysis of covariance observed significant group x time interactions from all variables: pain in numeric pain rating scale ( P < .001), FAAM Activities of Daily Living Subscale scale ( P < .002), and ultrasonographic measures of the plantar heel ( P < .002). Patients in the experimental group had better results posttreatment at 12 and 24 weeks compared with the control group.

CONCLUSION

With chronic plantar heel pain, ultrasound-guided percutaneous needle electrolysis improved pain and function. This treatment may also decrease fascia thickness.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Randomized, double-blind study comparing percutaneous electrolysis and dry needling for the management of temporomandibular myofascial pain

BACKGROUND

To assess whether the techniques of percutaneous needle electrolysis (PNE) and deep dry needling (DDN) used on trigger points (TrP) of lateral pterygoid muscle (LPM) can significantly reduce pain and improve function in patients with myofascial pain syndrome (MPS) compared to a control group treated with a sham needling procedure (SNP).

MATERIAL AND METHODS

Sixty patients diagnosed with MPS in the LPM were selected and randomly assigned to one of three groups. The PNE group received electrolysis to the LPM via transcutaneous puncture. The DDN group received a deep puncture to the TrP without the introduction of any substance. In the SNP group, pressure was applied to the skin without penetration. Procedures were performed once per week for 3 consecutive weeks. Clinical evaluation was performed before treatment, and on days 28, 42 and 70 after treatment.

RESULTS

Statistically significant differences (p <0.01) were measured for the PNE and DDN groups with respect to pain reduction at rest, during chewing, and for maximum interincisal opening (MIO). Values for the PNE group showed significantly earlier improvement. Differences for PNE and DDN groups with respect to SNP group were significant (p <0.05) up to day 70. Evaluation of efficacy as reported by the patient and observer was better for PNE and DDN groups. No adverse events were observed for either of the techniques.

CONCLUSIONS

PNE and DDN of the LPM showed greater pain reduction efficacy and improved MIO compared to SNP. Improvement was noted earlier in the PNE group than in the DDN group.

Intratissue Percutaneous Electrolysis vs Corticosteroid Infiltration for the Treatment of Plantar Fasciosis

BACKGROUND

Corticosteroid infiltration (CI) is commonly used for treatment of plantar fasciosis. In recent years, however, interest has grown in the use of intratissue percutaneous electrolysis (EPI) for the treatment of tendinopathies. The aim of our study was to compare the effectiveness of the above techniques in the treatment of plantar fasciosis.

METHODS

The results achieved over a period of 1 year following the use of these techniques to treat plantar fasciosis were examined. There were 64 patients; 32 of whom were treated with ultrasound-guided EPI and 32 with ultrasound-guided CI. A clinical examination was performed and ultrasound taken before treatment and at 3, 6, and 12 months. Clinical assessments were made using a visual analog scale (VAS) to record pain and the Foot and Ankle Disability Index (FADI) to evaluate function. Ultrasound was used to determine the thickness of the plantar fascia.

RESULTS

Both the ultrasound-guided EPI and CI techniques were associated with significant clinical and echographic improvements at 12 months post-treatment ( P < .001).

CONCLUSION

Both techniques were effective in the treatment of PF, providing excellent VAS pain and FADI results at 12 months. However, CI required fewer patient visits and appeared to provide somewhat better VAS and FADI results.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Randomized controlled trial comparing the effectiveness of the ultrasound-guided galvanic electrolysis technique (USGET) versus conventional electro-physiotherapeutic treatment on patellar tendinopathy

Background

Patellar tendinopathy has a high prevalence rate among athletes. Different therapeutic options can be found in the current literature, but none of them has been clearly established as the gold standard. The purpose of this study is to compare, in a randomized controlled trial, the clinical efficacy of eccentric exercise combined with either an ultrasound-guided galvanic electrolysis technique (USGET) or conventional electrophysiotherapy to treat patellar tendinopathy.

Methods

Sixty patients diagnosed with patellar tendinopathy were randomized into two groups. Group 1 (n = 30) received electrophysiotherapy treatment consisting of ultrasound, laser and interferential current techniques. Group 2 (n = 30) received USGET. Both groups did the same standardized eccentric exercise program. Periodic assessments of the subjects were carried out with the Victorian Institute of Sport Assessment-Patella (VISA-P) score. An analysis of means and a survival study were performed.

Results

There were statistically significant differences in the VISA-P between the baseline and final follow-up in each treatment group. Group 1 (conventional electrophysiotherapy) went from 52.5 ± 18.8 to 61.9 ± 13.7 (in VISA-P < 90 subgroup) and from 69.1 ± 9.1 to 95.2 ± 2.5 (in VISA-P > 90 subgroup). Group 2 (USGET) went from 51.4 ± 17.9 to 63.3 ± 14.3 (in VISA-P < 90 subgroup) and from 66.3 ± 13.1 to 97.1 ± 1.7 (in VISA-P > 90 subgroup). There were statistically significant correlations between the baseline and final score in the VISA-P > 90 subjects upon completing the study but no statistically significant correlations between subjects with VISA-P < 90. The mean number of sessions applied was 22.6 ± 2.5 in Group 1 and 3.2 ± 0.9 in Group 2. The success probability in Group 1 was 36.1% versus 72.4% in Group 2. The difference was statistically significant.

Conclusion

The results obtained with the combination of USGET and eccentric exercise reported better outcomes than with the conventional electrophysiotherapy techniques in the treatment of patellar tendinopathy.

Treatment of proximal hamstring tendinopathy-related sciatic nerve entrapment: presentation of an ultrasound-guided "Intratissue Percutaneous Electrolysis" application

BACKGROUND

Proximal Hamstring Tendinopathy-related Sciatic Nerve Entrapment (PHTrSNE) is a neuropathy caused by fibrosis interposed between the semimembranosus tendon and the sciatic nerve, at the level of the ischial tuberosity.

METHODS

Ultrasound-guided Intratissue Percutaneous Electrolysis (US-guided EPI) involves galvanic current transfer within the treatment target tissue (fibrosis) via a needle 0.30 to 0.33 mm in diameter. The galvanic current in a saline solution instantly develops the chemical process of electrolysis, which in turn induces electrochemical ablation of fibrosis. In this article, the interventional procedure is presented in detail, and both the strengths and limits of the technique are discussed.

RESULTS

US-guided EPI eliminates the fibrotic accumulation that causes PHTrSNE, without the semimembranosus tendon or the sciatic nerve being directly involved during the procedure. The technique is however of limited use in cases of compression neuropathy.

CONCLUSION

US-guided EPI is a technique that is quick to perform, minimally invasive and does not force the patient to suspend their activities (work or sports) to make the treatment effective. This, coupled to the fact that the technique is generally well-tolerated by patients, supports use of US-guided EPI in the treatment of PHTrSNE.

Autonomic responses to ultrasound-guided percutaneous needle electrolysis of the patellar tendon in healthy male footballers

BACKGROUND

Ultrasound (US)-guided percutaneous needle electrolysis (PNE) is a novel minimally invasive approach, which involves the application of a galvanic current via an acupuncture needle. As in any procedure involving needling, vagal reactions have been reported during PNE.

OBJECTIVE

To examine for changes in autonomic activity during the US-guided PNE technique on healthy patellar tendons by measurement and analysis of heart rate variability (HRV).

METHODS

Twenty-two male footballers were randomly allocated to: a control group (11 players), for whom HRV was recorded for 10 min, both at rest and during an exhaustive US examination of the patellar tendon and adjacent structures; and an experimental group (11 players), for whom HRV was recorded for 10 min, both at rest and during application of US-guided PNE on the patellar tendon. The following HRV parameters were assessed: mean NN interval, mean heart rate, time domain parameters (SDNN, rMSSD, pNN50), diameters of the Poincaré plot (SD1, SD2), stress score, and sympathetic/parasympathetic ratio.

RESULTS

There were no differences between groups in any baseline measurements, nor were there any significant differences between control group measurements (baseline vs intervention). The experimental group exhibited statistically significant increases in SDNN/SD1 (p=0.02/p=0.03) and SD2 (p=0.03), indicating increased parasympathetic and decreased sympathetic activity, respectively.

CONCLUSIONS

US-guided PNE was associated with an autonomic imbalance characterised by greater parasympathetic activity, which could potentially result in a vasovagal reaction. Care should be taken to monitor for adverse reactions during US-guided PNE and simple HRV indicators may have a role in early detection.

Ultrasound-Guided Percutaneous Electrolysis and Eccentric Exercises for Subacromial Pain Syndrome: A Randomized Clinical Trial

Objective. To compare effects of ultrasound- (US-) guided percutaneous electrolysis combined with an eccentric exercise program of the rotator cuff muscles in subacromial pain syndrome. Methods. Thirty-six patients were randomized and assigned into US-guided percutaneous electrolysis (n = 17) group or exercise (n = 19) group. Patients were asked to perform an eccentric exercise program of the rotator cuff muscles twice every day for 4 weeks. Participants assigned to US-guided percutaneous electrolysis group also received the application of galvanic current through acupuncture needle on each session once a week (total 4 sessions). Shoulder pain (NPRS) and disability (DASH) were assessed at baseline, after 2 sessions, and 1 week after the last session. Results. The ANOVA revealed significant Group∗Time interactions for shoulder pain and disability (all, P < 0.01): individuals receiving US-guided percutaneous electrolysis combined with the eccentric exercises experienced greater improvement than those receiving eccentric exercise alone. Conclusions. US-guided percutaneous electrolysis combined with eccentric exercises resulted in small better outcomes at short term compared to when only eccentric exercises were applied in subacromial pain syndrome. The effect was statistically and clinically significant for shoulder pain but below minimal clinical difference for function. Future studies should investigate the long-term effects and potential placebo effect of this intervention.

An experimental study of muscular injury repair in a mouse model of notexin-induced lesion with EPI® technique

BACKGROUND

The mechanisms of muscle injury repair after EPI® technique, a treatment based on electrical stimulation, have not been described. This study determines whether EPI® therapy could improve muscle damage.

METHODS

Twenty-four rats were divided into a control group, Notexin group (7 and 14 days) and a Notexin + EPI group. To induce muscle injury, Notexin was injected in the quadriceps of the left extremity of rats. Pro-inflammatory interleukin 1-beta (IL-1beta) and tumoral necrosis factor-alpha (TNF-alpha) were determined by ELISA. The expression of receptor peroxisome gamma proliferator activator (PPAR-gamma), vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor-1 (VEGF-R1) were determined by western-blot.

RESULTS

The plasma levels of TNF-alpha and IL-1beta in Notexin-injured rats showed a significant increase compared with the control group. EPI® produced a return of TNF-alpha and IL-1beta values to control levels. PPAR-gamma expression diminished injured quadriceps muscle in rats. EPI® increased PPAR-gamma, VEGF and VEGF-R1 expressions. EPI® decreased plasma levels of pro-inflammatory TNF-alpha and IL-1beta and increased anti-inflammatory PPAR-gamma and proangiogenic factors as well as VEGF and VEGF-R1 expressions.

CONCLUSION

The EPI® technique may affect inflammatory mediators in damaged muscle tissue and influences the new vascularization of the injured area. These results suggest that EPI® might represent a useful new therapy for the treatment of muscle injuries. Although our study in rats may represent a valid approach to evaluate EPI® treatment, studies designed to determine how the EPI® treatment may affect recovery of injury in humans are needed.

Effectiveness of the Intratissue Percutaneous Electrolysis (EPI®) technique and isoinertial eccentric exercise in the treatment of patellar tendinopathy at two years follow-up

AIM

to show the effect of Intratissue Percutaneous Electrolysis (EPI®) combined with eccentric programme in the treatment of patellar tendinopathy.

METHODS

prospective study of 33 athlete-patients consecutively treated for insertional tendinopathy with Intratissue Percutaneous Electrolysis (EPI®) and followed for 2 years. Functional assessment was performed at the first visit, at three months and two years with the Tegner scale and VISA-P.

RESULTS

an average improvement in the VISA-P of 35 points was obtained. The mean duration of treatment was 4.5 weeks. Some 78.8% of the patients returned to the same level of physical activity as before the injury by the end of treatment, reaching 100% at two years.

CONCLUSIONS

intratissue percutaneous electrolysis (EPI®) combined with an eccentric-based rehab program offers excellent results in terms of the clinical and functional improvement of the patellar tendon with low morbidity in a short-term period.

LEVEL OF EVIDENCE

Therapy, level 4.