Substance P and Prostaglandin E2 Release After Shock Wave Application to the Rabbit Femur:

Focused shock wave and ultrasound therapies in the treatment of lateral epicondylitis - a randomized control trial

Persistent symptoms of lateral epicondylitis prompt patients to seek effective conservative treatment. The study aimed to determine the effects of focused shock wave (FSWT) and ultrasound therapies for lateral epicondylitis. Sixty patients with tennis elbow were randomly divided into three equal groups: A, B, and C. Group A received a total of 3 FSWT sessions, with 7 days between treatments; Group B received ultrasound therapy in 10 sessions over 2 weeks, while patients in Group C were treated with placebo ultrasound. All patients were also given deep friction massage. Before the start of therapy, and at 1, 3, 6, and 12 weeks after its completion, pain intensity and function of the affected upper limb were assessed in all patients. Wrist extensor and flexor strength and grip strength were measured in the affected and unaffected limb. Significant reductions in pain and significant improvements in the function of the affected limb compared to baseline values were observed in all study groups at 6 and 12 weeks after the completion of therapy. Analysis of percentage changes in these variables showed significant differences between Groups A and B in favor of Group A. The strength of wrist extensors and grip strength of the affected limb at 6 and 12 weeks after treatment completion was significantly higher in Groups A and B compared to pre-therapy values. However, there were no statistically significant differences between the groups regarding percentage changes in muscle strength in the affected limb. Pain reduction and function improvement in patients with lateral epicondylitis were significantly greater after FSWT (0.2 mJ/mm2 / 4 Hz / 2000 shocks) than after sonotherapy (3 MHz / 0.5 W/cm2 / 20%). Increases in wrist extensor strength and grip strength of the affected limb were comparable after both therapies. Given the greater therapeutic effect in the subjective evaluation, we recommend a combination therapy of FSWT with deep friction massage.Trial registration The trial was prospectively registered in the ISRCTN registry (no. ISRCTN11907358 registration date 30.07.2020).

Efficacy and tolerability of extracorporeal shock wave therapy in patients with plantar fasciopathy: a systematic review with meta-analysis and meta-regression

INTRODUCTION

Plantar fasciopathy (PF) is a common musculoskeletal condition characterized by heel pain and functional impairment. Extracorporeal shock wave therapy (ESWT) has gained increasing interest in the treatment of PF, but the optimal ESWT program is still debated. Therefore, this systematic review with meta-analysis and meta-regression aimed at providing a comprehensive assessment of the efficacy and tolerability of ESWT in PF management.

EVIDENCE ACQUISITION

Randomized controlled trials (RCTs) published until February 2023 were systematically searched on PubMed/MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and PEDro. Studies assessing adult patients with PF treated with ESWT were considered. The primary outcome was the tolerability of ESWT, measured by treatment adherence, dropouts, and safety. Secondary outcomes were pain intensity and functional outcomes. Meta-analysis and meta-regression were performed to examine the relationship between ESWT program characteristics and treatment outcomes. The quality of included studies was assessed using the Jadad scale and the Cochrane risk-of-bias tool.

EVIDENCE SYNTHESIS

Eleven studies met the inclusion criteria and were included in the analysis. Our findings showed that ESWT is effective in reducing pain intensity assessed by Visual Analogue Scale [focal-ESWT: -2.818 (SE 0.803, -4.393, -1.244; P< 0.0001; radial-ESWT: -3.038 (SE 0.428, -3.878, -2.199; P<0.001)]. Meta-regression analysis indicated a positive relationship between specific ESWT parameters (frequency, number of pulses, energy flux density and frequency, and number of pulses, pressure) and pain intensity (all P<0.05) and dropout (all P<0.05).

CONCLUSIONS

ESWT seems to be an effective and tolerable treatment for PF, albeit the peculiarity of parameters might affect both the efficacy in pain relief and the adherence to the treatment. Physicians should consider individual patient characteristics when selecting the ESWT parameters for PF treatment. Further high-quality studies are warranted to establish the optimal ESWT protocol to treat PF.

Outcomes After Extracorporeal Shockwave Therapy for Chronic Noninsertional Achilles Tendinopathy Compared With Chronic Insertional Achilles Tendinopathy: A Retrospective Review

Background

Extracorporeal shockwave therapy (ESWT) is a noninvasive treatment modality that is used in the treatment of chronic Achilles tendinopathy (AT).

Purposes

To (1) retrospectively assess outcomes after ESWT for both noninsertional AT (NAT) and insertional AT (IAT) at >1-year follow-up and (2) identify potential predictors of outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

Chart review was conducted to identify patients who underwent ESWT for AT with a minimum of 1-year follow-up. Data collected and assessed included patient demographic characteristics, pathological characteristics including the location of AT (NAT or IAT), presence of a Haglund deformity, and severity of tendon degeneration on magnetic resonance imaging (MRI), in addition to treatment characteristics including number of sessions and intensity of ESWT. The Victorian Institute of Sports Assessment-Achilles (VISA-A) and visual analog scale (VAS) pain scores were obtained before ESWT, 6 months after ESWT, and at final follow-up. Failures were also recorded, which were defined as no improvement in VISA-A or VAS scores or need for surgical intervention. Linear regression was performed to identify potential predictors of inferior subjective clinical outcomes and failures. Survival analysis was conducted using Kaplan-Meier curves.

Results

The study included 52 patients with IAT and 34 patients with NAT. The mean follow-up in the NAT cohort was 22.3 ± 10.2 months and the mean follow-up in the IAT cohort was 26.8 ± 15.8 months. Improvements in VISA-A and VAS scores were observed in the NAT cohort at 6-month follow-up and at final follow-up (P < .05). Improvements in VISA-A and VAS scores were recorded in the IAT cohort at 6-month follow-up, which subsequently deteriorated at final follow-up. In the NAT cohort, the failure rate at 6-month follow-up was 11.8%, which increased to 29.4% at final follow-up. In the IAT cohort, the failure rate at 6-month follow-up was 32.7%, which increased to 59.6% at final follow-up. Predictors of inferior subjective clinical outcomes and failures in the NAT cohort included pre-ESWT subjective clinical score, male sex, presence of a cardiovascular risk factor, and more severe MRI grading of tendinopathy. Predictors of inferior subjective clinical outcomes and failures in the IAT cohort included pre-ESWT subjective clinical score and more severe MRI grading of tendinopathy.

Conclusion

Superior subjective clinical outcomes together with a lower failure rate were maintained for >1 year in the NAT cohort compared with the IAT cohort, calling into question the long-term benefit of ESWT for patients with IAT.

Investigation of The Effectiveness of Extracorporeal Shock Wave Therapy in Patients Diagnosed with Plantar Fasciitis: Comparison of Radial and Focus Applications

The aim of the study was to investigate the effectiveness of radial and focus (extracorporeal shock wave therapy) ESWT treatment on pain, function and size of the calcaneal spur in patients with clinical and radiological diagnosis of plantar fasciitis. A total of 112 patients aged between 18 and 95 years, were divided into 2 groups; group 1, rESWT (2.4 bar 12 hz 2000 beats), group 2 received fESWT (0.14 bar 14 hz 1000 beats) 3 times a week for 3 weeks. All patients were evaluated using the Visual Analog Scale (VAS)-pain and Foot Function Index before and after the treatment, at 4 week and 12 weeks. Calcaneal spur size was measured radiographically in the patients before and after the treatment at the 12th week follow-up. According to our records, VAS scores were found to be similar between the groups before treatment and at follow-ups (all p > .05). In both groups, a significant decrease in VAS scores was found in the follow-ups compared to before treatment (p < .001). FFI total, pain, activity and disability scores were found to be similar between the groups before treatment and at follow-up (all p > .05). In both groups, a significant decrease in Foot Function Index scores was found in the follow-ups compared to before treatment (p < .001). Both of rESWT and fESWT were effective in plantar fasciitis treatment there were no significant difference between 2 modalities in long term.

Peripheral and central pathogenesis of postherpetic neuralgia

BACKGROUND

Postherpetic neuralgia (PHN) is a classic chronic condition with multiple signs of peripheral and central neuropathy. Unfortunately, the pathogenesis of PHN is not well defined, limiting clinical treatment and disease management.

OBJECTIVE

To describe the peripheral and central pathological axes of PHN, including peripheral nerve injury, inflammation induction, central nervous system sensitization, and brain functional and structural network activity.

METHODS

A bibliographic survey was carried out, selecting relevant articles that evaluated the characterization of the pathogenesis of PHN, including peripheral and central pathological axes.

RESULTS

Currently, due to the complexity of the pathophysiological mechanisms of PHN and the incomplete understanding of the exact mechanism of neuralgia.

CONCLUSION

It is essential to conduct in-depth research to clarify the origins of PHN pathogenesis and explore effective and comprehensive therapies for PHN.

Extracorporeal Shockwave Therapy for Greater Trochanteric Pain Syndrome: A Systematic Review with Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Greater trochanteric pain syndrome (GTPS) affects 17.6% of adults aged 50 to 79 years, particularly women. While exercise therapy and corticosteroid injections (CSIs) are common treatments, their limitations include inadequate pain control and potential tendon weakening. Extracorporeal shockwave therapy (ESWT) is an emerging alternative for GTPS. This systematic review assessed ESWT's efficacy in GTPS by evaluating pain and functional outcomes at different follow-up intervals.

METHODS

A literature search of PubMed, Embase, and Web of Science for randomized clinical trials (RCTs) was conducted comparing ESWT with other GTPS treatments up to March 1, 2024. Two reviewers independently extracted data, assessing study quality using the Cochrane risk-of-bias tool. A random-effects pairwise meta-analysis compared ESWT with other treatments.

RESULTS

Eight RCTs involving 754 patients (169 male, 585 female patients) were included. Seven RCTs were deemed high risk of bias, and 1 RCT had some concerns. Five RCTs investigated focused on focused ESWT, and 3 examined radial ESWT. ESWT provided significantly lower pain scores than other treatments at 2 to 4 months (standardized mean difference = -0.431; 95% confidence interval [CI], -0.82 to -0.039; I2 = 83%). Functional improvement (Lower Extremity Functional Scale) was significantly higher at 6 months (weighted mean difference = 6.68; 95% CI, 3.11-10.25; I2 = 0%) but did not exceed the minimal clinically important difference. Focused ESWT provided greater pain reduction than radial ESWT.

CONCLUSION

Three weekly ESWT sessions offer short-term pain relief at 2 to 4 months for patients with GTPS, especially with focused ESWT. Functional improvements at 6 months were notable but not clinically significant. These findings suggest ESWT may complement or serve as an alternative to CSIs and exercise. However, caution is needed when interpreting these results due to high risk of bias with the included RCTs and heterogeneity across the studies. Further high-quality trials are needed to confirm ESWT's long-term benefits over other treatments.

LEVEL OF EVIDENCE

Level II. See Instructions for Authors for a complete description of levels of evidence.

Radial extracorporeal shockwave therapy reduces pain and promotes proximal tendon healing after rotator cuff repair: Randomized clinical trial

BACKGROUND

Extracorporeal shockwave therapy (ESWT) is widely used to treat soft tissue disorders, but evidence for its application after rotator cuff (RC) repair is lacking.

OBJECTIVES

To investigate the effect of ESWT on short-term functional and structural outcomes after RC repair.

METHODS

Thirty-eight individuals were randomly assigned to the ESWT group (n = 19) or control group (n = 19) 3 months after RC repair. Both groups underwent 5 weeks of advanced rehabilitation and participants in the ESWT group additionally received 2000 pulses of shockwave therapy every week for 5 weeks. The primary outcome was pain measured on a visual analog scale (VAS). Secondary outcomes were range of motion (ROM), Constant score, University of California Los Angeles score (UCLA), American Shoulder and Elbow Surgeons form (ASES), and Fudan University shoulder score (FUSS). Changes in signal/noise quotient (SNQ), muscle atrophy and fatty infiltration were analyzed from MRI. All participants underwent clinical and MRI examinations 3 months (baseline) and 6 months (follow-up) post repair.

RESULTS

A total of 32 participants completed all assessments. Pain and function improved in both groups. At 6 months post repair, pain intensity was lower and ASES scores higher in the ESWT than in the control group (all p-values < 0.01). SNQ near the suture anchor site decreased significantly from baseline to follow-up in the ESWT group (p = 0.008) and was significantly lower than that in the control group (p = 0.036). Muscle atrophy and the fatty infiltration index did not differ between groups.

CONCLUSION

ESWT and exercise more effectively reduced early shoulder pain than rehabilitation alone and accelerated proximal supraspinatus tendon healing at the suture anchor site after RC repair. However, ESWT may not be more effective than advanced rehabilitation in terms of functional outcomes at the short-term follow-up.

Comparison between radial and focused types of extracorporeal shock-wave therapy in plantar calcaneal spur: A randomized sham-controlled trial

OBJECTIVES

Both radial and focused types of extracorporeal shock wave therapy (ESWT) have been used in patients with plantar calcaneal spur (PCS). However, no study has yet addressed the comparative effects of these treatments on the condition. Considering radial and focused waves are different from each other, their effectiveness may also be different in clinical practice. The aim of this study was to compare the effects of radial and focused types of ESWT on PCS.

METHODS

Ninety-nine patients with plantar calcaneal spur were randomised into three groups according to ESWT types: focused, radial, and sham. ESWT was applied as three sessions, with 2-4 days intervals (excluding weekends). All patients were evaluated at baseline (week 0) and weeks 1, 5, and 13. The Foot Function Index (FFI) scores were used as outcome measures.

RESULTS

Compared with baseline (week 0), at the end of treatment (week 1) and at the follow-up periods (weeks 5, and 13) the FFI scores were significantly reduced in both focused and radial ESWT groups (for all, p < 0.001). When considering the change in data from baseline to follow-up periods (weeks 5, and 13), both focused and radial ESWT groups were significantly superior to the sham group in the all outcome measures (for all, p < 0.05). Importantly, the radial group was significantly superior to focused group based on the changes in the FFI scores (for all, p < 0.05).

CONCLUSION

Both focused ESWT and radial ESWT are effective in plantar calcaneal spur. When considering the degree and continuity of the positive effects, radial ESWT is superior to focused ESWT in plantar calcaneal spur.

More than Ninety Percent of the Light Energy Emitted by Near-Infrared Laser Therapy Devices Used to Treat Musculoskeletal Disorders Is Absorbed within the First Ten Millimeters of Biological Tissue

There is increasing interest in the application of near-infrared (NIR) laser light for the treatment of various musculoskeletal disorders. The present study thoroughly examined the physical characteristics of laser beams from two different laser therapy devices that are commercially available for the treatment of musculoskeletal disorders. Then, these laser beams were used to measure the penetration depth in various biological tissues from different animal species. The key result of the present study was the finding that for all investigated tissues, most of the initial light energy was lost in the first one to two millimeters, more than 90% of the light energy was absorbed within the first ten millimeters, and there was hardly any light energy left after 15-20 mm of tissue. Furthermore, the investigated laser therapy devices fundamentally differed in several laser beam parameters that can have an influence on how light is transmitted through tissue. Overall, the present study showed that a laser therapy device that is supposed to reach deep layers of tissue for treatments of musculoskeletal disorders should operate with a wavelength between 800 nm and 905 nm, a top-hat beam profile, and it should emit very short pulses with a large peak power.

Case study: Treating infraspinatus and supraspinatus trigger points and supraspinatus tendinopathy utilizing piezoelectric shockwave

Two individual case studies demonstrate piezoelectric shockwave treatment for the resolution of a supraspinatus tendinopathy and supraspinatus and infraspinatus myofascial trigger points (MTPs) via musculoskeletal ultrasound. This is the first documentation of improvement of both tendon and muscle fiber patterns in canine patients treated with piezoelectric shockwave. These cases validate the use of piezoelectric shockwave during the rehabilitation of common canine shoulder injuries.

Effect of Vitamin C on Tendinopathy Recovery: A Scoping Review

Tendinopathies represent 30-50% of all sports injuries. The tendon response is influenced by the load (volume, intensity, and frequency) that the tendon support, resulting in irritability and pain, among others. The main molecular component of tendons is collagen I (60-85%). The rest consist of glycosaminoglycans-proteoglycans, glycoproteins, and other collagen subtypes. This study's aim was to critically evaluate the efficacy of vitamin C supplementation in the treatment of tendinopathies. At the same time, the study aims to determine the optimal conditions (dose and time) for vitamin C supplementation. A structured search was carried out in the SCOPUS, Medline (PubMed), and Web of Science (WOS) databases. The inclusion criteria took into account studies describing optimal tendon recovery when using vitamin C alone or in combination with other compounds. The study design was considered, including randomized, double-blind controlled, and parallel designs in animal models or humans. The main outcome is that vitamin C supplementation is potentially useful as a therapeutic approach for tendinopathy recovery. Vitamin C supplementation, alone or in combination with other products, increases collagen synthesis with a consequent improvement in the patient's condition. On the other hand, vitamin C deficiency is mainly associated with a decrease in procollagen synthesis and reduced hydroxylation of proline and lysine residues, hindering the tendon repair process.

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.

Effects of Repeated Injection of 1% Lidocaine vs. Radial Extracorporeal Shock Wave Therapy for Treating Myofascial Trigger Points: A Randomized Controlled Trial

Background and Objectives: This study tested the hypothesis that treatment of myofascial trigger points (MTrPs) in the upper trapezius muscle (UTM) with repeated injection of 1% lidocaine results in better alleviation of muscular stiffness and soreness as well as improved metabolism in the hypercontracted MTrP area than treatment with radial extracorporeal shock wave therapy (rESWT). Materials and Methods: A single-blinded, prospective, randomized controlled trial was conducted on patients suffering from MTrPs in the UTM. Thirty patients were treated with repeated injection of 2 mL of 1% lidocaine (three injections; one injection per week). Another 30 patients were treated with rESWT (three treatment sessions; one treatment session per week; 2000 radial extracorporeal shock waves per treatment session; positive energy flux density = 0.10 mJ/mm2). The primary outcome measure was pain severity using the VAS score. The secondary outcome measures included muscle elasticity index, pressure pain threshold and neck disability index. Evaluation was performed at baseline (T1), 15−30 min after the first treatment in order to register immediate treatment effects (T2), before the second treatment (i.e., one week after baseline) (T3) and one week after the third treatment (i.e., four weeks after baseline) (T4). Results: There were no statistically significant differences in the primary and secondary outcome measures between the patients in the lidocaine arm and the patients in the rESWT arm at T1 and T4. Within the arms, the mean differences of all outcomes were statistically significant (p < 0.001) when comparing the data obtained at T1 with the data obtained at T3 and the data obtained at T4. Conclusions: The results of this pilot study suggest that the use of rESWT in patients with MTrPs in the UTM is safe and leads to reduced pain and improved muscle elasticity, pressure pain threshold and neck disability index, without adverse effects. Larger trials are necessary to verify this. Clinicians should consider rESWT instead of injections of lidocaine in the treatment of MTrPs in the UTM.

Effects of β-Hydroxy β-Methylbutyric Supplementation in Combination with Conservative Non-Invasive Treatments in Athletes with Patellar Tendinopathy: A Pilot Study

The aim of the present study was to analyze the effect of conservative non-invasive treatments based on eccentric training, stretching and extracorporeal shock wave therapy (ESWT) supplemented with β-Hydroxy β-methylbutyric (HMB) or placebo (PLAC) on body composition, pain and muscular function (jump ability, muscular power and muscular strength) in athletes with patellar tendinopathy (PT). In a double-blind randomized trial, 8 athletes (4 males and 4 females) performed a physical rehabilitation for 4 weeks. They were randomly divided into two experimental groups (two males and two females in each one) that ingested HMB (HMBG) or PLAC (PLACG). In pre- and post-intervention were assessed body composition, pain, countermovement jump (CMJ), back-squat (BS) for analyzing peak power (W) (PPPP), load (kg) associated to PPPP (PPKG) and mean velocity (m/s) (PPMV) in addition to a 5-RM leg extension tests. An interaction intervention·supplementation (p = 0.049; Ƞ2p = 0.774) was observed in the height reached in the CMJ as an intervention effect in PPPP detected for the HMBG (p = 0.049). In addition, an enhancement in PPKG (p = 0.028; Ƞ2p = 0.842) was detected in the intervention, but not in PPMV, as an increase in the intervention in the 5-RM test (p = 0.001; Ƞ2p = 0.981) was observed. No changes were noted on body composition or pain (p > 0.05). The combination of eccentric training with stretching and ESWT increased concentric muscular power and strength after 4 weeks without changes in body lean mass or pain. In addition, HMB supplementation could enhance the power muscular performance in athletes with PT, optimizing the intervention adaptions.

Ground reaction force analysis for assessing the efficacy of focused and radial shockwaves in the treatment of symptomatic plantar heel spur

BACKGROUND

Extracorporeal shock wave therapy is among the conservative treatments for symptomatic heel spur.

OBJECTIVE

The purpose of this trial is to evaluate and compare the therapeutic effects of radial shock wave (RSWT) and focused shock wave (FSWT) applied in the treatment of symptomatic heel spur.

METHODS

Fifty-five participants were randomly divided into two comparative groups that were administered FSWT and RSWT, respectively. The severity of dysfunction (Foot Function Index, FFI), ground reaction forces (GRF) and walking temporal parameters were measured in all patients at baseline and at weeks 1, 3, 6, 12 and 24 after treatment.

RESULTS

In both groups, a gradual decrease in the FFI values occurred after treatment. The percentage reduction in the FFI was comparable for both groups. Statistically significant changes were only noted between some measurements of GRF and walking temporal parameters. The percentage changes in the values of the force and temporal parameters were similar between the groups.

CONCLUSIONS

Both FSWT and RSWT are efficacious in the treatment of symptomatic heel spur and their therapeutic effects are comparable. Objective data registered by force platforms during walking are not useful for tracing the progress of treatment applied to patients with symptomatic heel spur between consecutive procedures.

A Narrative Review Evaluating Extracorporeal Shockwave Therapy as a Potential Regenerative Treatment for Musculoskeletal Conditions in Military Personnel

INTRODUCTION

Extracorporeal shockwave therapy (ESWT) has a wide variety of clinical applications ranging from urology to orthopedics. Extracorporeal shockwave therapy is of particular interest to military medicine in the treatment of diverse musculoskeletal injuries, including recalcitrant tendinopathy. Much of the evidence for ESWT is from studies in the civilian population, including athletes. A few investigations have been conducted within military personnel. Musculoskeletal conditions within military personnel may contribute to pain and physical limitations. Optimal functional outcomes could be achieved through ESWT. The purpose of this narrative review is to summarize the current evidence on the efficacy of ESWT the in management of lower extremity musculoskeletal injuries in the military. Further, we explore the relative efficacy of ESWT compared to regenerative medicine procedures, including studies with treatment using platelet-rich plasma.

MATERIALS AND METHODS

A literature review was performed in April 2020 to identify studies evaluating the use of ESWT for lower extremity conditions commonly observed in military personnel, including plantar fasciitis, Achilles tendinopathy, patellar tendinopathy, medial tibial stress syndrome, and knee arthritis. The literature search was completed by two researchers independently, using PubMed and Embase databases and same search terms. Disagreements were adjudicated by a senior author. Due to the paucity of relevant search results, the search term parameters were expanded to incorporate active participants.

RESULTS

Two studies evaluated the use of ESWT in a military population for lower extremity injuries. This included a randomized control trial in active military with medial tibial stress syndrome and an unblinded retrospective study for the chronic plantar fasciitis condition. Both studies in the military had favorable outcomes in the use of ESWT compared to other treatment arms. The remaining studies predominantly included athletes. Although heterogeneity on the quality of the studies may prevent meta-analysis and limit the generalization of the findings, the majority of studies demonstrated an improvement in pain and return to activity using ESWT. Two studies using platelet-rich plasma as a treatment arm identified similar short-term outcomes compared to ESWT for Achilles tendinopathy and patellar tendinopathy.

CONCLUSION

Our findings suggest that ESWT is a safe and well-tolerated intervention with positive outcomes for lower extremity conditions commonly seen in the military. The few studies comparing ESWT to PRP suggest regenerative benefits similar to orthobiologics in the shorter term. More robust quality designed research may enable the evaluation of ESWT efficacy within the military population. In summary, the use of ESWT may provide pain reduction and improved function in active populations with lower extremity musculoskeletal injuries. Further research in the military is needed to evaluate shockwave efficacy in order to advance musculoskeletal care and improve outcomes.

Does the Type of Extracorporeal Shock Therapy Influence Treatment Effectiveness in Lateral Epicondylitis? A Systematic Review and Meta-analysis

BACKGROUND

Extracorporeal shock wave therapy (ESWT) has been used in various musculoskeletal disorders, including lateral epicondylitis. However, in 2005, a meta-analysis of randomized controlled trials showed that ESWT provides minimal or no benefit in terms of pain and function in patients with lateral epicondylitis. Since the review, several randomized controlled trials including different types of ESWT such as radial type for lateral epicondylitis have been published. Investigations of the effect modifiers such as symptom and follow-up duration on the effects of ESWT on lateral epicondylitis have not been performed.

QUESTIONS/PURPOSES

(1) Does ESWT reduce pain and improve grip strength in patients with lateral epicondylitis? (2) Which type of ESWT, radial or focused, is more effective? (3) Is the duration of symptoms associated with the efficacy of ESWT for lateral epicondylitis? (4) Do improvements in pain scores remain in patients with longer follow-up?

METHODS

The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched up to July 2019 for articles published in English or Korean. Studies were included if patient allocation was randomized, the sample was composed of patients with lateral epicondylitis, interventions were ESWT (focused or radial), comparison group only received sham stimulation or no additional treatment, and the study outcome was pain intensity or grip strength. The quality of the evidence was assessed using the Cochrane risk of bias tool. Twelve studies including 1104 participants fulfilled the inclusion criteria and were included in the meta-analysis. The mean difference for pain reduction and improvement in grip strength was calculated.

RESULTS

The meta-analysis showed no clinically important difference in the VAS score (2.48 ± 7.55 versus 3.17 ± 9.78, mean difference -0.68 [95% confidence interval -1.17 to -0.19]; p = 0.006) and grip strength (38.02 ± 70.56 versus 34.85 ± 108.26, mean difference 3.33 [95% CI 0.93 to 5.73]; p = 0.007) after ESWT relative to the comparison group's score. Even though radial ESWT showed more improvement than focused, the mean difference for VAS did not exceed the minimal clinically important differences threshold. There were no clinically important effects on the VAS scores of patients with lateral epicondylitis (2.78 ± 5.57 versus 3.92 ± 6.29, mean difference -1.13 [95% CI -1.84 to -0.42]; p = 0.002) and focused ESWT did not improve pain in patients with lateral epicondylitis. In the subgroup analysis, ESWT was effective in patients with a symptom duration of more than 6 months (2.28 ± 8.48 versus 3.31 ± 11.81, mean difference -0.95 [95% CI -1.75 to -0.15]; p = 0.02) but not for those with shorter symptom duration. The effects did not last beyond 24 weeks (2.52 ± 9.19 versus 3.34 ± 5.93, mean difference -0.82 [95% CI -2.57 to 0.93]; p = 0.36).

CONCLUSIONS

ESWT did not show clinically important improvement in pain reduction and grip strength. Radial ESWT, symptom duration of longer than 6 months, and short follow-up duration (less than 24 weeks) were related to better effects. Further studies are needed to determine the appropriate protocol and elucidate the effects according to the intervention type and specific disease condition.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Efficacy and safety of the extracorporeal shockwave therapy in patients with postherpetic neuralgia: study protocol of a randomized controlled trial

Background

Postherpetic neuralgia (PHN) is one of the most common types of chronic neuropathic pain, which seriously affects quality of the life because of pain severity and poor response to the currently available treatments. The main strategies for PHN management are medication and invasive interventional therapies; however, these approaches have many adverse effects, so it is important to find another effective and safe treatment for PHN.

Methods

A single-center, single-blind randomized clinical trial will evaluate 98 study participants randomized in a 1:1 ratio into control and experimental groups. The control group will receive conventional treatment including medication therapy and invasive interventional therapy. The experimental group will receive extracorporeal shockwave therapy (ESWT) in addition to conventional therapy. The primary outcome is pain intensity assessed on a visual analogue scale (VAS); the secondary outcomes are the following: quality of life assessed by the 36-Item Short-Form Health Survey (SF-36), psychological state for anxiety and depression measured by the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS), and sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). Assessors blinded to the randomization will collect data during the intervention period at baseline and weeks 1, 4, and 12. The plasma levels of tumor necrosis factor-α and interleukin-6 will be assessed before and after ESWT to explore the biochemical mechanisms of ESWT in the treatment of PHN.

Discussion

This randomized controlled trial will evaluate the effectiveness and safety of ESWT in patients with PHN and thus will provide clinical evidence for its use in the management of PHN and explore the potential biochemical mechanisms of this treatment.

Trial registration

www.ChiCTR.org.cn, identifier: ChiCTR1900025828. Registered on 10 September 2019

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 Immediately Affects Achilles Tendon Structure and Widespread Pressure Pain Thresholds in Healthy People: A Repeated-Measures Observational Study

OBJECTIVE

Extracorporeal shockwave therapy is a common clinical treatment for tendinopathy, yet negative effects on tendon structure have been shown in animal studies. This study aimed to investigate the effect of extracorporeal shockwave therapy in healthy participants (i.e., no Achilles tendon pain or pathology).

DESIGN

This study examined the effect of three bouts of weekly extracorporeal shockwave therapy for 3 wks in 13 healthy participants. Outcomes measures assessed were as follows: (a) Achilles tendon structure, quantified using ultrasound tissue characterization (before and 3 hrs after extracorporeal shockwave therapy), (b) pressure pain thresholds, over the Achilles tendon and common extensor tendon origin (before, immediately after, and 3 hrs after extracorporeal shockwave therapy), and (c) hop pain (before and immediately after extracorporeal shockwave therapy).

RESULTS

There was a significant reduction in echo type I (P < 0.05) and increase in echo type II (P < 0.05) at 3 hrs after the first extracorporeal shockwave therapy session that recovered to baseline levels before week 2. There were no significant changes in ultrasound tissue characterization echo pattern observed in subsequent sessions. There were increased pressure pain thresholds immediately after extracorporeal shockwave therapy at the common extensor tendon origin but no significant change at the Achilles tendon. Pressure pain thresholds returned to baseline at 3 hrs after extracorporeal shockwave therapy. There were no significant changes in pressure pain threshold in subsequent sessions.

CONCLUSIONS

Extracorporeal shockwave therapy resulted in transient changes to tendon structure and widespread hyperalgesia.

Johnson M. Pain and Function in the Runner a Ten (din) uous Link

A male runner (30 years old; 10-km time: 33 min, 46 s) had been running with suspected insertional Achilles tendinopathy (AT) for ~2 years when the pain reached a threshold that prevented running. Diagnostic ultrasound (US), prior to a high-volume stripping injection, confirmed right-sided medial insertional AT. The athlete failed to respond to injection therapy and ceased running for a period of 5 weeks. At the beginning of this period, the runner completed the Victoria institute of sports assessment–Achilles questionnaire (VISA-A), the foot and ankle disability index (FADI), and FADI sport prior to undergoing an assessment of bi-lateral gastrocnemius medialis (GM) muscle architecture (muscle thickness (MT) and pennation angle (PA); US), muscle contractile properties (maximal muscle displacement (Dm) and contraction time (Tc); Tensiomyography (TMG)) and calf endurance (40 raises/min). VISA-A and FADI scores were 59%/100% and 102/136 respectively. Compared to the left leg, the right GM had a lower MT (1.60 cm vs. 1.74 cm), a similar PA (22.0° vs. 21.0°), a lower Dm (1.2 mm vs. 2.0 mm) and Tc (16.5 ms vs. 17.7 ms). Calf endurance was higher in the right leg compared to the left (48 vs. 43 raises). The athlete began a metronome-guided (15 BPM), 12-week progressive eccentric training protocol using a weighted vest (1.5 kg increments per week), while receiving six sessions of shockwave therapy concurrently (within 5 weeks). On returning to running, the athlete kept daily pain (Numeric Rating Scale; NRS) and running scores (miles*rate of perceived exertion (RPE)). Foot and ankle function improved according to scores recorded on the VISA-A (59% vs. 97%) and FADI (102 vs. 127/136). Improvements in MT (1.60 cm vs. 1.76 cm) and PA (22.0° vs. 24.8°) were recorded via US. Improvements in Dm (1.15 mm vs. 1.69 mm) and Tc (16.5 ms vs. 15.4 ms) were recorded via TMG. Calf endurance was lower in both legs and the asymmetry between legs remained (L: 31, R: 34). Pain intensity (mean weekly NRS scores) decreased between week 1 and week 12 (6.6 vs. 2.9), while running scores increased (20 vs. 38) during the same period. The program was maintained up to week 16 at which point mean weekly NRS was 2.2 and running score was 47.

Prospective randomized comparison of platelet rich plasma to extracorporeal shockwave therapy for treatment of proximal suspensory pain in western performance horses

Proximal suspensory desmitis (PSD) is a frequent cause of lameness in the performance horse. Extracorporeal shockwave therapy (EST) and platelet rich plasma (PRP) have become common treatments for PSD yet clinical data on efficacy is limited. The main objective of this randomized, prospective clinical study was to compare long-term effectiveness of EST and PRP in Western performance horses. One hundred horses with lameness localized to the proximal suspensory ligament received treatment with either PRP or EST following baseline ultrasonographic evaluation. A veterinarian and agent evaluated the horses for lameness independently four days following the first treatment and long-term follow up was obtained from the agent at six and twelve months. Four days post treatment, horses treated with EST had significantly greater lameness improvement compared to PRP. At one-year horses with less severe baseline ultrasound changes (grades 0-1) appeared to respond better (degree of lameness) with EST treatment whereas horses with more severe ultrasound changes (grade 2) responded better to PRP. Horses with baseline lameness graded 1 or 2 were 5.1 times more likely to be back in work at 1 year compared to those presenting with grade 3 or 4. EST treatment was associated with going back to work 3.8 times more at one year compared to PRP independent of baseline ultrasound score. Both PRP and EST can be expected to yield favorable therapeutic responses in Western performance horses with lameness localized to the proximal suspensory region. Baseline ultrasound may guide treatment selection.

[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 shock wave therapy improves short-term limb use after canine tibial plateau leveling osteotomy

OBJECTIVE

To determine the influence of postoperative extracorporeal shock wave therapy (ESWT) on hind limb use after tibial plateau leveling osteotomy (TPLO).

STUDY DESIGN

Randomized, prospective clinical trial.

ANIMALS

Sixteen client-owned dogs, 2 to 10 years old weighing 18 to 75 kg.

METHODS

Dogs were randomly assigned to treatment cohorts, TPLO with ESWT (ESWT, n = 9) or TPLO without ESWT (control, n = 7). Treatment consisted of 1000 pulses at 0.15 mJ/mm² immediately and 2 weeks after surgery. Subjective pain, stifle goniometry, stifle circumference, peak vertical force (PVF) and vertical impulse (VI) were measured before surgery, prior to ESWT, and 2 and 8 weeks after surgery. Measures were compared between treatments at each time point and among time points for each treatment (P < .05).

RESULTS

The PVF (5.5 ± 1.0 N/kg, mean ± SD) and VI (0.67 ± 0.14 N-s/kg) of surgically treated limbs in the ESWT cohort were higher 8 weeks after surgery compared with preoperative (3.8 ± 1.1 N/kg, P < .0001 and 0.47 ± 0.21 N-s/kg, P = .0012, respectively) values. In the control cohort, PVF (2.9 ± 1.3 N/kg, P = .0001) and VI (0.33 ± 0.20 N-s/kg, P = .0003) 2 weeks after surgery and VI (0.42 ± 0.2 N-s/kg, P = .0012) 8 weeks after surgery were lower (4.59 ± 2.33 N/kg and 0.592 ± 0.35 N-s/kg, respectively) than before surgery. Other parameters did not differ between groups.

CONCLUSION

Weight bearing increased faster after TPLO in dogs treated with postoperative ESWT.

CLINICAL SIGNIFICANCE

This study provides evidence to consider adjunct ESWT after TPLO.

Radial extracorporeal shock wave therapy in flexor tendon pathology of the hand: A feasibility study

BACKGROUND

Radial extracorporeal shock wave therapy (rESWT) is an effective and safe non-invasive therapeutic option for various musculoskeletal pathologies. However, data on possible application of radial extracorporeal shock waves (rESWs) on soft tissue components of fingers is still scarce.

OBJECTIVE

We now aimed to analyze the feasibility of applying rESWs to human fingers ex vivo.

METHODS

Fresh frozen human cadaveric fingers were exposed to rESWs of varying energy density. The penetration of the rESWs into the soft tissue was determined using pressure sensitive Fuji films that were placed underneath the flexor tendons and other soft tissue components at the proximal phalanx. Then, rESWs were applied and activation of the Fuji film was recorded. Software based image analysis was performed on all films treated with rESWT under ultrasound gel.

RESULTS

Penetration of the rESWs through the soft tissue was detected in all settings. Increasing energy density of the rESWs resulted in increasing film activation. Image analysis of films used under ultrasound showed a significant difference among the groups.

CONCLUSION

The results of this study demonstrate that rESWs can penetrate soft tissues including the flexor tendons of human cadaveric fingers. rESWT should be considered as a valuable potential therapeutic option of different finger pathologies. Further studies focusing on the clinical application of rESWT for finger pathologies are required.

Endometriosis treatment with shock waves: A novel approach

Endometriosis affects 10-15% of women. When medication is unsatisfactory, not well tolerated or unwanted, surgery remains the sole option. There is a need for a less invasive treatment. We suggest the application of shock wave therapy (SWT) to endometriotic nodules (including deep infiltrating endometriosis), endometriomas and adenomyosis. We hypothesize pain relief via an antiinflammatory effect, an antioxidant effect and neural pathways modulation, as well as a direct effect on the lesions by the energy thus delivered. Questions to be answered before a clinical application is tested include route of administration (external versus internal transducers), dose regimen, optimal duration of treatment and type of shock waves used (focalised versus radial).

Exposure to radial extracorporeal shock waves modulates viability and gene expression of human skeletal muscle cells: a controlled in vitro study

BACKGROUND

Recent clinical and animal studies have shown that extracorporeal shock wave therapy has a promoting influence on the healing process of musculoskeletal disorders. However, the underlying biological effects of extracorporeal shock wave therapy on human skeletal muscle cells have not yet been investigated.

METHODS

In this study, we investigated human skeletal muscle cells after exposure to radial extracorporeal shock waves in a standardized in vitro setup. Cells were isolated from muscle specimens taken from adult patients undergoing spine surgery. Primary muscle cells were exposed once or twice to radial extracorporeal shock waves in vitro with different energy flux densities. Cell viability and gene expression of the paired box protein 7 (Pax7), neural cell adhesion molecule (NCAM), and myogenic factor 5 (Myf5) and MyoD as muscle cell markers were compared to non-treated muscle cells that served as controls.

RESULTS

Isolated muscle cells were positive for the hallmark protein of satellite cells, Pax7, as well as for the muscle cell markers NCAM, MyoD, and Myf5. Exposure to radial extracorporeal shock waves at low energy flux densities enhanced cell viability, whereas higher energy flux densities had no further significant impact. Gene expression analyses of muscle specific genes (Pax7, NCAM, Myf5, and MyoD) demonstrated a significant increase after single exposure to the highest EFD (4 bar, 0.19 mJ/mm²) and after double exposure with the medium EFDs (2 and 3 bar; 0.09 and 0.14 mJ/mm², respectively). Double exposure of the highest EFD, however, results in a significant down-regulation when compared to single exposure with this EFD.

CONCLUSIONS

This is the first study demonstrating that radial extracorporal shock wave therapy has the potential to modulate the biological function of human skeletal muscle cells. Based on our experimental findings, we hypothesize that radial extracorporal shock wave therapy could be a promising therapeutic modality to improve the healing process of sports-related structural muscle injuries.

Shock wave-induced permeabilization of mammalian cells

Controlled permeabilization of mammalian cell membranes is fundamental to develop gene and cell therapies based on macromolecular cargo delivery, a process that emerged against an increasing number of health afflictions, including genetic disorders, cancer and infections. Viral vectors have been successfully used for macromolecular delivery; however, they may have unpredictable side effects and have been limited to life-threatening cases. Thus, several chemical and physical methods have been explored to introduce drugs, vaccines, and nucleic acids into cells. One of the most appealing physical methods to deliver genes into cells is shock wave-induced poration. High-speed microjets of fluid, emitted due to the collapse of microbubbles after shock wave passage, represent the most significant mechanism that contributes to cell membrane poration by this technique. Herein, progress in shock wave-induced permeabilization of mammalian cells is presented. After covering the main concepts related to molecular strategies whose applications depend on safer drug delivery methods, the physics behind shock wave phenomena is described. Insights into the use of shock waves for cell membrane permeation are discussed, along with an overview of the two major biomedical applications thereof-i.e., genetic modification and anti-cancer shock wave-assisted chemotherapy. The aim of this review is to summarize 30 years of data showing underwater shock waves as a safe, noninvasive method for macromolecular delivery into mammalian cells, encouraging the development of further research, which is still required before the introduction of this promising tool into clinical practice.

High-energy extracorporeal shock wave therapy for nontraumatic osteonecrosis of the femoral head

Background

Nontraumatic osteonecrosis of the femoral head (ONFH) is treated with a series of methods. High-energy extracorporeal shock wave therapy (ESWT) is an option with promising mid-term outcomes. The objective of this study was to determine the long-term outcomes of ESWT for ONFH.

Methods

Fifty-three hips in 39 consecutive patients were treated with ESWT in our hospital between January 2005 and July 2006. Forty-four hips in 31 patients with stage I–III nontraumatic ONFH, according to the Association Research Circulation Osseous (ARCO) system, were reviewed in the current retrospective study. The visual analog pain scale (VAS), Harris hip score, radiography, and magnetic resonance imaging were used to estimate treatment results. The progression of ONFH was evaluated by imaging examination and clinical outcomes. The results were classified as clinical success (no progression of hip symptoms) and imaging success (no progression of stage or substage on radiography and MRI).

Results

The mean follow-up duration was 130.6 months (range, 121 to 138 months). The mean VAS decreased from 3.8 before ESWT to 2.2 points at the 10-year follow-up (p < 0.001). The mean Harris hip score improved from 77.4 before ESWT to 86.9 points at the 10-year follow-up. The clinical success rates were 87.5% in ARCO stage I patients, 71.4% in ARCO stage II patients, and 75.0% in ARCO stage III patients. Imaging success was observed in all stage I hips, 64.3% of stage II hips, and 12.5% of stage III hips. Seventeen hips showed progression of the ARCO stage/substage on imaging examination. Eight hips showed femoral head collapse at the 10-year follow-up. Four hips in ARCO stage III and one hip in ARCO stage II were treated with total hip arthroplasty during the follow-up. Three were performed 1 year after ESWT, one at 2 years, and one at 5 years.

Conclusions

The results of the current study indicated that ESWT is an effective treatment method for nontraumatic ONFH, resulting in pain relief and function restoration, especially for patients with ARCO stage I–II ONFH.

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.

Dose-dependent and cell type-specific cell death and proliferation following in vitro exposure to radial extracorporeal shock waves

Radial extracorporeal shock wave (rESW) therapy is widely used in musculoskeletal disorders and wound repair. However, the mechanisms of action are still largely unknown. The current study compared the effects of rESWs on two cell types. Human fetal foreskin fibroblasts (HFFF2) and human placental choriocarcinoma cell line JEG-3 were exposed to 0, 100, 200, 500 or 5000 rESWs generated with a Swiss DolorClast device (2.5 bar, 1 Hz). FACS analysis immediately after rESW exposure showed that initially, rESWs rather induced mechanical cell destruction than regulated or programmed cell death. Cell damage was nearly negated by reducing cavitation. Furthermore, cell viability decreased progressively with higher numbers of rESWs. Exposure to rESWs had no impact on growth potential of JEG-3 cells, but dose-dependently increased growth potential of HFFF2 cells. Cultivation of cells that were initially exposed to sham-rESWs in conditioned media increased the growth potential of HFFF2 cells, nevertheless, an even stronger effect was achieved by direct exposure to rESWs. Additionally, cell cycle distribution analysis demonstrated a shift in proportion from G0/G1 to G2/M phase in HFFF2 cells, but not in JEG-3 cells. These data demonstrate that rESWs leads to initial and subsequent dose-dependent and cell type-specific effects in vitro.

Prognostic factors of extracorporeal shock wave therapy for tendinopathies

INTRODUCTION

Extracorporeal shock wave therapy is very widely used for the management of tendinopathies and plantar fasciitis.

AIM

The aim of the study is to determine whether there are prognostic factors that may influence the outcome of extracorporeal shock wave therapy for these diseases.

METHODS

Three hundred fifty-five patients were analyzed 2 months after shock wave treatment for rotator cuff tendinitis, epicondylitis, Achilles tendinopathy, trocanteritis, jumper's knee or plantar fasciitis. We recorded the epidemiological, clinical and treatment protocol, and these data were correlated with treatment outcome.

RESULTS

Clinical improvement was achieved in 45.9 % of these patients. We discovered that laterality different to the dominant limb (p < 0.0001) and repeated shock wave treatments (p = 0.004) are prognostic factors in an unsuccessful therapy, while being male (p = 0.015) and a high body mass index (p = 0.004) are factors for success. We found no differences in relation to age, diet, blood type, work or sport activity, presence of co-morbidities, drugs, type of tendinopathy, density of energy delivered and other physiotherapy treatment. Knowledge of these prognostic factors may lead to improved insight for physicians and physiotherapists to predict the extent of the recovery and adjust rehabilitation and patient expectations accordingly.

Comparison of shock wave therapy and nutraceutical composed of Echinacea angustifolia, alpha lipoic acid, conjugated linoleic acid and quercetin (perinerv) in patients with carpal tunnel syndrome

Even though the initial treatment of carpal tunnel syndrome (CTS) is conservative, knowledge of the clinical effects of supplements and of some methods of physiotherapy is still preliminary. Many biological mechanisms can support the administration of shock wave therapy (ESWT) or of alpha lipoic acid (ALA) based nutraceutical, conjugated linoleic acid (GLA), anti-oxidants and Echinacea angustifolia for CTS. The shock waves reduce the nerve compression, produce an anti-inflammatory action, and accelerate the regeneration of neuropathy. ALA and GLA induce antioxidant protective actions, reduce inflammation, promote neuroregeneration, and decrease pain. The Echinacea modulates the endogenous cannabinoid system.The aim of study is to verify the efficiency of shock wave therapy versus nutraceutical composed of ALA, GLA, and Echinacea in CTS. Sixty patients were enrolled in this study and they were randomly assigned to one of two treatments. Both groups showed significant improvements in pain, symptoms' severity and functional scores, and electrodiagnostic results until the sixth month. We verified a trend to a better pain regression in the nutraceutical group. The presence of the medicinal Echinacea represents an added value to the antioxidant effect in ALA and GLA, which can justify this result. ESWT or the association of ALA, GLA, and Echinacea proved to be two effective treatments for controlling symptoms and improving the evolution of CTS.

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

SOURCES OF DATA

This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

AREAS OF AGREEMENT

ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

AREAS OF CONTROVERSY

The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

GROWING POINTS

There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.

Effects of extracorporeal shock wave therapy on functional and strength recovery of handgrip in patients affected by epicondylitis

Extracorporeal shock wave therapy (ESWT) is effective in the treatment of tendinopathy. We designed a prospective observational clinical study to assess the correlation between clinical and functional measures and recovery of strength after ESWT for epicondylitis. We analyzed 26 patients. We measured progressive improvement in visual analogue scale values (p < 0.0005) and Mayo Elbow Performance Index scores (p = 0.004) for the pathologic limb. Monitoring of handgrip failed to reveal changes in values at any follow-up (p > 0.05). We found no correlation between degree of clinical function and muscle deficit during follow-up. After ESWT, there was a tendency toward a decrease in grip strength, especially in the dominant limb. This could be related to the effects of ESWT, which reduces spasticity in painful hypertonic muscles. These data may be useful in defining the expectations for function during ESWT for epicondylitis, particularly for elite athletes.

Effect of radial shock wave therapy on pain and muscle hypertonia: a double-blind study in patients with multiple sclerosis

Background:

Radial shock wave therapy (RSWT) has been extensively used in rehabilitative medicine to treat pain, and more recently muscle hypertonia, in patients with cerebral palsy and stroke.

Objectives:

To assess the long-term effects of RSWT in a cohort of subjects affected by multiple sclerosis (MS) who were suffering from painful hypertonia of ankle extensor muscles.

Methods:

In this randomised, double blind, placebo-controlled study, we treated 34 patients with four sessions of RSWT (once weekly) and treated 34 patients with placebo. Participants were assessed at baseline, 1 week after the first session, and 1 week and 4 weeks after the last session. We measured pain using the visual analogue scale for pain, while we assessed muscle tone using the modified Ashworth scale and evaluated spinal excitability using the H-reflex.

Results:

After RSWT, muscle tone decreased 1 week after the last session and pain decreased at all the follow-up evaluations, while spinal excitability was unaffected. No significant changes were found after the placebo treatment.

Conclusions:

RSWT can reduce pain and muscle tone in MS patients without adverse effects. The lack of RSWT effects on spinal excitability supports the idea that RSWT is likely to act on non-reflex hypertonia, for example reducing muscle fibrosis.

ESWT for tendinopathy: technology and clinical implications

PURPOSE

The general consensus that tendinopathy, at least in the chronic stage, is mainly a degenerative condition and inflammation plays a minor role has led to a shift from treatments that target inflammation towards treatment options that promote regeneration. One of these treatments is extracorporeal shockwave therapy (ESWT), a physical therapy modality that uses pressure waves to treat tendinopathy. This review was undertaken to give an overview of the literature concerning this treatment, and special attention is given to the differences between focused and radial ESWT.

METHODS

A narrative description of wave characteristics, generation methods and in vitro effects of ESWT is given. The literature on ESWT as a treatment for one common tendinopathy, patellar tendinopathy, was systematically reviewed.

RESULTS

Waves that are generated for focused and radial ESWT have very different physical characteristics. It is unclear how these characteristics are related to clinical effectiveness. Studies into the biological effects of ESWT have mainly used focused shockwave therapy, showing a number of effects of shockwaves on biological tissue. The systematic review of studies into the clinical effects of ESWT for patellar tendinopathy showed conflicting evidence for its effectiveness.

CONCLUSION

Physical characteristics of focused and radial waves differ substantially, but effect on clinical effectiveness is unclear. Whereas in vitro studies often show the effects of ESWT on tendon tissue, results of clinical studies are inconsistent. Based on the review of the literature, suggestions are given for the use of ESWT in clinical practice regarding timing and treatment parameters.