Second application of low-energy shock waves has a cumulative effect on free nerve endings

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).

Analgesic effect and efficacy rate of radial extracorporeal shock wave therapy for plantar fasciitis: a retrospective study

[Purpose] This study aimed to measure the analgesic effects and efficacy of radial extracorporeal shock wave therapy, for which no consensus has been reached regarding optimal treatment parameters. [Participants and Methods] The study included 40 feet of 40 patients with plantar fasciitis. The visual analogue scale was used to determine the immediate and cumulative effects of radial extracorporeal shock wave therapy as well as the efficacy rate. Efficacy was calculated as a percentage visual analogue scale change of ≥20 mm and visual analogue scale improvement of ≥60%. [Results] Immediate and continued efficacy of radial extracorporeal shock wave therapy was observed and recorded. Efficacy rates based on a percentage visual analogue scale change of ≥20 mm and visual analogue scale improvement of ≥60% were both 57.5%. [Conclusion] Radial extracorporeal shock wave therapy has immediate and cumulative analgesic effects on plantar fasciitis. However, cumulative results of interventions with various treatment parameters are required to determine the optimal treatment parameter settings for diffuse pressure wave therapy for plantar fasciitis.

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

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

Synergistic effect of LCI with ESWT on treating patients with mild to moderate CTS: a randomized controlled trial

BACKGROUND

Applying radial extracorporeal shock wave therapy (R-ESWT) with LCI(local corticosteroid injection) in carpal tunnel syndrome (CTS) management is gaining momentum. The objective is to actualize the topic of this study.

METHODS

In this prospective randomized controlled trial, forty patients with mild to moderate CTS are divided into two sham- R-ESWT and R-ESWT groups subject to LCI(local corticosteroid injection). The first group received four sessions of sham-ESWT weekly, which involved sound but no energy; the second group received R-ESWT at equal intervals and were assessed for pain score (VAS score) and symptoms (GSS) baseline, 1st month, 3rd month, and 6th month.

RESULTS

A considerable improvement is observed in both groups for pain at (P < 0.05) and symptoms at (P < 0.05) in the 3rd month. The second group revealed more significant symptom improvement at (P < 0.05) in the 6th month.

CONCLUSION

The R-ESWT + LCI combined therapy course is the first line of treatment in patients with mild to moderate symptoms and leads to control and reduction of symptoms and the need for surgery, thus a primary concern in CTS treatment with an orthopedist.

Effects of individual shock wave therapy vs celecoxib on hip pain caused by femoral head necrosis

BACKGROUND

Celecoxib has been used to treat hip discomfort and functional difficulties associated with osteonecrosis of the femoral head (ONFH), although significant adverse reactions often follow long-term use. Extracorporeal shock wave therapy (ESWT) can delay the progression of ONFH, alleviate the pain and functional limitations it causes, and avoid the adverse effects of celecoxib.

AIM

To investigate the effects of individual ESWT, a treatment alternative to the use of celecoxib, in alleviating pain and dysfunction caused by ONFH.

METHODS

This was a randomized, controlled, double-blinded, non-inferiority trial. We examined 80 patients for eligibility in this study; 8 patients were excluded based on inclusion and exclusion criteria. A total of 72 subjects with ONFH were randomly assigned to group A (n = 36; celecoxib + alendronate + sham-placebo shock wave) or group B (n = 36; individual focused shock wave [ESWT based on magnetic resonance imaging three-dimensional (MRI-3D) reconstruction] + alendronate). The outcomes were assessed at baseline, at the end of treatment, and at an 8-wk follow-up. The primary outcome measure was treatment efficiency after 2 wk of intervention using the Harris hip score (HHS) (improvement of 10 points or more from the baseline was deemed sufficient). Secondary outcome measures were post-treatment HHS, visual analog scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores.

RESULTS

After treatment, the pain treatment efficiency of group B was greater than that of group A (69% vs 51%; 95%CI: 4.56% to 40.56%), with non-inferiority thresholds of -4.56% and -10%, respectively. Furthermore, the HHS, WOMAC, and VAS scores in group B dramatically improved during the follow-up period as compared to those in group A (P < 0.001). After therapy, the VAS and WOMAC in group A were significantly improved from the 2^nd to 8^th wk (P < 0.001), although HHS was only significantly altered at the 2 wk point (P < 0.001). On the 1^st d and 2^nd wk after treatment, HHS and VAS scores were different between groups, with the difference in HHS lasting until week 4. Neither group had severe complications such as skin ulcer infection or lower limb motor-sensory disturbance.

CONCLUSION

Individual shock wave therapy (ESWT) based on MRI-3D reconstruction was not inferior to celecoxib in managing hip pain and restrictions associated with ONFH.

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

OBJECTIVE

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

DESIGN

Retrospective case series.

SETTING

Funabashi Orthopedic Hospital.

PATIENTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

Shock wave lithotripsy and therapy

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

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

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

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

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

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

Application of shock wave therapy in the treatment of calcific tendinopathies

Tendons are the soft tissue that connects muscles to bones. They are made of collagen and elastin, they are strong and solid, and have no possibility of contraction. Their strength helps us to move. Recovery of tendon injuries is long-lasting and can take more than six months. If a tendon is shed during a time injury, calcification occurs at the site of the injury and the disease is called calcifying tendinopathy. The very existence of calcifications is an indication for treatment with a mechanical shock wave (Shock wave). Mechanical shock waves can act in focus or radially. The difference between focused and radial waves is primarily in their physical basis. Focused shock waves differ from radial shock waves in terms of therapeutic depth of penetration into the tissue. The basic biological effect of a mechanical shock wave is stimulating. The energy of the mechanical shock wave acts at the cellular level by stimulating the reduction of inflammation and pain in the tissue. Using mechanical shock wave in the treatment of calcified tendinopathies, a safe method for breaking calcifications was obtained. Shock wave can be applied to using: different frequency, different number of strokes, as well as different strength of strokes in their studies. The choice of parameters for the application depends on whether it is calcified or non-calcified tendinopathy. Indications for the use are: painful shoulder, heel spur, plantar fasciitis, tennis elbow, Achilles tendon tendinopathy, jumping knee, patellar tendinitis, myalgia, myogelosis and muscular tendon overstrain syndrome. Contraindications for the use are: the existence of prostheses, knees and hips, as well as various orthopedic material, pacemaker, as well as the presence of chronic diseases such as multiple sclerosis, amyotrophic lateral sclerosis or tumors. The application of a mechanical shock wave is new, non-invasive method, easy to apply, always reduces pain and practically without side effects. This method has a special role in the treatment of chronic inflammation of diseased tendons, with or without calcification. The only dilemma in the application of a mechanical shock wave can be in the number of applications as well as the time break between the applications of two consecutive mechanical shock waves therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fragmentation and propulsive effect of shock wave lithotripsy in treatment of small renal calculi

Background

Small renal calculi are frequently observed in clinical practice, and chemo-lytic therapy has limited effects. The purpose of the study is to evaluate the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in the treatment of small renal calculi.

Methods

We studied 60 patients with small renal stones from March 2017 to March 2019. After excluding eight patients with incomplete data, the remaining 52 patients were evaluated. Patients with symptomatic single or multiple stones of 6–8 mm in diameter or asymptomatic on ultrasound and kidney-ureter-bladder radiograph were eligible for inclusion. Small stones were treated by ESWL. The data were analyzed using the Statistical Packages for Social Sciences - version 25 (IBM Corporation).

Results

The mean age of the 52 patients was 34.5 ± 9.5 years. Forty-one (78.8%) patients were symptomatic, while 11 (21.2%) were asymptomatic. Forty-seven (90.4%) had single small renal stones, while four patients had two stones (7.7%) and only one patient had three stones (1.9%). Forty-five stones were successfully treated by ESWL, while 13 stones failed to respond.

Conclusion

ESWL is a useful tool for treating small renal calculi; it works either by fragmenting the stones or by acting as a pushing force. However, further large prospective studies are needed to corroborate the above conclusions.

Vibration-induced injuries in workers exposed to transient and high frequency vibrations

Background

The risk of developing vibration white fingers and neurosensory symptoms increases with the duration and intensity of the exposure. The aim of this study was to investigate the risk of developing vibration white fingers (VWF), neurosensory symptoms and musculoskeletal disorders among workers exposed to transient and high frequency vibrations.

Methods

The study included 38 vibration exposed workers from a loader assembly plant in Sweden (30 males and 8 females). All participants answered questionnaires and had a structured interview about work and medical history. A following medical examination included the determination of vibration and temperature perception thresholds and musculoskeletal symptoms in the neck, shoulder, elbow and hands. The individual vibration exposure expressed as A (8)-values and vibration exposure in minutes per day, were obtained from questionnaires answered by the participants.

Results

The prevalence of VWF was 30% among the male workers and 50% among the females. The corresponding prevalence of neurosensory symptoms was 70% among the males and 88% among the females. Musculoskeletal findings were common among the male workers. Dominant symptoms/syndromes were tension neck syndrome, biceps tendinitis, carpal tunnel syndrome and ulnar entrapment in hand/wrist. A total of 32 diagnoses were observed among the male workers and four diagnoses among the female workers. Numbness in fingers and age had the strongest impact on perceived work ability.

Conclusions

ISO 5349-1 considerably underestimates the risks of VWF for this group of workers exposed to transient and high frequency vibrations. It is therefore important to develop a risk assessment standard also covering this frequency range.

Comparison of Radial Extracorporeal Shock Wave Therapy in Plantar Fasciitis Treatment Using Two Different Frequencies

Objective To compare results of two different frequencies and densities of radial extracorporeal shock wave therapy (rESWT) after 10 sessions. Methods A total of 41 patients with plantar fasciitis were included in this study. Patients were randomly divided into two groups. Both groups were administered 10 sessions of treatment consisting of 15 Hz frequency, 3.0 Bar density and 2000 impulses/ session for the 1^st group, and 10 Hz frequency, 2.0 Bar density and 2000 impulses/ session for the 2^nd group. Visual analog scale (VAS) and a modification of the clinical rating system of the American Orthopedic Foot and Ankle Society (AOFAS) were used for outcome measurement. The patients were assessed before treatment and followed up four weeks, and 12 weeks after end of treatment. Results Mean VAS scores were reduced after rESWT from 7.52 ± 2.34 (mean ± SEM) at baseline to 0.57 ± 0.68 at 12 weeks in the 1^st group and from 6.45 ± 2.04 at baseline to 0.40 ± 0.60 at 12 weeks in the 2^nd group. Similar changes were found for mean AOFAS scores from baseline after rESWT but were not observed significance between groups. Conclusion There is no significant different effect between the two treatment groups' results.

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.

Efficacy of Extracorporeal Shockwaves Therapy on Peripheral Nerve Regeneration

PURPOSE

This study was conducted to determine the effects of different doses and methods of extracorporeal shock wave treatment (ESWT) on the sciatic nerve regeneration of rat model using unbiased quantitative stereological techniques and to know which method and dose were effective.

METHODS

Twenty-five Wistar albino rats were used in the experiment. All animals were randomly divided into 5 groups. To the first group (control, n = 5) ESWT and surgery were not applied. To 2nd group (E300*2, n = 5), twice doses of 300 impulses uESWs (unfocused) were applied. To 3rd group (E500*2, n = 5), twice doses of 500 impulses uESWs (unfocused) were applied. To 4th group (E300*2, n = 5), twice doses of 300 impulses of fESWs (focused) were applied. To 5th group (E500*2, n = 5), twice doses of 500 impulses of fESWs (focused) were applied. Rats were sacrificed and nerve samples analyzed on the 22nd day following the operation.

RESULTS

There is a variable increase in the axon numbers among the shockwave treated groups in compare to the control group. The focused groups showed better improvement and the 300-focused group has shown the highest regeneration rate.

CONCLUSION

The authors found that ESWT promotes nerve regeneration, increases the thickness of the myelin sheath and that the most effective result is in the 300 shock wave.

Randomized Trial on Comparison of the Efficacy of Extracorporeal Shock Wave Therapy and Dry Needling in Myofascial Trigger Points

OBJECTIVE

The aim of the study was to compare the efficacy of radial extracorporeal shock wave therapy and dry needling in the treatment of myofascial trigger points in the upper trapezius muscle.

DESIGN

A total of 65 patients with myofascial trigger points were randomly divided into extracorporeal shock wave therapy group (n = 32) and dry needling group (n = 33). Patients received 3 wks of treatment at 1-wk intervals (in both groups). Visual analog scale, pressure pain threshold, Neck Disability Index, and shear modulus were evaluated before treatment, immediately after the first therapy, 1 mo, and 3 mos after the completion of the third therapy.

RESULTS

Significant improvements of visual analog scale, pressure pain threshold, and Neck Disability Index scores were observed at all time points after treatment (P < 0.01) in both treatment groups. The shear modulus of myofascial trigger points was reduced in both dry needling group (P < 0.05) and extracorporeal shock wave therapy group (P < 0.01) immediately after the first treatment. Significant reductions in shear modulus were maintained up to 3-mo posttreatment in both groups (P < 0.01). There were no significant differences between the radial extracorporeal shock wave therapy group and dry needling group.

CONCLUSIONS

The extracorporeal shock wave therapy is as effective as dry needling for relieving pain, improving function, and reducing shear modulus for patients with myofascial trigger points after a series of three treatments.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Power Doppler Ultrasound Findings before and after Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Pilot Study on Pain Reduction and Neovascularization Effect

Extracorporeal shock wave therapy (ESWT) has been found to have a positive effect in the treatment of pain in Achilles tendinopathy, although the exact mechanism is not yet completely understood. Among the mechanisms suggested to underlie ESWT effects are direct stimulation of healing, neovascularization and direct suppressive effects on nociceptors and hyperstimulation, which would block the gate-control system. The neovascularization observed in flogistic tissue is associated with stimulated nerve fibers around tendons and induces a painful condition. The objectives of the present study were to evaluate the effect of ESWT on pain and function in patients with non-insertional Achilles tendinopathy (NIAT) and to assess the neovascularization phenomenon using power Doppler ultrasound (PDU). Twelve patients with NIAT underwent five sessions of focused ESWT over 5 wk. Outcome measures were the visual analogue scale, the Victorian Institute of Sport Assessment-Achilles questionnaire and active dorsiflexion and plantar flexion ankle articular range of motion. Moreover, the patients' clinical impressions of treatment results after ESWT were investigated using the Roles and Maudsley score. Patients were assessed at baseline and 1 and 3 mo after treatment. They had a significant reduction in pain with improvement of arthrokinematic motion and functionality and a positive clinical impression of treatment outcome (50% of patients considered their clinical picture as good/excellent after 3 mo). However, the pulse Doppler ultrasound exam did not reveal neovascularization in 91.7% of the patients 1 and 2 mo after focused ESWT, and in some patients there was a reduction in blood vessels related to flogistic processes. The present observational study confirmed the efficacy of ESWT in pain reduction in NIAT, with a higher degree of patient satisfaction, although doubt persists over the neovascularization effect on the Achilles tendons treated.

Timing of extracorporeal shock wave therapy in rabbits with carpal tunnel syndrome

The purpose of this study is to evaluate the effect of extracorporeal shock wave therapy (ESWT) according to treatment timing in rabbits with 10% dextrose-induced carpal tunnel syndrome (CTS); 0.1-ml 10% dextrose solution was injected under ultrasound guidance twice weekly to the left forepaw subsynovial connective tissue (SSCT) within the carpal tunnel of 36 New Zealand white rabbits to induce CTS. The rabbits were randomly allocated into four groups: G1-S (sham ESWT), G2-E4 (ESWT at 4 weeks), G3-E8 (at 8 weeks), and G4-E16 (at 16 weeks). Radial ESWT (500 pulses, 0.08 mJ/mm² , 2 Hz) was repeated thrice weekly. Median nerve distal motor latency (DML) was measured before injection and at 4, 8, 12, 16, and 20 weeks after the first injection. All rabbits were sacrificed 20 weeks after injection. The median nerve cross-sectional area (CSA) and SSCT thickness were measured with light microscopy. The mean median nerve DML at 4 weeks after the first dextrose injection did not differ from that at preinjection in all groups. The mean median nerve DML significantly increased before ESWT in all groups (p < .05); however, it did not increase in G2-E4 and G3-E8 for 12 weeks after ESWT and in G4-E16 for 4 weeks (p > .05). Mean CSA of the median nerve and mean SSCT thickness in G2-E4 were significantly lower than those in the other groups (p < .05). ESWT may prevent the progression of CTS for 12 weeks in rabbits with dextrose-induced CTS regardless of treatment timing, and early application results in superior outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Extracorporeal shockwave therapy vs. kinesiotherapy for osteoarthritis of the knee: A pilot randomized controlled trial

BACKGROUND

Osteoarthritis (OA) of the knee is a degenerative, painful pathology, needing conservative treatment for symptoms' relief.

OBJECTIVE

Comparing the effects of Extracorporeal shockwave therapy (ESWT) and Kinesiotherapy (KIN) on perceived health and range of motion (ROM) of the affected knee.

METHOD

A pilot randomized controlled trial with concealed allocation, assessor blinding, intention-to-treat analysis. Forty participants, aged 40-75 with OA of the knee were randomized to an ESWT and a KIN groups. The ESWT group completed 5 interventions for 5 weeks, the KIN group completed the same number of interventions. All evaluations were performed at baseline and after the treatment for: perceived health (Western Ontario and McMaster Universities questionnaire - WOMAC), range of motion (ROM).

RESULTS

After the intervention the statistical significant between groups differences favoring the ESWT were found in the WOMAC with regard to pain (p< 0.000), stiffness (p= 0.018), physical function (p< 0.000), total score (p< 0.000), extension and flexion of the affected knee (p= 0.015, p< 0.000) respectively.

CONCLUSIONS

ESWT improves WOMAC and ROM better then KIN on the affected knee in patients with OA of the knee.

Radial Extracorporeal Shock Wave Therapy for Relief of Arthralgia in Rheumatoid Arthritis

More than one-third of the population with rheumatoid arthritis requires adjuvant analgesic treatment after antirheumatic therapy. In addition to analgesics, another option is radial extracorporeal shock wave therapy (rESWT), a novel physical therapy that has been successfully used in the treatment of many types of chronic soft tissue pain. We report a series of 15 patients who suffered from arthralgia after being on disease-modifying antirheumatic drugs for more than 3 months. Participants received rESWT for 3 months as an adjuvant therapy. Compared to the pretherapy baseline, follow-up at 3 months post-therapy revealed a significant reduction in resting state visual analog scale scores from 2.90 ± 0.74 to 0.80 ± 0.79 (P = 0.004), active state visual analog scale scores from 5.70 ± 1.33 to 2.20 ± 0.63 (P < 0.001), morning stiffness duration from 2.25 ± 0.79 to 1.05 ± 0.69 hours (P = 0.004), disease activity score with 28-joint counts based on erythrocyte sedimentation rate from 6.34 ± 0.72 to 4.19 ± 0.59 (P = 0.001), and Health Assessment Questionnaire scores from 10.20 ± 2.35 to 5.00 ± 2.62 (P = 0.005). The pre-post changes in erythrocyte sedimentation rate and C-reactive protein were not statistically significant. By the end of treatment, 11 participants stopped analgesics completely; the other 4 participants were on a smaller dosage. No severe adverse effects related to rESWT were observed. To our knowledge, this is the first report using this therapy to treat arthralgia in rheumatoid arthritis.

New and Accurate Predictive Model for the Efficacy of Extracorporeal Shock Wave Therapy in Managing Patients With Chronic Plantar Fasciitis

OBJECTIVE

To identify factors for the outcome of a minimum clinically successful therapy and to establish a predictive model of extracorporeal shock wave therapy (ESWT) in managing patients with chronic plantar fasciitis.

DESIGN

Randomized, controlled, prospective study.

SETTING

Outpatient of local medical center settings.

PARTICIPANTS

Patients treated for symptomatic chronic plantar fasciitis between 2014 and 2016 (N=278).

INTERVENTIONS

ESWT was performed by the principal authors to treat chronic plantar fasciitis. ESWT was administered in 3 sessions, with an interval of 2 weeks (±4d). In the low-, moderate-, and high-intensity groups, 2400 impulses total of ESWT with an energy flux density of 0.2, 0.4, and 0.6mJ/mm², respectively (a rate of 8 impulses per second), were applied.

MAIN OUTCOME MEASURES

The independent variables were patient age, sex, body mass index, affected side, duration of symptoms, Roles and Maudsley score, visual analog scale (VAS) score when taking first steps in the morning, edema, bone spurs, and intensity grade of ESWT. A minimal reduction of 50% in the VAS score was considered as minimum clinically successful therapy. The correlations between the achievement of minimum clinically successful therapy and independent variables were analyzed. The statistically significant factors identified were further analyzed by multivariate logistic regression, and the predictive model was established.

RESULTS

The success rate of ESWT was 66.9%. Univariate analysis found that VAS score when taking first steps in the morning, edema, and the presence of heel spur in radiograph significantly affected the outcome of the treatment. Logistic regression drew the equation: minimum clinically successful therapy=(1+e^{[.011+42.807×heel spur+.109×edema+5.395×VASscore]})^-1.The sensitivity of the predictive factors was 96.77%, 87.63%, and 86.02%, respectively. The specificity of the predictive factors was 45.65%, 42.39%, and 85.87%, respectively. The area under the curve of the predictive factors was .751, .650, and .859, respectively. The Youden index was .4243, .3003, and .7189, respectively. The Hosmer-Lemeshow test showed a good fitting of the predictive model, with an overall accuracy of 89.6%.

CONCLUSIONS

This study establishes a new and accurate predictive model for the efficacy of ESWT in managing patients with chronic plantar fasciitis. The use of these parameters, in the form of a predictive model for ESWT efficacy, has the potential to improve decision-making in the application of ESWT.

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

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

The dose-dependent efficiency of radial shock wave therapy for patients with carpal tunnel syndrome: a prospective, randomized, single-blind, placebo-controlled trial

Recently, extracorporeal shock wave therapy (ESWT) has been shown to be a novel therapy for carpal tunnel syndrome (CTS). However, previous studies did not examine the diverse effects of different-session ESWT for different-grades CTS. Thus, we conducted a randomized, single-blind, placebo-controlled study. Sixty-nine patients (90 wrists) with mild to moderate CTS were randomized into 3 groups. Group A and C patients received one session of radial ESWT (rESWT) and sham eESWT per week for 3 consecutive weeks, respectively; Group B patients received a single session of rESWT. The night splint was also used in all patients. The primary outcome was Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) points, whereas secondary outcomes included the sensory nerve conduction velocity and cross-sectional area of the median nerve. Evaluations were performed at 4, 10, and 14 weeks after the first session of rESWT. Compared to the control group, the three-session rESWT group demonstrated significant BCTQ point reductions at least 14 weeks, and the effect was much longer lasting in patients with moderate CTS than mild CTS. In contrast, the effect of single-session rESWT showed insignificant comparison. rESWT is a valuable strategy for treating CTS and multiple-session rESWT has a clinically cumulative effect.

Radial extracorporeal shockwave therapy for the treatment of finger tenosynovitis (trigger digit)

Introduction

Stenosing tenosynovitis that is characterized by the inability to flex the digit smoothly, usually leads to prolonged rehabilitation or surgery.

Study design

This case series is a retrospective cohort study.

Purpose

The aim of this case series was to evaluate the effectiveness of radial extracorporeal shockwave therapy (rESWT) for the treatment of stenosing tenosynovitis of the digital flexor tendon (trigger digit).

Methods

A retrospective analysis of 44 patients (49 fingers) treated with an individually adapted rESWT protocol was conducted. Trigger digit pain and function were evaluated at baseline and 1-, 3-, and 12-months posttreatment. Recurrence and pretreatment symptom duration were analyzed.

Results

Significant reductions in pain scores and functional improvement were found between baseline and all follow-up assessments (P<0.001). Pretreatment symptom duration was significantly correlated with the number of rESWT sessions required (r=0.776, P<0.001) and 1-year posttreatment pain score (r=0.335, P=0.019).

Conclusion

This study provides initial evidence that rESWT is an effective treatment for trigger digit, but randomised controlled trials are required to provide further evidence of this effect.

Success and Recurrence Rate after Radial Extracorporeal Shock Wave Therapy for Plantar Fasciopathy: A Retrospective Study

Background and Aims. The exploration of an individualised protocol of radial extracorporeal shock wave therapy (rESWT) for plantar fasciopathy, assessing success rates and the recurrence rate over a 1-year period after treatment, is not yet identified in literature. Methods and Results. Between 2006 and 2013, 68 patients (78 heels) were assessed for plantar fasciopathy. An individualised rESWT treatment protocol was applied and retrospectively analysed. Heels were analysed for mean number of shock wave impulses, mean pressure, and mean frequency applied. Significant mean pain reductions were assessed through Visual Analogue Scale (VAS) after 1-month, 3-month, and 1-year follow-up. Success rates were estimated as the percentage of patients having more than 60% VAS pain decrease at each follow-up. 1-year recurrence rate was estimated. The mean VAS score before treatment at 6.9 reduced to 3.6, 1 month after the last session, and to 2.2 and 0.9, after 3 months and 1 year, respectively. Success rates were estimated at 19% (1 month), 70% (3 months), and 98% (1 year). The 1-year recurrence rate was 8%. Moderate positive Spearman's rho correlation (r = 0.462, p < 0.001) was found between pretreatment pain duration and the total number of rESWT sessions applied. Conclusions. Individualised rESWT protocol constitutes a suitable treatment for patients undergoing rESWT for plantar fasciitis.

Effect of radial shock wave therapy for carpal tunnel syndrome: A prospective randomized, double-blind, placebo-controlled trial

Three recent studies demonstrated the positive effect of extracorporeal shock wave therapy (ESWT) for treating carpal tunnel syndrome (CTS). However, none have entirely proved the effects of ESWT on CTS because all studies had a small sample size and lacked a placebo-controlled design. Moreover, radial ESWT (rESWT) has not been used to treat CTS. We conducted a prospective randomized, controlled, double-blinded study to assess the effect of rESWT for treating CTS. Thirty-four enrolled patients (40 wrists) were randomized into intervention and control groups (20 wrists in each). Participants in the intervention group underwent three sessions of rESWT with nightly splinting, whereas those in the control group underwent sham rESWT with nightly splinting. The primary outcome was visual analog scale (VAS), whereas the secondary outcomes included the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), cross-sectional area (CSA) of the median nerve, sensory nerve conduction velocity of the median nerve, and finger pinch strength. Evaluations were performed before treatment and at 1, 4, 8, and 12 weeks after the third rESWT session. A significantly greater improvement in the VAS, BCTQ scores, and CSA of the median nerve was noted in the intervention group throughout the study as compared to the control group (except for BCTQ severity at week 12 and CSA at weeks 1 and 4) (p < 0.05). This is the first study to assess rESWT in a randomized placebo-controlled trial and demonstrate that rESWT is a safe and effective method for relieving pain and disability in patients with CTS. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:977-984, 2016.

Therapeutic Effect of Extracorporeal Shock Wave Therapy According to Treatment Session on Gastrocnemius Muscle Spasticity in Children With Spastic Cerebral Palsy: A Pilot Study

Objective

To investigate the therapeutic effect of extracorporeal shockwave therapy (ESWT) according to treatment session on gastrocnemius muscle spasticity in children with spastic cerebral palsy (CP).

Methods

Twelve children with spastic CP underwent 1 ESWT and 2 sham ESWT sessions for gastrocnemius (group 1) or 3 ESWT sessions (group 2) once per week for 3 weeks. Modified Ashworth Scale (MAS) score, passive range of motion (PROM) of the ankle plantar-flexor muscles with knee extension, and median red pixel intensity (RPI) of color histogram of medial gastrocnemius on real-time sonoelastography (RTS) were measured before ESWT, immediately after the first and third ESWT, and at 4 weeks after the third ESWT.

Results

Mean ankle PROM was significantly increased whereas as mean ankle MAS and median gastrocnemius RPI were significantly decreased in both groups after the first ESWT. Clinical and RTS parameters before ESWT were not significantly different from those immediately after the third ESWT or at 4 weeks after the third ESWT in group 1. However, they were significantly different from those immediately after the third ESWT or at 4 weeks after the third ESWT in group 2. Mean ankle PROM, mean ankle MAS, and median gastrocnemius RPI in group 2 were significantly different from that in group 1 at 4 weeks or immediately after the third ESWT.

Conclusion

The therapeutic effect of ESWT on spastic medial gastrocnemius in children with spastic CP is dependent on the number of ESWT sessions.

The Effect of Low Dose Extracorporeal Shock Wave Therapy (ESWT) on Plantar Fasciitis: A Trial Study in Queen Mary Hospital

Background/Purpose

To assess the efficacy of low-energy extracorporeal Shockwave therapy (ESWT) for the treatment of plantar fasciitis.

Methods

This was a prospective case series study that was performed at the Department of Orthopaedics, Queen Mary Hospital, Hong Kong. Twenty-one symptomatic feet in 16 patients with persistent symptoms of plantar fasciitis despite 3 months of conservative treatment were recruited in November 2008. All patients received five sessions of low energy ESWT and their corresponding 10-point visual analogue scale scores were recorded before and after each treatment sessions for each symptomatic foot. The patients were assessed for up to 6 months post-treatment.

Results

The mean visual analogue scale scores reduction for pain on first step in the morning, daily activities, and heel compression test were 2.62 (44.3%), 3 (38.3%), and 1.6 (36.8%), respectively, post-treatment. The analgesic effect was maintained in 52.3% (n = 11) of the patients at 6 months post treatment.

Conclusion

Low energy ESWT was shown to be an effective outpatient treatment option for patients with plantar fasciitis.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Effect of shockwave therapy on plantar fasciopathy

It has been suggested that extracorporeal shockwave therapy is a safe and effective treatment for pain relief from recalcitrant plantar fasciopathy (PF). However, the changes in gait and associated biomechanical parameters have not been well characterised. We recruited 12 female patients with recalcitrant PF who had a mean age of 59 years (50 to 70) and mean body mass index of 25 kg/m2 (22 to 30). The patients reported a mean duration of symptoms of 9.3 months (6 to 15). Shockwave therapy consisting of 1500 impulses (energy flux density 0.26 mJ/mm2) was applied for three sessions, each three weeks apart. A pain visual analogue scale (VAS) rating, plantar pressure assessment and motion analysis were carried out before and nine weeks after first shock wave therapy. It was demonstrated that patients increased their walking velocity and cadence as well indicating a decrease in pain after shockwave therapy. In the symptomatic foot, the peak contact pressure over the forefoot increased and the contact area over the digits decreased. The total foot impulse also decreased as did stance duration. The duration the centre of pressure remained in the hindfoot increased in the symptomatic foot after shockwave therapy. The differences in centre of pressure trajectory at baseline decreased at final follow-up. In conclusion, shockwave therapy not only decreased the pain VAS rating but also improved the gait parameters of the symptomatic foot in PF patients.

Cite this article: Bone Joint J 2013;95-B:1088–93.

Dose-related effect of extracorporeal shock wave therapy for plantar fasciitis

Objective

To examine the dose-related effect of extracorporeal shock wave therapy (ESWT) for plantar fasciitis.

Methods

Sixty patients with plantar fasciitis despite conservative treatment were enrolled. The patients were divided into a low-energy group (group L: n=30, 1,000 shocks/session, energy flux density [EFD] per shock 0.08 mJ/mm²) and a medium-energy group (group M: n=30, 1,000 shocks/session, EFD 0.16 mJ/mm²). The main outcome measures were visual analogue scale (VAS), Roles and Maudsley (RM) score, and thickness of plantar fascia (PF). To compare the effects between each group, follow-up was carried out 1 week after 3 and 6 sessions, and 1 and 3 months after ESWT.

Results

Significant VAS and RM score improvement, and PF thickness reduction were observed in both groups (p<0.01). After 3 sessions of ESWT, group M showed significant improvement in the VAS and RM score than group L, whereas after 3 additional sessions applied in group L, the main outcomes were no longer significantly different in both groups (p>0.05).

Conclusion

Therapeutic effect might disclose a dose-related relationship; therefore, EFD and the times of the session are considerable factors when treating with ESWT.

Degeneration and recovery of the neuromuscular junction after application of extracorporeal shock wave therapy

It is known that free nerve endings are degenerated after application of shock waves. We therefore hypothesized that the application of shock waves to muscle induces dysfunction of neuromuscular transmission at neuromuscular junctions. We investigated changes in neuromuscular transmission in response to shock wave application. Sprague-Dawley rats were used in this study. Two thousand shock waves at an energy flux density of 0.18 mJ/mm(2) were applied to their right calf muscles. Neuromuscular junctions of gastrocnemius muscles were evaluated using rhodamine-α-bungarotoxin on the day of treatment (n  =  5). Amplitude and latency of compound muscle action potentials were measured on the day of treatment and 1, 2, 4, 6, and 8 weeks after treatment (n  =  10, each group). Degenerated acetylcholine receptors existed in all treated muscles. Although the action potential amplitude on the treated side was significantly less than on the control side from the day of treatment (25.1 ± 7.8 vs. 34.5 ± 9.1, p  =  0.012) to 6 weeks (27.9 ± 7.2 vs. 34.5 ± 7.2, p  =  0.037), there was no significant difference at 8 weeks. There was no significant difference in transmission latency between the groups. The application of shock waves to muscle induced a transient dysfunction of nerve conduction at neuromuscular junctions.

Long-Term Effectiveness of Combined Mechanotransduction Treatment in Jumper's Knee

The aim of the study was to show that the addition of extracorporeal shockwave therapy (ESWT) may significantly improve beneficial effects of eccentric training together with high efficiency focused acoustic waves for jumper's knee. We speculate that such an effect may be due to increased mechanotransduction effects on affected tissues. We assessed changes in pain and function in 42 male football players (aged 1834 years) after a treatment protocol consisting of I session with focused ESWT per week combined with 3 physiotherapy sessions per week, for 3 consecutive weeks. While treatment protocol was administered, ordinary activities, but not playing football were permitted. Their condition was evaluated before treatment, at the end of the rehabilitation period (3 weeks) and at 2 months, 4 months and 6 months after the end of treatment by clinical examination, instrumental analysis and VAS for pain assessment. Functional ability related to symptoms was assessed with VISA score. At the end of 2005,2006,2007,2008 and 2009 we carried out a telephone interview to investigate changes in pain and function and the efficacy of the treatment over time. Follow-up controls showed a reduction of average VAS score; after 6 months, tendons showed a structure closer to normal at ultrasonographic investigation. At the last telephone interview in 2009 many patients reported to consider ESWT as an effective treatment and described a significant improvement in their functional abilities, a significant reduction in drug consumption and 88% of subjects continued to play agonistic football. In conclusion, our results showed that, through the addition of ESWT, the effects of the classic vibration and eccentric training combination were improved compared to those found in our experience without ESWT. Although a control group was not included in the study (vibration and eccentric training without ESWT), results show a promising improvement and justify future prospective studies with a control group and more case series.

Vibration from a riveting hammer causes severe nerve damage in the rat tail model

INTRODUCTION

Hand-arm vibration syndrome (HAVS) is an occupational neurodegenerative and vasospastic disorder in workers who use powered hand tools. Frequency weighting (ISO 5349) predicts little risk of injury for frequencies >500 HZ. Potentially damaging high frequencies abound in impact tool-generated shock waves.

METHODS

A rat tail impact vibration model was developed to deliver shock-wave vibration from a riveting hammer to simulate bucking bar exposure. Rat tails were vibrated continuously for 12 min. Tail flick withdrawal times were determined for noxious heat. Nerve trunks and skin were processed for light and electron microscopy.

RESULTS

Immediately after vibration, the tails were hyperalgesic and had disrupted myelinated axons, fragmented nerve endings, and mast-cell degranulation. By 4 days, the tails were hypoalgesic; nerve endings were lost in the skin.

CONCLUSIONS

Shock-wave vibration causes severe nerve damage. Frequency weighting seriously underestimates the risk of nerve injury with impact tools.

Mechanisms of primary blast-induced traumatic brain injury: insights from shock-wave research

Traumatic brain injury caused by explosive or blast events is traditionally divided into four phases: primary, secondary, tertiary, and quaternary blast injury. These phases of blast-induced traumatic brain injury (bTBI) are biomechanically distinct and can be modeled in both in vivo and in vitro systems. The primary bTBI injury phase represents the response of brain tissue to the initial blast wave. Among the four phases of bTBI, there is a remarkable paucity of information about the cause of primary bTBI. On the other hand, 30 years of research on the medical application of shockwaves (SW) has given us insight into the mechanisms of tissue and cellular damage in bTBI, including both air-mediated and underwater SW sources. From a basic physics perspective, the typical blast wave consists of a lead SW followed by supersonic flow. The resultant tissue injury includes several features observed in bTBI, such as hemorrhage, edema, pseudoaneurysm formation, vasoconstriction, and induction of apoptosis. These are well-described pathological findings within the SW literature. Acoustic impedance mismatch, penetration of tissue by shock/bubble interaction, geometry of the skull, shear stress, tensile stress, and subsequent cavitation formation, are all important factors in determining the extent of SW-induced tissue and cellular injury. Herein we describe the requirements for the adequate experimental set-up when investigating blast-induced tissue and cellular injury; review SW physics, research, and the importance of engineering validation (visualization/pressure measurement/numerical simulation); and, based upon our findings of SW-induced injury, discuss the potential underlying mechanisms of primary bTBI.

Shock wave therapy as a treatment of nonunions, avascular necrosis, and delayed healing of stress fractures

Shock wave therapy (SWT) stimulates angiogenesis and osteogenesis. SWT is commonly used to treat soft tissue musculoskeletal conditions such as fasciopathies and tendinopathies. Recent basic science and clinical data suggest that SWT can also be used to treat disorders of bone. Nonunions, avascular necrosis, and delayed healing of stress fractures have all been successfully treated with SWT. Success rates with SWT are equal to those with standard surgical treatment, but SWT has the advantage of decreased morbidity. The procedure is safe, well tolerated, yields few complications, and, typically, can be performed on an outpatient basis. SWT is a viable noninvasive alternative to stimulate healing of bone.

Radial shock waves effectively introduced NF-kappa B decoy into rat achilles tendon cells in vitro

The purpose of this study was to test if radial shock waves could enhance the introduction of nuclear factor-kappa B (NF-kappaB) decoy oligodeoxynucleotides, which is reported to markedly inhibit NF-kappaB activation and suppress pro-inflammatory cytokine gene expression, using rat Achilles tendon cells. In the presence of NF-kappaB decoy labeled with or without fluorescein isothiocyanate (FITC) in culture media, radial shock waves were applied to the tendon cells in variable conditions and cultivated for 24 h. The transfection rate was assessed by counting FITC-positive cells, and IL-1-induced NF-kappaB activation in the cells was assessed. Radial shock waves significantly enhanced introduction of NF-kappaB decoy-FITC into the tendon cells. IL-1-induced NF-kappaB activation was significantly inhibited by pretreatment of the cells with NF-kappaB decoy combined with radial shock wave exposure. The present study demonstrated the effectiveness of radial shock waves on introduction of NF-kappaB decoy into tendon cells. Radial shock wave treatment combined with local NF-kappaB decoy administration could be a novel therapeutic strategy for chronic tendinopathy.

Shockwave therapy in the management of complex regional pain syndrome in medial femoral condyle of the knee

The aim of this prospective study was to assess the efficacy of shockwave (SW) therapy in the management of complex regional pain syndrome (CRPS). In this study, 30 patients (pts) who were affected by CRPS of the medial femoral condyle and unresponsive to previous standard physiotherapeutic and pharmacological treatment underwent 3 SW sessions at 72-h intervals, each consisting of 4000 shocks emitted by a MiniLith SL1 Storz electromagnetic generator. An energy flux density (EFD) of 0.035 or 0.09 mJ/mm(2) was used, depending on how well the patient endured the pain during the treatment. Satisfactory results were observed in 76.7% of the cases (23 pts) at the 2-month follow-up (FU) visit, and in 80% (24 pts) at the 6-month FU visit. The therapeutic effects of SW were caused by decreasing pain. The significant improvements we obtained bear witness to the potential value of SW therapy in the management of CRPS.

Conservative treatment of Achilles tendinopathy: emerging techniques

Achilles tendinopathy is a painful condition that occurs commonly in both active and inactive individuals. It seems that this condition is painful as a result of ingrowth of neural structures and neovessels leading to poor healing, rather than from inflammatory mediators. Traditional conservative measures are often successful. There is a subset of patients who fail to respond to these measures, however, and this has led to the investigation of newer conservative techniques. This article provides a review of many of the emerging techniques in the treatment of Achilles tendinopathy.

Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial

BACKGROUND

Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.

PURPOSE

To compare the effectiveness of 2 management strategies--group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis.

RESULTS

At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery.

CONCLUSION

At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.