Radial Shock Wave Devices Generate Cavitation

Efficacy of radial shock wave therapy on rat models of adjuvant arthritis

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective treatment for musculoskeletal pain, tendinopathy, and fasciitis with an anti-inflammatory effect. ESWT can be categorized into two groups: radial pressure wave (RPW) and focused shock wave (FSW). Although there have been several studies on the inflammation and pain-improvement mechanisms of FSW, there are few studies on the pain-improvement mechanisms of RPW. This study aimed to elucidate the efficacy of RPW in a rat model of adjuvant arthritis.

METHODS

Ninety-six rats were randomly categorized into three groups: RPW, control, and sham as follows: (I) RPW group, which received RPW application after complete Freund's adjuvant (CFA) injection; (II) Control group, which received only CFA injection; and (III) Sham group, which received only saline injection. All rats were evaluated at 0, 4, 7, 14, 28, and 56 days post-RPW application based on foot circumference, von Frey test, and immunohistochemistry of nerve fibers for calcitonin gene-related peptide (CGRP) and protein gene product (PGP) 9.5 in plantar skins.

RESULTS

There were no significant differences in foot circumference between the RPW and control groups at any time point. The RPW group showed significant improvements in the von Frey test results on days 7 and 14. The total CGRP-immunoreactive (ir) and PGP9.5-ir nerve fiber lengths in the RPW group decreased on day 0; however, both were increased in the control group. The CGRP-ir and PGP9.5-ir nerve fibers in the RPW group were significantly shorter than those in the control group until day 14 after RPW.

CONCLUSIONS

RPW improved the mechanical hypersensitivity between days 7 and 14 after application. Like FSW, RPW also induced the degeneration of sensory nerve fibers in the skin in the early period after irradiation, and reinnervation occurred between 14 and 28 days. Thus, our results demonstrate one of the pain relief mechanisms after RPW application.

Radial extracorporeal shockwave therapy (rESWT) for coccydynia: a prospective study of 14 patients

Background

Coccydynia is defined as pain in the coccyx. We investigated the effect of radial extracorporeal shockwave therapy (rESWT) in the management of coccydynia.

Methods

In this prospective study, patients (≥18 years) diagnosed with coccydynia at a sports clinic located in Thessaloniki, Greece, were eligible for rESWT treatment when they reported a visual analogue scale (VAS) pain level ≥6. Treatment sessions were once weekly and ended when VAS pain levels decreased to ≤3. Recurrence rates were documented at 3-month and 12-month follow-ups.

Results

Fourteen patients were treated using rESWT. The mean age and symptom duration of our cohort was 33.6±7.9 (range: 20-45) years and 9.4±8.5 (range: 3-36) months, respectively. The mean number of treatment sessions per patient was 6.4±1.6 (range: 4-8). The mean device pressure, frequency, and number of pulses was 1.2±0.1 (range: 1-1.4) bar, 5.0±0.1 (range: 5-6) Hz, and 2082±74.8 (range: 2000-2300) pulses, respectively. Treatment alleviated pain in all patients, and no recurrence of symptoms was reported during follow-up. There was a positive correlation between symptom duration and the number of treatment sessions (r=0.701, P=0.005). Pairwise comparison highlighted significant reductions in VAS pain levels between each stage of treatment (P<0.001).

Conclusion

Our study affirms the safety and efficacy of rESWT in managing coccydynia.

Shockwave Therapy in Veterinary Rehabilitation

Extracorporeal shockwave therapy (ESWT) is a noninvasive treatment that involves the transcutaneous delivery of high-energy sound waves into tissue creating therapeutic effects. Shockwaves are nonlinear, high-pressure, high-velocity acoustic waves characterized by low tensile amplitude, short rise time to peak pressure, and a short duration (less than 10 milliseconds). ESWT has been shown to increase the expression of cytokines and growth factors leading to decreased inflammation, neovascularization, and cellular proliferation; activation of osteogenesis by osteoblast differentiation and then by increased proliferation; inhibition of cartilage degeneration and rebuilding of subchondral bone; and increased serotonin in the dorsal horn and descending inhibition of pain signals. Musculoskeletal conditions that can benefit from ESWT include osteoarthritis, tendinopathies, fracture/bone healing, and wound healing.

Effect and Optimal Timing of Extracorporeal Shock-Wave Intervention to Patients With Spasticity After Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

This study investigated the efficacy of extracorporeal shock wave therapy as well as the optimal intervention timing for extracorporeal shock wave therapy for patients with spasticity after stroke.

DESIGN

A search of randomized controlled trials was conducted in different electronic databases. We performed a meta-analysis to measure the effect of extracorporeal shock wave therapy versus sham interventions on spasticity and limb functionality. The meta-regression analysis was performed to determine the adequate intervention timing of extracorporeal shock wave therapy. The follow-up period of the outcomes was divided into the short (<2 wks), mid (>2 wks and ≤4 wks), and long (>4 wks and ≤3 mos) terms.

RESULTS

Thirteen studies with 677 participants were evaluated. Spasticity significantly improved throughout the follow-up duration. Limb functionality significantly improved in the short-term follow-up period. The meta-regression analysis showed that patients with stroke duration less than 45 mos may be benefited from extracorporeal shock wave therapy in improving limb function in all follow-up periods.

CONCLUSIONS

Extracorporeal shock wave therapy is an effective method for reducing spasticity in patients with stroke, and the effect could be maintained for up to 3 mos. Its effects on limb functionality could persist for at least 2 wks. Patients who had stroke for less than 45 mos may have significant benefit from extracorporeal shock wave therapy in all follow-up periods.

Influence of the pulse repetition rate on the acoustic output of ballistic pressure wave devices

Ballistic devices that generate radial pressure waves are used for the treatment of different therapeutic indications. In order to assess the effectiveness of these devices and to interpret and transfer the results of clinical trials, it is important to know their acoustic output. In this paper, two ballistic devices and their reproducibility at different clinically relevant settings were investigated in the same in-vitro test setup. Pressure curves were measured in water at different intensity levels and pulse repetition rates. The sound field parameters (peak pressures, positive pulse intensity integral) were calculated from the pressure curves. Additionally, the surface velocity of the applicator was determined in air using a vibrometer. Both devices show a good pulse-to-pulse reproducibility. While the peak maximum pressure and the positive pulse intensity integral decrease only slightly (p_max up to 12%, PII⁺ up to 18.8%) comparing 1 Hz and 25 Hz for one device, they drop sharply (p_max up to 68.4%, PII⁺ up to 90.2%) for the other device comparing 1 Hz to 21 Hz. The same effect was observed in the vibrometer measurements. The results show that with increasing pulse repetition rate the stability of the parameters varies between different devices. Hence, all sound field parameters should be compared before transferring settings from one device to another.

Application of extracorporeal shock wave therapy in nervous system diseases: A review

Neurological disorders are one of the leading causes of morbidity and mortality worldwide, and their therapeutic options remain limited. Recent animal and clinical studies have shown the potential of extracorporeal shock wave therapy (ESWT) as an innovative, safe, and cost-effective option to treat neurological disorders. Moreover, the cellular and molecular mechanism of ESWT has been proposed to better understand the regeneration and repairment of neurological disorders by ESWT. In this review, we discuss the principles of ESWT, the animal and clinical studies involving the use of ESWT to treat central and peripheral nervous system diseases, and the proposed cellular and molecular mechanism of ESWT. We also discuss the challenges encountered when applying ESWT to the human brain and spinal cord and the new potential applications of ESWT in treating neurological disorders.

How to report parameters and procedures for shockwave therapy in musculoskeletal disorders: A narrative review

Shockwave therapy (SWT) has been successful in the management of musculoskeletal conditions. The limitations of the use of SWT in clinical practice regard a lack of familiarity with the device and the lack of uniformity in information reported in scientific publications. Standardization in the reporting of these parameters could facilitate the reproduction and interpretation of data in future studies. Most studies fail to offer a detailed description of the parameters. Therefore, the aim of the present paper is to prepare a report on how to standardize the presentation of this information and serve a reference guide to report physical parameters and procedures of SWT when used on patients with musculoskeletal disorders. The terms were selected from the Medical Subject Headings database of controlled vocabulary. An extensive process of systematic searching of databases was performed, after which experts met and discussed on the main findings, and a consensus was achieved. SWT parameters were described, including the physiological meaning and clinical relevance of each parameter. Also, the description of patient and equipment positioning was added. The consensus-based guideline on how to report SWT parameters for the treatment of musculoskeletal conditions was developed to help clinicians and researchers.

Comparative Effectiveness of Focused Extracorporeal versus Radial Extracorporeal Shockwave Therapy for Knee Osteoarthritis—Randomized Controlled Study

Both focused extracorporeal shockwave (f-ESWT) and radial extracorporeal shockwave therapy (r-ESWT) can alleviate symptoms in patients with knee osteoarthritis, but no trials have directly compared f-ESWT with r-ESWT for knee osteoarthritis. This study aimed to compare the effectiveness of f-ESWT and r-ESWT on knee osteoarthritis. Forty-two patients with bilateral knee osteoarthritis were randomly assigned to receive three sessions of either f-ESWT or r-ESWT at 1-week intervals. The patients were evaluated at baseline and at 4 and 8 weeks after the final treatment. The primary outcome was the change in pain intensity, as measured on the visual analog scale (VAS). Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion of the knee joint, and the 6-minute walk test. At the end of 4 weeks, the VAS score was substantially reduced in both groups (f-ESWT, −4.5 ± 2.5 points; r-ESWT, −2.6 ± 2.0 points), with a greater reduction in the f-ESWT group. Both groups showed significant improvement in secondary outcomes; however, the f-ESWT group yielded greater improvement in the VAS score, WOMAC score, and 6-minute walk test. Our results showed that f-ESWT was more effective than r-ESWT in improving pain and physical function in patients with knee osteoarthritis.

Safety and efficacy of treating post-burn pathological scars with extracorporeal shock wave therapy: A meta-analysis of randomised controlled trials

The clinical application of shockwave therapy has expanded to the treatment of pathological scars. The objective of this systematic review and meta-analysis is to quantitatively evaluate the efficacy and safety of extracorporeal shockwave therapy combined with comprehensive rehabilitation therapy on post-burn pathological scars compared to comprehensive rehabilitation therapy alone. The randomised controlled trials of extracorporeal shockwave therapy for post-burn pathological scars published in English and Chinese languages before October 2021 were included. The methodological quality and risk of bias of the selected articles were assessed with the Cochrane Collaboration's 'risk of bias' tool. RevMan software was applied for data analysis. This is the first systematic review and meta-analysis considering the effectiveness and safety of extracorporeal shockwave therapy on post-burn pathological scars. And nine randomised controlled trials involving 422 patients were included in this meta-analysis. The meta-analysis results showed that, compared with comprehensive rehabilitation therapy alone, extracorporeal shockwave therapy combined with comprehensive rehabilitation therapy was more effective in relieving pain (standardized mean difference [SMD] = -0.59, 95% confidence interval [CI]: [-0.87 to -0.31], p < 0.0001) and pruritus related to pathological scars (SMD = -0.94; 95% CI: [-1.25 to -0.63], p = 0.004), improving scars' appearance (SMD = -1.78, 95% CI: [-3.37 to -0.19], p = 0.03) and elasticity (SMD = 0.25, 95% CI: [0.29-0.21], p < 0.00001), decreasing scars thickness (SMD = -0.13, 95% CI: [-0.25 to -0.01], p = 0.04) and promoting the maturation status of scars (SMD = -2.86, 95% CI: [-3.96 to -1.76], p < 0.00001). There were no reported serious adverse events during and after extracorporeal shockwave therapy in the included studies. Available data preliminarily suggested that the combination of extracorporeal shockwave therapy and comprehensive rehabilitation therapy had better therapeutic effect on post-burn pathological scars than comprehensive rehabilitation therapy alone, without obvious side effects. However, further clinical well-controlled randomised controlled trials are needed. Systematic review registration ID: PROSPERO CRD42022297573.

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.

Translational Applications of Extracorporeal Shock Waves in Dental Medicine: A Literature Review

Extracorporeal shock wave therapy (ESWT) has been studied and applied extensively in medical practice for various applications including musculoskeletal, dermal, vascular, and cardiac indications. These indications have emerged from primary ESWT use in treating urolithiasis and cholelithiasis. Likewise, dental medicine has had its share of utilizing ESWT in various investigations. This review aimed to provide an up-to-date summary of ESWT use in preclinical and clinical dental medicine. There is growing interest in ESWT use stemming from its non-invasiveness, low cost, and safe qualities in addition to its proven regenerative biostimulating aspects. Targeted tissue and parameters of ESWT delivery continue to be an integral part of successful ESWT treatment to attain the clinical value of the anticipated dose’s effect.

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.

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.

Return to play after treating acute muscle injuries in elite football players with radial extracorporeal shock wave therapy

Background

To compare lay-off times achieved by treating acute muscle injuries in elite football players with a multimodal therapy approach that includes a specific protocol of almost daily radial extracorporeal shock wave therapy (rESWT) with corresponding data reported in the literature.

Methods

We performed a retrospective analysis of treatments and recovery times of muscle injuries suffered by the players of an elite football team competing in the first/second German Bundesliga during one of the previous seasons.

Results

A total of 20 acute muscle injuries were diagnosed and treated in the aforementioned season, of which eight (40%) were diagnosed as Type 1a/muscular tightness injuries, five (25%) as Type 2b/muscle strain injuries, four (20%) as Type 3a/partial muscle tear injuries and three (15%) as contusions. All injuries were treated with the previously mentioned multimodal therapy approach. Compared with data reported by Ekstrand et al. (Br J Sports Med 47:769–774, 2013), lay-off times (median/mean) were shortened by 54% and 58%, respectively, in the case of Type 1a injuries, by 50% and 55%, respectively, in the case of Type 2b injuries as well as by 8% and 21%, respectively, in the case of Type 3a injuries. No adverse reactions were observed.

Conclusions

Overall, the multimodal therapy approach investigated in this study is a safe and effective treatment approach for treating Type 1a and 2b acute muscle injuries amongst elite football players and may help to prevent more severe, structural muscle injuries.

Exposure of zebra mussels to radial extracorporeal shock waves: implications for treatment of fracture nonunions

Background

Radial extracorporeal shock wave therapy (rESWT) is an attractive, non-invasive therapy option to manage fracture nonunions of superficial bones, with a reported success rate of approximately 75%. Using zebra mussels (Dreissena polymorpha), we recently demonstrated that induction of biomineralization after exposure to focused extracorporeal shock waves (fESWs) is not restricted to the region of direct energy transfer into calcified tissue. This study tested the hypothesis that radial extracorporeal shock waves (rESWs) also induce biomineralization in regions not directly exposed to the shock wave energy in zebra mussels.

Methods

Zebra mussels were exposed on the left valve to 1000 rESWs at different air pressure (between 0 and 4 bar), followed by incubation in calcein solution for 24 h. Biomineralization was evaluated by investigating the fluorescence signal intensity found on sections of the left and right valves prepared two weeks after exposure.

Results

General linear model analysis demonstrated statistically significant (p < 0.05) effects of the applied shock wave energy as well as of the side (left/exposed vs. right/unexposed) and the investigated region of the valve (at the position of exposure vs. positions at a distance to the exposure) on the mean fluorescence signal intensity values, as well as statistically significant combined energy × region and energy × side × region effects. The highest mean fluorescence signal intensity value was found next to the umbo, i.e., not at the position of direct exposure to rESWs.

Conclusions

As in the application of fESWs, induction of biomineralization by exposure to rESWs may not be restricted to the region of direct energy transfer into calcified tissue. Furthermore, the results of this study may contribute to better understand why the application of higher energy flux densities beyond a certain threshold does not necessarily lead to higher success rates when treating fracture nonunions with extracorporeal shock wave therapy.

Mechanical Stimulation of Fibroblasts by Extracorporeal Shock Waves: Modulation of Cell Activation and Proliferation Through a Transient Proinflammatory Milieu

Extracorporeal shock waves (ESWTs) are “mechanical” waves, widely used in regenerative medicine, including soft tissue wound repair. Although already being used in the clinical practice, the mechanism of action underlying their biological activities is still not fully understood. In the present paper we tried to elucidate whether a proinflammatory effect may contribute to the regenerative potential of shock waves treatment. For this purpose, we exposed human foreskin fibroblasts (HFF1 cells) to an ESWT treatment (100 pulses using energy flux densities of 0.19 mJ/mm² at 3 Hz), followed by cell analyses after 5 min, up to 48 h. We then evaluated cell proliferation, reactive oxygen species generation, ATP release, and cytokine production. Cells cultured in the presence of lipopolysaccharide (LPS), to induce inflammation, were used as a positive control, indicating that LPS-mediated induction of a proinflammatory pattern in HFF1 increased their proliferation. Here, we provide evidence that ESWTs affected fibroblast proliferation through the overexpression of selected cytokines involved in the establishment of a proinflammatory program, superimposable to what was observed in LPS-treated cells. The possibility that inflammatory circuits can be modulated by ESWT mechanotransduction may disclose novel hypothesis on their biological underpinning and expand the fields of their biomedical application.

Extracorporeal shock wave therapy: an update

Extracorporeal shock wave therapy (ESWT) is a safe therapy and there are only a few side effects known (such as pain during ESWT and minor haematomata), but no severe complications are to be expected if it is performed as recommended.

Contraindications are severe coagulopathy for high-energy ESWT, and ESWT with focus on the foetus or embryo and focus on severe infection.

The effect mechanism of ESWT is still a component of diverse studies, but as far as we can summarize today, it is a similar process to a cascade triggered by mechano-transduction: mechanical energy causes changes in the cellular skeleton, which provokes a reaction of the cell core (for example release of mRNA) to influence diverse cell structures such as mitochondria, endoplasmic reticulum, intracellular vesicles, etc., so the enzymatic response leads to the improvement of the healing process.

The usage of ESWT should be taught, to improve the outcome. Courses should be organized by national societies, since the legal framework conditions are different from one country to another.

In this update the musculoskeletal indications are addressed (mainly bone and tendons): pseudoarthrosis, delayed fracture healing, bone marrow oedema and osteonecrosis in its early stages, insertional tendinopathies such as plantar fasciitis and Achilles tendon fasciitis, calcifying tendonitis of the rotator cuff, tennis elbow, and wound healing problems.

Cite this article: EFORT Open Rev 2020;5:584-592. DOI: 10.1302/2058-5241.5.190067

In Vivo Modulation of Angiogenesis and Immune Response on a Collagen Matrix via Extracorporeal Shockwaves

The effective management of tissue integration and immunological responses to transplants decisively co-determines the success of soft and hard tissue reconstruction. The aim of this in vivo study was to evaluate the eligibility of extracorporeal shock wave therapy (ESWT) with respect to its ability to modulate angiogenesis and immune response to a collagen matrix (CM) for tissue engineering in the chorioallantoic membrane (CAM) assay, which is performed with fertilized chicken eggs. CM were placed on the CAM on embryonic development day (EDD) 7; at EDD-10, ESWT was conducted at 0.12 mJ/mm² with 500 impulses each. One and four days later, angiogenesis represented by vascularized area, vessel density, and vessel junctions as well as HIF-1α and VEGF gene expression were evaluated. Furthermore, immune response (iNOS2, MMP-9, and MMP-13 via qPCR) was assessed and compared between ESWT- and non-ESWT-groups. At EDD-14, the vascularized area (+115% vs. +26%) and the increase in vessel junctions (+751% vs. +363%) were significantly higher in the ESWT-group. ESWT significantly increased MMP-9 gene expression at EDD-11 and significantly decreased MMP-13 gene expression at EDD-14 as compared to the controls. Using the CAM assay, an enhanced angiogenesis and neovascularization in CM after ESWT were observed. Furthermore, ESWT could reduce the inflammatory activity after a latency of four days.

Does radial shock wave therapy works in pseudarthrosis? Prospective analysis of forty four patients

INTRODUCTION

In this study, we analyze a new treatment option for pseudarthrosis using radial shock waves. The traditional treatment to pseudarthrosis is surgical. As an option to specific cases, focal shock waves seem to present good results with bone union without a subsequent surgical procedure. As radial shock waves reach less energy and less depth penetration than focal shock waves, they usually are not indicated for the treatment of pseudarthrosis of any bone segment. There are publications that show evidences of the action of radial shock waves stimulating bone consolidation in vitro, in animals and in humans. We will present a new option for failure of consolidation in superficial bones submitted to radial shock wave therapy.

OBJECTIVE

To analyze the effectiveness of radial shock waves in the treatment of superficial bone pseudarthrosis.

PATIENTS AND METHODS

Between 2016 and 2019, we conducted a prospective study with 44 consecutive patients with pseudarthrosis. All patients had prior indication for treatment with surgery and were treated with radial shock waves as a nonsurgical treatment option. Patients were evaluated clinically and radiographically pre-treatment and 6 months after. Clinically, patients complained of pain and dysfunction, according to the segment affected, and radiographically, evidences of pseudarthrosis in at least two X-ray views. As the outcomes: satisfactory when there was bone union, no pain, and return function; unsatisfactory when there was no bone union and maintain pain and dysfunction. All patients were treated with the same equipment and by the same physician. The treatment consisted in 3 sessions with weekly interval; in each session, 3000 radial shock waves were applied with 4 bar of energy.

RESULTS

After 6 months, clinical analysis and X-ray evidence on 77.2% of the patients presented bone union and clinical improvement classified as satisfactory result. There were no complications.

CONCLUSION

Treatment of pseudarthrosis in superficial bones with radial shock waves is effective and safe.

Cavitation-induced traumatic cerebral contusion and intracerebral hemorrhage in the rat brain by using an off-the-shelf clinical shockwave device

Traumatic cerebral contusion and intracerebral hemorrhages (ICH) commonly result from traumatic brain injury and are associated with high morbidity and mortality rates. Current animal models require craniotomy and provide less control over injury severity. This study proposes a highly reproducible and controllable traumatic contusion and ICH model using non-invasive extracorporeal shockwaves (ESWs). Rat heads were exposed to ESWs generated by an off-the-shelf clinical device plus intravenous injection of microbubbles to enhance the cavitation effect for non-invasive induction of injury. Results indicate that injury severity can be effectively adjusted by using different ESW parameters. Moreover, the location or depth of injury can be purposefully determined by changing the focus of the concave ESW probe. Traumatic contusion and ICH were confirmed by H&E staining. Interestingly, the numbers of TUNEL-positive cells (apoptotic cell death) peaked one day after ESW exposure, while Iba1-positive cells (reactive microglia) and GFAP-positive cells (astrogliosis) respectively peaked seven and fourteen days after exposure. Cytokine assay showed significantly increased expressions of IL-1β, IL-6, and TNF-α. The extent of brain edema was characterized with magnetic resonance imaging. Conclusively, the proposed non-invasive and highly reproducible preclinical model effectively simulates the mechanism of closed head injury and provides focused traumatic contusion and ICH.

Improved Healing of Diabetic Foot Ulcer upon Oxygenation Therapeutics through Oxygen-Loading Nanoperfluorocarbon Triggered by Radial Extracorporeal Shock Wave

Diabetic foot ulcers (DFUs), the most serious complication of diabetes mellitus, can induce high morbidity, the need to amputate lower extremities, and even death. Although many adjunctive strategies have been applied for the treatment of DFUs, the low treatment efficiency, potential side effects, and high cost are still huge challenges. Recently, nanomaterial-based drug delivery systems (NDDSs) have achieved targeted drug delivery and controlled drug release, offering great promises in various therapeutics for diverse disorders. Additionally, the radial extracorporeal shock wave (rESW) has been shown to function as a robust trigger source for the NDDS to release its contents, as the rESW harbors a potent capability in generating pressure waves and in creating the cavitation effect. Here, we explored the performance of oxygen-loaded nanoperfluorocarbon (Nano-PFC) combined with the rESW as a treatment for DFUs. Prior to in vivo assessment, we first demonstrated the high oxygen affinity in vitro and great biocompatibility of Nano-PFC. Moreover, the rESW-responsive oxygen release behavior from oxygen-saturated Nano-PFC was also successfully verified in vitro and in vivo. Importantly, the wound healing of DFUs was significantly accelerated due to improved blood microcirculation, which was a result of rESW therapy (rESWT), and the targeted release of oxygen into the wound from oxygen-loaded Nano-PFC, which was triggered by the rESW. Collectively, the oxygen-saturated Nano-PFC and rESW provide a completely new approach to treat DFUs, and this study highlights the advantages of combining nanotechnology with rESW in therapeutics.

Effect of Low-Intensity Pulsed Ultrasound Stimulation, Extracorporeal Shockwaves and Radial Pressure Waves on Akt, BMP-2, ERK-2, FAK and TGF-β1 During Bone Healing in Rat Tibial Defects

An experimental study was conducted to determine whether low-intensity pulsed ultrasound stimulation (LIPUS), extracorporeal shockwave treatment (ESWT) and radial pressure wave treatment (RPWT) modulate Akt, bone morphogenetic protein-2 (BMP-2), extracellular signal-regulated kinase-2 (ERK-2), focal adhesion kinase (FAK) and transforming growth factor-β1 (TGF-β1) during bone healing in rat tibial defects. Rat tibial defects were exposed to 500 shots of ESWT delivered at 0.12 mJ/mm², 500 impulses of RPWT operated at 2.0 bar or to daily 20-min 30 mW/cm² LIPUS. Following 1, 3 and 6 wk, bones were harvested to determine the expression and activity of Akt, BMP-2, ERK-2, FAK and TGF-β1. Animals exposed to ultrasound were followed up to 3 wk. Protein expression and activity were unchanged following LIPUS treatment. ESWT increased Akt activity 2.11-fold (p = 0.043) and TGF-β1 expression 9.11-fold (p = 0.016) at 1 wk and increased FAK activity 2.16-fold (p = 0.047) at 3 wk. RPWT increased FAK activity 2.6-fold (p = 0.028) at 3 wk and decreased Akt expression 0.52-fold (p = 0.05) at 6 wk. In conclusion, the protocols employed for ESWT and RPWT modulated distinct signaling pathways during fracture healing, while LIPUS standard protocol did not change the usual signaling pathways of the proteins investigated. Future studies are required to monitor osteogenesis so that the biologic meaning of our results can be clarified.

Is radial extracorporeal shock wave therapy combined with a specific rehabilitation program (rESWT + RP) more effective than sham-rESWT + RP for acute hamstring muscle complex injury type 3b in athletes? Study protocol for a prospective, randomized, double-blind, sham-controlled single centre trial

Background

Acute injuries of the hamstring muscle complex (HMC) type 3b (interfascicle/bundle-tear) are frequently observed in various sports disciplines both in elite and recreational sport. The treatment of choice of acute HMC injuries type 3b is a progressive physiotherapeutic exercise programme. Besides this, there is currently only insufficient scientific evidence to support other treatment methods, including local infiltrations and injections of platelet-rich-plasma. Very recently, it was demonstrated that extracorporeal shock wave therapy (ESWT) may accelerate regeneration after acute skeletal muscle injury. The aim of the present study is to test the hypothesis that the combination of radial ESWT (rESWT) and a specific rehabilitation program (RP) is effective and safe in treatment of acute HMC injury type 3b in athletes, and is statistically significantly more effective than the combination of sham-rESWT and RP.

Methods

We will perform a double blind, randomized, sham-controlled clinical trial at the clinic KinEf Kinesiología Deportiva, Ciudad Autónoma de Buenos Aires, Argentina. Forty patients with acute HMC injury type 3b will be randomly allocated to receive either rESWT (nine rESWT sessions; three sessions per week; 2500 radial extracorporeal shock waves (rESWs) per session; energy density depending on what the patient tolerates) or sham-rESWT. In addition, all patients will receive a specific rehabilitation program that will last for 8 weeks. The primary outcome measure will be the individual time (days) necessary to return to play. Secondary outcomes will include the presence or absence of reinjury during a time period of 6 months after inclusion into the study.

Discussion

Because of the lack of adequate treatment options for acute HMC injury type 3b in athletes and particularly the high reinjury rate, we hypothesize that the results of this trial will be of importance and have impact on clinical practice.

Trial registration

ClinicalTrials.gov ID NCT03473899. Registered March 22, 2018.

Determinants of Early Response to Low-Intensity Extracorporeal Shockwaves for the Treatment of Vasculogenic Erectile Dysfunction: An Open-Label, Prospective Study

The aim of this study was to expand existing literature on the effects of cardiovascular risk factors on the outcome of low-intensity extracorporeal shockwaves therapy (LIESWT), and to evaluate the role of hormone concentrations. Twenty patients with long-standing, PDE5i-resistant, vasculogenic erectile dysfunction (VED) were treated with six weekly sessions of LIESWT (9000 pulses). After a three-week break, four poor responders underwent another six weekly sessions. Rigidity score (RS) questionnaire was administered at baseline (T0), last session (T1), and three months after LIESWT (T2), while the Improvement component of the Clinical Global Impression of Change (CGIC-I) and the International Index of Erectile Function-5 (IIEF-5) questionnaires were administered at T1 and T2, and at T0 and T2, respectively. At T0 serum luteinizing hormone (LH), testosterone, sex hormone binding globulin (SHBG), calculated free testosterone, and prolactin levels were also recorded. At T1 and T2, 12/20 (60%) and 11/20 (55%) patients reached a RS ≥ 3; 16/20 (80%) and 13/20 (65%) improved their erections variably. Testosterone levels correlated positively with CGIC-I at T1. Patients < 65 years and those nonhypercholesterolemic had higher RS at T1 and T2. Age correlated negatively with RS at T1 and T2. At T0, diabetic patients had lower IIEF-5 scores, but those with RS ≥ 3 at T1 had higher IIEF-5 compared to those with RS < 3. Also, diabetes duration correlated inversely with IIEF-5 at T0. At T2, IIEF-5 improved significantly by an average of 2.8-points. We confirm safety and effectiveness of LIESWT for the treatment of VED. Age ≥ 65 years, diabetes, and hypercholesterolemia influence early and negatively the outcome of LIESWT.

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.

[Extracorporeal shockwave therapy for osteonecrosis of femoral head: traps and challenges]

Extracorporeal shock wave (ESW), as a noninvasive, safe, and effective treatment, was applied to the treatment in osteonecrosis of femoral head (ONFH) since the end of last century. Although this therapy is more and more widely used, there are many traps and challenges. We recommend using the high-energy focus ESW to treat ONFH, rather than using the low energy radial pressure wave. Furthermore, for different types ONFH, scientific personalized treatment planning should be made first. There are demands of multicenter united researches for this unknown field of ONFH treated with ESW, and so to provide high-level evidence-based medicine evidence.

Radial extracorporeal shock wave promotes the enhanced permeability and retention effect to reinforce cancer nanothermotherapeutics

Since most cancer nanomedicine relies on the enhanced permeability and retention (EPR) effect to eradicate tumors, strategies that are able to promote nanoparticle (NP) delivery and extravasation are presupposed to elevate the EPR effect for more effective cancer therapeutics. However, nanothermotherapeutics still suffers from limited drug delivery into tumor sites, for even though numerous efforts have been made to enhance the selective tumor targeting of NPs. In this study, we uncovered that radial extracorporeal shock wave therapy (rESWT), an important approach in physical therapy that has been overlooked in cancer treatment in the past, can largely improve the EPR-dependent tumor uptake of NPs. We here defined the optimal low dosage and desirable combinatory manner for rESWT in driving NP accumulation towards tumors. Two underlying biophysical mechanisms responsible for the rESWT-enhanced EPR effect were proposed. On one hand, rESWT-conducted compressive and tensile forces could relieve high intra-tumoral pressure; on the other hand, rESWT-induced cavitation bubbles could directly distend and disrupt tumor blood vessels. All these together synergistically promoted vessel vasodilation, tumor perfusion and NP extravasation. Further experiments revealed that the combinatory therapeutics between rESWT and nanothermotherapeutics greatly improved the tumor-killing efficacy. Thus, our findings open a new path to improve EPR-mediated drug delivery with the assistance of rESWT.

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.

Quantitative Assessments of Mechanical Responses upon Radial Extracorporeal Shock Wave Therapy

Although radial extracorporeal shock wave therapy (rESWT) has been widely used to treat orthopedic disorders with promising clinical results, rESWT largely relies on clinicians' personal experiences and arbitrary judgments, without knowing relationships between administration doses and effective doses at target sites. In fact, practitioners lack a general and reliable way to assess propagation and distribution of pressure waves inside biological tissues quantitatively. This study develops a methodology to combine experimental measurements and computational simulations to obtain pressure fields from rESWT through calibrating and validating computational models with experimental measurements. Wave pressures at the bottom of a petri dish and inside biological tissues are measured, respectively, by attaching and implanting flexible membrane sensors. Detailed wave dynamics are simulated through explicit finite element analyses. The data decipher that waves from rESWT radiate directionally and can be modeled as acoustic waves generated from a vibrating circular piston. Models are thus established to correlate pressure amplitudes at the bottom of petri dishes and in the axial direction of biological tissues. Additionally, a pilot simulation upon rESWT for human lumbar reveals a detailed and realistic pressure field mapping. This study will open a new avenue of personalized treatment planning and mechanism research for rESWT.

Cadaveric experiments to evaluate pressure wave generated by radial shockwave treatment of plantar fasciitis

BACKGROUND

Shockwave treatment is increasingly used for plantar fasciitis and Achilles tendinopathy. To be effective it is believed that high pressure must be achieved in the tissues. We report on the first human cadaveric experiments to characterize pressure from radial shockwave therapy (rSWT) for plantar fasciitis.

METHODS

The pressure from rSWT was measured in two cadaveric feet using a needle hydrophone. Maximal pressure and energy flux were calculated from the measurements.

RESULTS

The pressure persisted longer than supposed, for up to 400μs. The peak negative pressure was up to two Mega Pascal. The predicted energy in the tissue strongly depended on the time interval used in calculations.

CONCLUSIONS

The measured pressure may be sufficiently high to cause cavitation in the tissue, which is one of the proposed healing mechanisms associated with rSWT. The results suggest that the energy is imparted to the tissues for much longer than previously thought.

Radial extracorporeal shock wave therapy is efficient and safe in the treatment of fracture nonunions of superficial bones: a retrospective case series

BACKGROUND

A substantial body of evidence supports the use of focused extracorporeal shock wave therapy (fESWT) in the non-invasive treatment of fracture nonunions. On the other hand, virtually no studies exist on the use of radial extracorporeal shock wave therapy (rESWT) for this indication.

METHODS

We retrospectively analyzed 22 patients treated with rESWT for fracture nonunions of superficial bones that failed to heal despite initial surgical fixation in most cases. Radial extracorporeal shock wave therapy was applied without anesthesia in three rESWT sessions on average, with one rESWT session per week and 3000 radial extracorporeal shock waves at an energy flux density of 0.18 mJ/mm² per session. Treatment success was monitored with radiographs and clinical examinations.

RESULTS

Six months after rESWT radiographic union was confirmed in 16 out of 22 patients (73%), which is similar to the success rate achieved in comparable studies using fESWT. There were no side effects. The tibia was the most common treatment site (10/22) and 70% of tibia nonunions healed within 6 months after rESWT. Overall, successfully treated patients showed a mean time interval of 8.8 ± 0.8 (mean ± standard error of the mean) months between initial fracture and commencement of rESWT whereas in unsuccessfully treated patients the mean interval was 26.0 ± 10.1 months (p < 0.05). In unsuccessful tibia cases, the mean interval was 43.3 ± 13.9 months.

CONCLUSIONS

Radial extracorporeal shock wave therapy appears to be an effective and safe alternative in the management of fracture nonunions of superficial bones if diagnosed early and no fESWT device is available. The promising preliminary results of the present case series should encourage the implementation of randomized controlled trials for the early use of rESWT in fracture nonunions.

Extracorporeal Shock Wave Rebuilt Subchondral Bone In Vivo and Activated Wnt5a/Ca2+ Signaling In Vitro

Background

This study aimed to identify the optimal extracorporeal shock wave (ESW) intensity and to investigate its effect on subchondral bone rebuilt in vivo and Wnt5a/Ca²⁺ signaling in vitro using an osteoarthritis (OA) rat model and bone marrow mesenchymal stem cells (BMMSCs), respectively.

Methods

OA rats treated with (OA + ESW group) or without (OA group) ESW (n = 12/group) were compared with healthy controls (control group, n = 12). Gait patterns and subchondral trabecular bone changes were measured. Western blot and quantitative real-time polymerase chain reaction detected protein expression and gene transcription, respectively.

Results

The gait disturbances of OA + ESW group were significantly improved compared with the OA group at 6th and 8th weeks. The micro-CT analysis indicated that the BMD, BSV/BV, BV/TV, Tr.S, and Tr.Th are significantly different between OA group and OA + ESW group. Expression of Wnt5a was increased rapidly after ESW treatment at 0.6 bar and peaked after 30 min.

Conclusions

ESW were positive for bone remodeling in joint tibial condyle subchondral bone of OA rat. ESW prevented histological changes in OA and prevented gait disturbance associated with OA progression. Optimal intensity of ESW induced changes in BMMSCs via activation of the Wnt5a/Ca²⁺ signaling pathway.

Radial Extracorporeal Shock Wave Therapy Is Effective and Safe in Chronic Distal Biceps Tendinopathy

OBJECTIVE

To assess the efficacy and safety of radial extracorporeal shock wave therapy (rESWT) for chronic distal biceps tendinopathy (cDBT).

DESIGN

Case-control study (level of evidence, 3).

SETTING

SUN Orthopaedics and Sports Medicine.

PATIENTS

Patients with a diagnosis of cDBT were recruited between January 2010 and February 2015.

INTERVENTIONS

Patients received a single session of rESWT (2000 shock waves with energy flux density of 0.18 mJ/mm) or other forms of nonoperative therapy.

MAIN OUTCOME MEASURES

Patients completed the visual analog scale (VAS), the modified QuickDASH (MQD) score, and the Roles and Maudsley (RM) score over a 12-month period.

RESULTS

Forty-eight patients completed the final review at 12 months and were included in the study. Subjects ranged in age from 30 to 64 years. Mean pretreatment VAS scores for the rESWT and control groups were 8.3 and 8.5, respectively. Three and 12 months after inclusion in the study, the mean VAS scores for the rESWT and control groups were 3.4 and 5.6 (P < 0.001) and 2.7 and 4.7 (P < 0.001), respectively. Twelve-month follow-up MQD-Sports and MQD-Work scores for the rESWT and control groups were 3.7 and 1.7 (P < 0.001) and 3.8 and 1.8 (P < 0.001), respectively. Differences in mean RM scores were statistically significant between groups at 3 months after the treatment. There were no significant complications.

CONCLUSIONS

Overall, rESWT is an effective and safe treatment for cDBT.

CLINICAL RELEVANCE

Radial ESWT as a novel, effective, and safe treatment for cDBT.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Intramuscular Hematoma Following Radial Extracorporeal Shockwave Therapy for Chronic Neurogenic Heterotopic Ossification: A Case Report

Extracorporeal shockwave therapy (ESWT) has been reported to be a safe and effective method for decreasing pain and relieving range of motion (ROM) limitations caused by neurogenic heterotopic ossification (NHO), though there has been no report that it might cause hematoma if applied to NHO. We hereby report a case of massive hematoma after ESWT, specifically the radial shockwave therapy (RSWT) device at both hips in a 49-year-old female patient with NHO. She had developed NHO after extensive subarachnoid hemorrhage. We had applied RSWT according to the previous report. The pain and the ROM limitations were gradually improved. Six weeks later, she reported pain and ROM limitations on the right hip. From a medial aspect, swelling and bruising of the right thigh could be seen. Magnetic resonance imaging and ultrasonography suggested a large hematoma between right hip adductor muscles. The symptoms disappeared after conservative treatment for one month, and subsequent follow-up imaging studies demonstrated resolution of the hematoma.

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.