Effect of extracorporeal shock wave therapy on denervation atrophy and function caused by sciatic nerve injury

Comparison of the Effects of Botulinum Toxin Doses on Nerve Regeneration in Rats with Experimentally Induced Sciatic Nerve Injury

This study was designed to compare the effects of various doses of botulinum neurotoxin A (BoNT/A) on nerve regeneration. Sixty-five six-week-old rats with sciatic nerve injury were randomly allocated to three experimental groups, a control group, and a sham group. The experimental groups received a single session of intraneural BoNT/A (3.5, 7.0, or 14 U/kg) injection immediately after nerve-crushing injury. The control group received normal intraneural saline injections after sciatic nerve injury. At three, six, and nine weeks after nerve damage, immunofluorescence staining, an ELISA, and toluidine blue staining was used to evaluate the regenerated nerves. Serial sciatic functional index analyses and electrophysiological tests were performed every week for nine weeks. A higher expression of GFAP, S100β, GAP43, NF200, BDNF, and NGF was seen in the 3.5 U/kg and 7.0 U/kg BoNT/A groups. The average area and myelin thickness were significantly greater in the 3.5 U/kg and 7.0 U/kg BoNT/A groups. The sciatic functional index and compound muscle action potential amplitudes exhibited similar trends. These findings indicate that the 3.5 U/kg and 7.0 U/kg BoNT/A groups exhibited better nerve regeneration than the 14 U/kg BoNT/A and control group. As the 3.5 U/kg and the 7.0 U/kg BoNT/A groups exhibited no statistical difference, we recommend using 3.5 U/kg BoNT/A for its cost-effectiveness.

Polydeoxyribonucleotide and Shock Wave Therapy Sequence Efficacy in Regenerating Immobilized Rabbit Calf Muscles

This study primarily aimed to investigate the combined effects of polydeoxyribonucleotide (PDRN) and extracorporeal shock wave therapy (ESWT) sequences on the regenerative processes in atrophied animal muscles. Thirty male New Zealand rabbits, aged 12 weeks, were divided into five groups: normal saline (Group 1), PDRN (Group 2), ESWT (Group 3), PDRN injection before ESWT (Group 4), and PDRN injection after ESWT (Group 5). After 2 weeks of cast immobilization, the respective treatments were administered to the atrophied calf muscles. Radial ESWT was performed twice weekly. Calf circumference, tibial nerve compound muscle action potential (CMAP), and gastrocnemius (GCM) muscle thickness after 2 weeks of treatment were evaluated. Histological and immunohistochemical staining, as well as Western blot analysis, were conducted 2 weeks post-treatment. Staining intensity and extent were assessed using semi-quantitative scores. Groups 4 and 5 demonstrated significantly greater calf muscle circumference, GCM muscle thickness, tibial nerve CMAP, and GCM muscle fiber cross-sectional area (type I, type II, and total) than the remaining three groups (p < 0.05), while they did not differ significantly in these parameters. Groups 2 and 3 showed higher values for all the mentioned parameters than Group 1 (p < 0.05). Group 4 had the greatest ratio of vascular endothelial growth factor (VEGF) to platelet endothelial cell adhesion molecule-1 (PECAM-1) in the GCM muscle fibers compared to the other four groups (p < 0.05). Western blot analysis revealed significantly higher expression of angiogenesis cytokines in Groups 4 and 5 than in the other groups (p < 0.05). The combination of ESWT and PDRN injection demonstrated superior regenerative efficacy for atrophied calf muscle tissue in rabbit models compared to these techniques alone or saline. In particular, administering ESWT after PDRN injection yielded the most favorable outcomes in specific parameters.

Effectiveness of ultrasound and median nerve gliding with and without shock-wave therapy in patients with moderate carpal tunnel syndrome

[Purpose] The aim of this research was to see how ultrasound and nerve gliding with and without shock wave therapy effects on clinical and sonographic data of patients with carpal tunnel syndrome (CTS). [Participants and Methods] Forty four patients with moderate carpal tunnel syndrome participated in this research. One group got shock-wave therapy in addition to median nerve glide exercises and ultrasound, whereas the other group received median nerve glide exercises and ultrasound alone. Hand grip strength (HGS), pinch grip strength (PGS), Visual Analogue Scale (VAS)-pain, Boston Questionnaire (BQ), and Cross-sectional area (CSA) of median nerve were examined before and after 10 sessions of treatment. [Results] HGS, PGS, VAS, BQ and CSA of median nerve improved considerably after therapy. [Conclusion] Patients with moderate CTS who received ultrasound and median nerve glide exercises with and without shock-wave therapy improved considerably without preference of adding shock-wave therapy to other treatment.

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.

ESWT Diminishes Axonal Regeneration following Repair of the Rat Median Nerve with Muscle-In-Vein Conduits but Not after Autologous Nerve Grafting

Investigations reporting positive effects of extracorporeal shockwave therapy (ESWT) on nerve regeneration are limited to the rat sciatic nerve model. The effects of ESWT on muscle-in-vein conduits (MVCs) have also not been investigated yet. This study aimed to evaluate the effects of ESWT after repair of the rat median nerve with either autografts (ANGs) or MVCs. In male Lewis rats, a 7 mm segment of the right median nerve was reconstructed either with an ANG or an MVC. For each reconstructive technique, one group of animals received one application of ESWT while the other rats served as controls. The animals were observed for 12 weeks, and nerve regeneration was assessed using computerized gait analysis, the grasping test, electrophysiological evaluations and histological quantification of axons, blood vessels and lymphatic vasculature. Here, we provide for the first time a comprehensive analysis of ESWT effects on nerve regeneration in a rat model of median nerve injury. Furthermore, this study is among the first reporting the quantification of lymphatic vessels following peripheral nerve injury and reconstruction in vivo. While we found no significant direct positive effects of ESWT on peripheral nerve regeneration, results following nerve repair with MVCs were significantly inferior to those after ANG repair.

Resistance exercise promotes functional test via sciatic nerve regeneration, and muscle atrophy improvement through GAP-43 regulation in animal model of traumatic nerve injuries

Resistance training improves muscle strength through a combination of neural plasticity and muscle hypertrophy. This study aimed to evaluate the effects of resistance exercise on sciatic nerve regeneration and histology, growth-associated protein 43 (GAP-43) expressions, and soleus muscle atrophy following traumatic nerve injuries in Wistar rats. In the present study, 40 male Wistar rats were randomly assigned into four groups: healthy control (HC) as a sham group was exposed to the surgical procedures without any sciatic nerve compression, lesioned control (LC), resistance training (RT,non-lesioned), and lesioned rats+RT (LRT) (n=10 in each). The RT group performed a resistance-training program 5 days/week for 4 weeks. Sciatic functional index (SFI) score, beam score and Basso, Beattie, and Bresnahan (BBB) score decreased and the hot plate time increased significantly in the LC‌ group compared to the HC (p<0.05) group. However, the LRT‌ group showed a significant increase in the SFI score (p=0.001) and a significant decrease in hot plate time (p=0.0232) compared to the LC group. The LC group also showed neurological morphological damage and muscle atrophy and a decrease in GAP-43 in nerve tissue. In comparison to the LC group, a significant increase in sciatic nerve caliber, diameter, number of muscle fibers, and the expression of GAP-43‌ (p<0.05) was observed in the LRT group. Doing resistance training even for four weeks seems to affect sciatic nerve lesions and injuries. It can also repair and regenerate nerve tissue by upregulating GAP-43 expression‌, improving motor behavioral tests, and controlling muscle atrophy.

New Frontiers of Extracorporeal Shock Wave Medicine in Urology from Bench to Clinical Studies

A shock wave (SW), which carries energy and propagates through a medium, is a type of continuous transmitted sonic wave that can achieve rapid energy transformations. SWs have been applied for many fields of medical science in various treatment settings. In urology, high-energy extracorporeal SWs have been used to disintegrate urolithiasis for 30 years. However, at lower energy levels, SWs enhance the expression of vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase (eNOS), proliferating cell nuclear antigen (PCNA), chemoattractant factors, and the recruitment of progenitor cells, and inhibit inflammatory molecules. Low energy extracorporeal shock wave (LESW) therapy has been used in urology for treating chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), interstitial cystitis/bladder pain syndrome (IC/BPS), overactive bladder, stress urinary incontinence, and erectile dysfunction through the mechanisms of anti-inflammation, neovascularization, and tissue regeneration. Additionally, LESW have been proven to temporarily increase tissue permeability and facilitate intravesical botulinum toxin delivery for treating overactive bladders in animal studies and in a human clinical trial. LESW assisted drug delivery was also suggested to have a synergistic effect in combination with cisplatin to improve the anti-cancer effect for treating urothelial cancer in an in vitro and in vivo study. LESW assisted drug delivery in uro-oncology is an interesting suggestion, but no comprehensive clinical trials have been conducted as of yet. Taken together, LESW is a promising method for the treatment of various diseases in urology. However, further investigation with a large scale of clinical studies is necessary to confirm the real role of LESW in clinical use. This article provides information on the basics of SW physics, mechanisms of action on biological systems, and new frontiers of SW medicine in urology.

Effect of Botulinum Toxin Injection and Extracorporeal Shock Wave Therapy on Nerve Regeneration in Rats with Experimentally Induced Sciatic Nerve Injury

This study was designed to compare the roles of botulinum neurotoxin A (BoNT/A) and extracorporeal shock wave therapy (ESWT) in promoting the functional recovery and regeneration of injured peripheral nerves. A total of 45 six-week-old rats with sciatic nerve injury were randomly divided into two experimental groups and one control group. The experimental groups received a single session of intranerve BoNT/A or ESWT immediately after a nerve-crushing injury. The control group was not exposed to any treatment. Differentiation of Schwann cells and axonal sprouting were observed through immunofluorescence staining, ELISA, real-time PCR, and Western blot at 3, 6, and 10 weeks post-nerve injury. For clinical assessment, serial sciatic functional index analysis and electrophysiological studies were performed. A higher expression of GFAP and S100β was detected in injured nerves treated with BoNT/A or ESWT. The levels of GAP43, ATF3, and NF200 associated with axonal regeneration in the experimental groups were also significantly higher than in the control group. The motor functional improvement occurred after 7 weeks of clinical observation following BoNT/A and ESWT. Compared with the control group, the amplitude of the compound muscle action potential in the experimental groups was significantly higher from 6 to 10 weeks. Collectively, these findings indicate that BoNT/A and ESWT similarly induced the activation of Schwann cells with the axonal regeneration of and functional improvement in the injured nerve.

Effect of Extracorporeal Shock Wave Therapy on Muscle Mass and Function in Patients Undergoing Maintenance Hemodialysis: A Randomized Controlled Pilot Study

Patients undergoing maintenance hemodialysis (MHD) are susceptible to muscle wasting and decreased muscle function, resulting in shorter survival time. This study was aimed at evaluating the effect of radial extracorporeal shock wave therapy (rESWT) on muscle mass and function in patients on MHD. This single blind controlled study was conducted on patients on MHD from September 2018 to December 2019. Eighteen patients were enrolled in the rESWT and control groups. rESWT was performed once a week for 12 wk in both quadriceps femoris muscles of the ESWT group. Finally, 15 patients were assessed for body composition, handgrip strength, physical performance and blood chemistry before rESWT, after rESWT and at a 12-wk follow-up. Leg lean mass and appendicular skeletal muscle mass index increased significantly in the ESWT group compared with the control group (p = 0.001 and p = 0.017). The timed up-and-go test and sit-to-stand tests revealed greater significant improvement in the ESWT group (p = 0.023 and p = 0.046). This study is the first to report that rESWT can improve muscle mass and function in MHD patients. A subsequent study will be conducted to validate the clinical effects of rESWT in a larger sample of patients undergoing MHD.

Effect of extracorporeal shock wave therapy on different severities of carpal tunnel syndrome

Background

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome worldwide.

Objective

The current work aimed at determining the effect of extracorporeal shock wave therapy (ESWT) on different severities of carpal tunnel syndrome.

Subjects and methods

Sixty patients with unilateral carpal tunnel syndrome were participated in this study. They were divided into three equal groups according to severity (mild, moderate, and severe). All patients received shock wave therapy one session per week, for 6 weeks. Nerve conduction studies (NCs) were done for the median nerve. Pinch dynamometer was used to measure the degree of lateral pinch power, and Visual Analogue Scale (VAS) was used to assess degree of pain and Ultrasonography analysis measured cross-sectional area (CSA) of median nerve for all patients at the beginning and at the end of the study.

Results

There was significant improvement (P < 0.05) in sensory conduction parameters, CSA, lateral pinch power, and VAS after shock wave therapy in all groups. Also, there was significant improvement in motor latency, motor, and sensory amplitudes after shock wave therapy in mild and moderate groups only (P < 0.05). In all group samples, results revealed a highly significant correlations (p < 0.001) between peak sensory latency (PSL) with VAS, CSA with motor latency (ML), CSA with PSL, CSA with VAS, CSA with lateral pinch, and ML with lateral pinch.

Conclusion

It is recommended to use ESWT as a conservative treatment in patients with different severities of CTS, except patients with severe motor affection.

Trial registration

PACTR201804003293116. Registered on 26 April 2018 as retrospective registration in the pan African clinical trial registry (www.pactr.org).

Shock Waves as a Treatment Modality for Spasticity Reduction and Recovery Improvement in Post-Stroke Adults - Current Evidence and Qualitative Systematic Review

Purpose

This systematic review examines intervention studies using extracorporeal shock wave therapy (ESWT) application in post-stroke muscle spasticity with particular emphasis on the comparison of two different types of radial (rESWT) and focused shock waves (fESWT).

Methods

PubMed, PEDro, Scopus, and EBSCOhost databases were systematically searched. Studies published between the years 2000 and 2019 in the impact factor journals and available in the English full-text version were eligible for inclusion. All qualified articles were classified in terms of their scientific reliability and methodological quality using the PEDro criteria. The PRISMA guidelines were followed and the registration on the PROSPERO database was done.

Results

A total of 17 articles were reviewed of a total sample of 303 patients (age: 57.87±10.45 years and duration of stroke: 40.49±25.63 months) who were treated with ESWT. Recent data confirm both a subjective (spasticity, pain, and functioning) and objective (range of motion, postural control, muscular endurance, muscle tone, and muscle elasticity) improvements for post-stroke spasticity. The mean difference showing clinical improvement was: ∆=34.45% of grade for fESWT and ∆=34.97% for rESWT that gives a slightly better effect of rESWT (∆=0.52%) for spasticity (p<0.05), and ∆=38.83% of angular degrees for fESWT and ∆=32.26% for rESWT that determines the more beneficial effect of fESWT (∆=6.57%) for range of motion (p<0.05), and ∆=18.32% for fESWT and ∆=22.27% for rESWT that gives a slightly better effect of rESWT (∆=3.95%) for alpha motor neuron excitability (p<0.05). The mean PEDro score was 4.70±2.5 points for fESWT and 5.71±2.21 points for rESWT, thus an overall quality of evidence grade of moderate (“fair” for fESWT and “good” for rESWT). Three studies in fESWT and four in rESWT obtained Sackett’s grading system’s highest Level 1 of evidence.

Conclusion

The studies affirm the effectiveness of ESWT in reducing muscle spasticity and improving motor recovery after stroke.

Ultrasound and shock-wave stimulation to promote axonal regeneration following nerve surgery: a systematic review and meta-analysis of preclinical studies

Limited regeneration after nerve injury often leads to delayed or incomplete reinnervation and consequently insufficient muscle function. Following nerve surgery, application of low-intensity ultrasound or extracorporeal shock waves may promote nerve regeneration and improve functional outcomes. Because currently clinical data is unavailable, we performed a meta-analysis following the PRISMA-guidelines to investigate the therapeutic effect of ultrasound and shock wave therapies on motor nerve regeneration. Ten ultrasound-studies (N = 445 rats) and three shock-wave studies (N = 110 rats) were identified from multiple databases. We calculated the difference in means or standardized mean difference with 95% confidence intervals for motor function, nerve conduction velocity and histomorphological parameters of treated versus sham or non-treated animals. Ultrasound treatment showed significantly faster nerve conduction, increased axonal regeneration with thicker myelin and improved motor function on sciatic functional index scale (week two: DM[95%CI]: 19,03[13,2 to 25,6], 71 animals; week four: 7,4[5,4 to 9,5], 47 animals). Shock wave induced recovery improvements were temporarily significant. In conclusion, there is significant evidence for low-intensity ultrasound but not for extracorporeal shock wave treatment to improve nerve regeneration. Prospective clinical trials should therefore investigate available FDA-approved ultrasound devices as adjunct postoperative treatment following nerve surgery.

Comparison of single-dose radial extracorporeal shock wave and local corticosteroid injection for treatment of carpal tunnel syndrome including mid-term efficacy: a prospective randomized controlled trial

BACKGROUND

Recent studies have reported that radial extracorporeal shock wave therapy (rESWT) reduces pain and improves function in patients with mild to moderately severe carpal tunnel syndrome (CTS) compared to a placebo. However, most of those studies used multi-session rESWT combined with wrist support and evaluation of efficacy was limited to a maximum of 14 weeks.

METHODS

The prospective randomized controlled trial compared efficacy in relieving pain and improving clinical function between single-dose rESWT and local corticosteroid injection (LCsI) over the mid-term (24 weeks). Twenty-five patients with mild to moderately severe CTS were randomized to receive either single-dose rESWT (n = 13) or LCsI (n = 12). Primary outcomes were evaluated using the Boston self-assessment questionnaire (BQ), while secondary outcomes used the Visual analogue scale (VAS) and electrodiagnostic parameters. Evaluations at baseline and at 1, 4, 12 and 24 weeks after treatment were performed.

RESULTS

There was significantly greater improvement in symptom severity scores, functional scores and Boston questionnaire scores at weeks 12 to 24 in the rESWT group compared to the LCsI group. When compared to the baseline, there was significant reduction of VAS and functional score in the rESWT group at weeks 12 and 24. The LCsI group had no statistically significant differences in VAS reduction and functional score of the same period.

CONCLUSIONS

Treatment of CTS using single-dose rESWT has a carry-over effect lasting up to 24 weeks suggesting that single-dose rESWT is appropriate for treatment of mild to moderate CTS and provides longer-lasting benefits than LCsI.

TRIAL REGISTRATION

( TCTR20150709001 ). Registered 9 July 2015.

Radial Extracorporeal Shock Wave Therapy Enhances the Proliferation and Differentiation of Neural Stem Cells by Notch, PI3K/AKT, and Wnt/β-catenin Signaling

Neural stem cell (NSC) proliferation and differentiation play a pivotal role in the repair of brain function in central nervous system (CNS) diseases. Radial extracorporeal shock wave therapy (rESWT) is a non-invasive and innovative treatment for many conditions, yet little is known about the effects of this treatment on NSCs. Mouse NSCs (NE-4C) were exposed to rESWT with 1.0, 1.5, 2.0, 2.5, 3.0, and 3.5 bar (500 impulses, and 2 Hz) in vitro. Cell viability test results indicated that rESWT, at a dose of 2.5 bar, 500 impulses, and 2 Hz, increased NE-4C viability within 72 h, and that the PI3K/AKT pathway was involved in its mechanisms. Exposure to rESWT also affected proliferation and differentiation of NE-4C after 8 weeks, which may be associated with Wnt/β-catenin and Notch pathways. This assessment is corroborated by the ability of inhibitors of Wnt/β-catenin [Dickkopf-1 (Dkk-1)] and the Notch pathway (DAPT) to weaken proliferation and differentiation of NSCs. In summary, a proper dose of rESWT enhanced NSCs augment via the PI3K/AKT pathway initially. Also, Wnt/β-catenin and the Notch pathway play important roles in regulation of the long-term efficacy of rESWT. This study reveals a novel approach to culture NSCs in vitro and support neurogenesis.

Combined treatment with extracorporeal shock‑wave therapy and bone marrow mesenchymal stem cell transplantation improves bone repair in a rabbit model of bone nonunion

The aim of the present study was to analyze whether extracorporeal shock‑wave therapy (ESWT) combined with bone marrow mesenchymal stem cell (BMMSC) transplantation improves bone repair in a rabbit bone nonunion model. ESWT combined with BMMSC effectively enhanced mechanical strength, fracture stiffness and histological scores, and increased alkaline phosphatase activity, and osteopontin, runt related transcription factor 2 and collagen type I α1 chain protein expression levels in a rabbit bone nonunion model. In addition, ESWT combined with BMMSC effectively enhanced insulin‑like growth factor 1 and vascular endothelial growth factor contents, promoted transforming growth factor‑β (TGF‑β) contents, and induced the growth factors, bone morphogenetic protein (BMP)‑2, BMP‑4 and purinergic receptor P2X7 (P2X7) protein expression in the rabbit bone nonunion model. Thus, the present study demonstrated that ESWT combined with BMMSC transplantation improves bone repair in a rabbit bone nonunion model via the BMPs and P2X7 signaling pathways.

Radial extracorporeal shock wave therapy improves cerebral blood flow and neurological function in a rat model of cerebral ischemia

We performed middle cerebral artery occlusion (MCAO) in rats to investigate the effect and some of the underlying mechanisms of radial extracorporeal shock wave therapy (rESWT) in cerebral ischemia rats. We measured neurological function and cerebral blood flow (CBF) using a full-field laser perfusion imager and brain infarct volume on days 3, 12, and 30. Immunofluorescence, western blot, and real-time polymerase chain reaction (PCR) techniques were used to detect the expression of vascular endothelial growth factor (VEGF), neuron-specific enolase (NSE), nestin, Wnt3a, and β-catenin in the ischemic hemisphere. The dose of rESWT used on the head revealed remarkable advantages over sham rESWT, as demonstrated by improved neurological function scores, increased CBF, and reduced brain infarct volume. Furthermore, applying rESWT to the head and limbs enhanced short-term neurological function. Our results confirmed that rESWT can induce VEGF expression over an extended period with a profound effect, which may be the primary reason for CBF recovery. High NSE and nestin expression levels suggest that rESWT enhanced the number of neurons and neural stem cells (NSCs). Wnt3a and β-catenin expression were up-regulated in the ischemic hemisphere, indicating that rESWT promoted NSC proliferation and differentiation via the Wnt/β-catenin pathway. Overall, our findings suggest that an appropriate rESWT dose delivered to the head of rats helps restore neurological function and CBF, and additional application of rESWT to the limbs is more effective than treating the head alone.

The Effect of Radial Extracorporeal Shock Wave Stimulation on Upper Limb Spasticity in Chronic Stroke Patients: A Single-Blind, Randomized, Placebo-Controlled Study

The main purpose of this study was to determine the clinical, electrophysiological and thermal effects of radial extracorporeal shock wave (rESW) stimulation on upper limb muscles affected by spasticity in patients with chronic stroke. Patients included in the study were randomly assigned into the following two groups: 30 patients stimulated with active rESW (A); and 30 patients stimulated with placebo rESW (B). All patients were analyzed using the Modified Ashworth Scale (MAS) to test the spasticity levels of the elbow (E), radio carpal (RC) and fingers (FF) joints; surface electromyography (sEMG) was performed for the resting bioelectrical activity registration of the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) muscles; and infrared thermal imaging (IRT) was used to assess the temperature distributions of the carpal flexor muscles (CFM). All assessments were performed at baseline (t0), immediately after rESW (t1) as well as 1 and 24 h following its finalization (t2 and t3). Patients treated with active rESW showed a statistically significant reduction in the MAS score for the RC joint at t1 and for the FF joints at t1, t2 and t3 (p < 0.05). A significant decrease in sEMG activity was observed in the FCR and FCU muscles at t1, t2 and t3 (p < 0.05); significant increases in the mean and maximum values of the IRT detection was observed using inter-group comparisons in t2 and t3 (p < 0.05). No significant alterations were observed in patients after placebo rESW stimulation (p > 0.05). Applications of rESW demonstrating positive effects at reducing the level of spastic hypertonia of the upper limb muscles in patients with chronic stroke. ESW treatments should be considered as a potential anti-spastic effect to regulate vasculature.