Extracorporeal shock waves enhance normal fibroblast proliferation in vitro and activate mRNA expression for TGF-beta1 and for collagen types I and III

Ultrasonographic appearance of supraspinatus and biceps tendinopathy improves in dogs treated with low-intensity extracorporeal shock wave therapy: a retrospective study

Objective

This study aimed to determine whether dogs with shoulder tendinopathy diagnosed via musculoskeletal ultrasound would show improvement in imaging after treatment using piezoelectric shockwave therapy and rest.

Methods

Medical records were reviewed for dogs diagnosed with biceps and/or supraspinatus tendinopathy via musculoskeletal ultrasound, treated using piezowave shockwave, and re-imaged post-treatment. Data collected included patient signalment, duration and grade of lameness, prior rest, piezowave dose, and patient outcome, including a return to sport where applicable. Images were scored using an adapted ultrasound grading scale, in addition to obtaining cross-sectional area measurements. Statistics included Shapiro-Wilk tests (normality), Wilcoxon matched pairs signed rank tests (pre- vs. post-treatment comparisons), and Spearman's correlation coefficients (lameness grade vs. ultrasound score) (significant at P < 0.05).

Results

In total, 26 of 30 dogs had pathology involving both the biceps and supraspinatus tendons in one limb, with 27 of 30 having tendon/s affected bilaterally. For both tendons, post-treatment cross-sectional area and ultrasound score were significantly lower than pre-treatment (P < 0.001). Lameness decreased clinically (P < 0.0001) following piezowave shockwave treatment regardless of the tendons involved, but the lameness score did not correlate with the ultrasound score for either tendon.

Conclusion

Dogs with tendinopathy of the biceps brachii and supraspinatus showed significant improvement on follow-up musculoskeletal ultrasound and lameness evaluation after the treatment of their tendons using piezoelectric shockwave therapy with rest.

Clinical significance

Canine biceps brachii and supraspinatus tendinopathy can cause variable lameness and ultrasonographic appearance, which improves after shockwave therapy and rest. The ultrasound scoring system and cross-sectional area assessment provide useful outcome measures for clinical cases.

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

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

Efficacy and safety of cardiac shock wave therapy for patients with severe coronary artery disease: A randomized, double-blind control study

BACKGROUND

Previous studies proved the efficacy of cardiac shock wave therapy (CSWT) for coronary artery disease (CAD) patients who are not candidate for reperfusion therapy. Randomized control trials are limited. We try to explore the efficacy and safety of CSWT for patients with severe CAD.

METHODS

Thirty patients with severe CAD who had obvious ischemia on myocardial perfusion imaging (MPI) were enrolled and randomly assigned to the CSWT group or the control group. They had received optimal medication treatment for at least three months. Nine sessions of shock wave therapy were conducted over 3 months. CSWT group received the real treatment, while the control group received the pseudo-treatment. Clinical symptom, imaging outcomes and safety parameters were compared between two groups.

RESULTS

After treatment, regional stress score (P = .023), improvement rate (IR) of ischemic area (IA) stress (P < .001) and IR of IA difference (P < .001) were significantly favor CSWT group. The interaction of summed rest score (P < .001), summed stress score (P = .004), summed difference score (P = .036) were significantly improved in the CSWT group compared to the control group. Seattle angina questionnaire, quality of life (QOL) and the distance of six-minute walking test (6MWT) were improved in both groups without significant difference between them. Hemodynamic parameters were stable during procedure. Myocardial injury markers showed no changes in two groups.

CONCLUSIONS

Our study demonstrated CSWT could effectively and safely improve myocardial perfusion in patients with severe CAD. Clinical symptom, QOL and 6MWT were all improved after treatment, but no significant difference between two groups.

Effects of Electric-Toothbrush Vibrations on the Expression of Collagen and Non-Collagen Proteins through the Focal Adhesion Kinase Signaling Pathway in Gingival Fibroblasts

Electric-toothbrush vibrations, which remove plaque, are transmitted to the gingival connective tissue via epithelial cells. Physical energy affects cell function; however, the effects of electric-toothbrush vibrations on gingival extracellular matrix (ECM) protein expression remain unknown. We aimed to examine the effects of these vibrations on the expression of ECM proteins—type I collagen (col I), type III collagen (col III), elastin, and fibronectin (FN)—using human gingival fibroblasts (HGnFs). HGnFs were seeded for 5 days in a six-well plate with a hydrophilic surface, exposed to electric-toothbrush vibrations, and cultured for 7 days. Subsequently, the mRNA and protein levels of col I, col III, elastin, and FN were examined. To investigate the role of focal adhesion kinase (FAK) signaling on ECM protein expression in vibration-stimulated cells, the cells were treated with siRNA against protein tyrosine kinase (PTK). Electric-toothbrush vibrations increased col I, col III, elastin, and FN expression; promoted collagen and non-collagen protein production; and enhanced FAK phosphorylation in HGnFs. Moreover, PTK2 siRNA completely blocked the effects of these vibrations on the expression of col I, col III and elastin mRNA. The results suggest that electric-toothbrush vibrations increase collagen, elastin, and FN production through the FAK-signaling pathway in fibroblasts.

Cardiac Shockwave Therapy – A Novel Therapy for Ischemic Cardiomyopathy?

Over the past decades, shockwave therapy (SWT) has gained increasing interest as a therapeutic approach for regenerative medicine applications, such as healing of bone fractures and wounds. More recently, pre-clinical studies have elucidated potential mechanisms for the regenerative effects of SWT in myocardial ischemia. The mechanical stimulus of SWT may induce regenerative effects in ischemic tissue via growth factor release, modulation of inflammatory response, and angiogenesis. Activation of the innate immune system and stimulation of purinergic receptors by SWT appears to enhance vascularization and regeneration of injured tissue with functional improvement. Intriguingly, small single center studies suggest that SWT may improve angina, exercise tolerance, and hemodynamics in patients with ischemic heart disease. Thus, SWT may represent a promising technology to induce cardiac protection or repair in patients with ischemic heart disease.

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.

Could radial extracorporeal shock wave therapy have an effect on wound healing in clinical practice by creating genotoxic damage? An in vitro study in mouse fibroblasts

Objectives: This study aims to evaluate wound healing effects of in vitro radial extracorporeal shock wave (rESW) application on mouse fibroblasts and whether the cytotoxic effect of extracorporeal shock wave (ESW) was due to a possible genotoxic effect.

Patients and methods: After creating an in vitro wound healing model in L929 mouse fibroblast culture, fibroblasts were stimulated with a frequency of 3 Hz, and 100, 250, 500, 1,000 and 1,500 pulses shock waves were applied. Energy flux densities ranging from 0.01 to 0.23 mJ/mm2 (14.3 MPa) at a constant pressure level of 0.5 and 1 bar were applied. Wound healing, cell viability, and genotoxicity were evaluated at 24 and 48 h.

Results: All shot numbers for both pressures significantly reduced cell viability (p<0.05). For both 0.5 and 1 bar pressures, in both intervals, the rate of wound healing decreased, regardless of the number of shots (p<0.05). In vitro genotoxic damage was detected at both 0.5 and 1 bar pressures, in both time intervals, regardless of the number of shots. The genotoxic damage increased from 24 to 48 h.

Conclusion: The study results suggest that, when ESWT is applied in this in vitro experimental setup, cell viability decreases and wound healing is delayed under all conditions. Furthermore, genotoxic damage can be prevented by using shots below 1,000 pulses. Therefore, while investigating the therapeutic effect of ESW therapy in vitro, the upper limit for the number of shots should be 1,000 pulses.

Combined Effects of Extracorporeal Shockwave Therapy and Integrated Neuromuscular Inhibition on Myofascial Trigger Points of Upper Trapezius: A Randomized Controlled Trial

Objective

To investigate the combined effect of extracorporeal shockwave therapy (ESWT) and integrated neuromuscular inhibition (INI) on myofascial trigger points in the upper trapezius.

Methods

Sixty subjects aged 18–24 years old with active myofascial trigger points in the upper trapezius were studied. Participants were assigned randomly to either group A who received ESWT one session/week, group B who received INI three sessions/week, or group C who received ESWT in addition to INI. All groups completed 4 weeks of intervention. The following main outcome measures were evaluated at baseline and after 4 weeks of intervention: pain intensity, functional disability, pressure pain threshold (PPT), sympathetic skin response (SSR), and neuromuscular junction response (NMJR).

Results

Within-group analysis revealed a significant decline in visual analog scale (VAS), Arabic neck disability index (ANDI), and NMJR and incline in PPT and SSR latency post-intervention (p<0.001). Multiple comparison analysis showed a substantial difference between the groups, while the major changes favored group C (p<0.05).

Conclusion

Combined treatment with ESWT and INI for treating myofascial trigger points in the upper trapezius is more effective than using only one of the two approaches in terms of clinical, functional, and neurophysiological aspects.

Plantar Fasciitis/Fasciosis

Many randomized controlled trials demonstrate the effectiveness of conservative treatment of plantar fasciitis. Patients with acute plantar fasciitis generally respond to treatment more rapidly and more predictably than patients with chronic plantar fasciitis. If conservative treatment fails, endoscopic plantar fasciotomy offers patients a more prompt return to activity compared with open procedures.

Mechanotransduction in Wound Healing: From the Cellular and Molecular Level to the Clinic

GENERAL PURPOSE

To review the various mechanical forces that affect fibroblasts, keratinocytes, endothelial cells, and adipocytes at the cellular and molecular level as well as scar-reducing mechanical devices currently in clinical use.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Compare and contrast the responses of various types of cells to mechanical forces.2. Identify the mechanical devices and techniques that can help restore skin integrity.

Effectiveness of focused extracorporeal shock wave therapy in the treatment of carpal tunnel syndrome : A randomized, placebo-controlled pilot study

Background

The carpal tunnel syndrome is the most common entrapment neuropathy in the general population. A conservative treatment should be considered in mild to moderate cases. The aim of this study was to assess the effect of a focused extracorporeal shock wave therapy in the treatment of mild to moderate carpal tunnel syndrome.

Material and Methods

In this study 30 patients were randomly assigned into 2 groups. Subjects in the study group received three sessions of focused extracorporeal shock wave therapy, whereas the control group underwent a sham therapy. Patients were evaluated 3 and 12 weeks after treatment. The primary outcome was the visual analogue scale score. Secondary outcome measurements included hand grip strength, Boston Carpal Tunnel Syndrome Questionnaire, SF-36 Health Survey and electrodiagnostic measurements.

Results

A significant improvement of visual analogue scale at week 3 (p = 0.018) and week 12 (p = 0.007) as well as hand grip strength at week 12 (p = 0.019) could be observed in the study group. The study group showed a significantly better sensory nerve conduction velocity at week 12 than the control group, before correcting for multiple testing, and also a significant improvement in distal motor latency of the median nerve at week 12 (p = 0.009) as well as in both questionnaires (SF-36 subscale bodily pain, p = 0.020 and severity symptom scale, p = 0.003). No such improvement was observed in the control group.

Conclusion

Focused extracorporeal shock wave therapy is an effective and noninvasive treatment method for mild to moderate carpal tunnel syndrome.

The effects of shock wave therapy applied on hypertrophic burn scars: a randomised controlled trial

INTRODUCTION

A wide variety of non-invasive treatments has been proposed for the management of hypertrophic burn scars. Unfortunately, the reported efficacy has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a new non-invasive type of mechanotherapy to treat wounds and scars. The aim of the present study was to examine the objective and subjective scar-related effects of ESWT on burn scars in the early remodelling phase.

MATERIAL AND METHODS

Evaluations included the Patient and Observer Scar Assessment Scale (POSAS) for scar quality, tri-stimulus colorimetry for redness, tewametry for trans-epidermal water loss (TEWL) and cutometry for elasticity. Patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group, and were tested at baseline, after one, three and six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks.

RESULTS

Results for 20 patients in each group after six months are presented. The objective assessments showed a statistically significant effect of ESWT compared with placebo on elasticity (P = 0.011, η2P=0.107) but revealed no significant effects on redness and TEWL. Results of the clinical assessments showed no significant interactions between intervention and time for the POSAS Patient and Observer scores.

CONCLUSION

ESWT can give added value to the non-invasive treatment of hypertrophic scars, more specifically to improve elasticity when the treatment was already started in the first three months after wound closure.

LAY SUMMARY

Pathological scarring is a common problem after a burn injury. A wide variety of non-invasive treatments has been proposed for the management of these scars. Unfortunately, the reported efficacy of these interventions has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a relatively new non-invasive therapy to treat both wounds and scars. The aim of the present study was to examine the scar-related effects of ESWT on burn scars in the early phase of healing.The scars were subjectively assessed for scar quality by the patient and an observer using the Patient and Observer Scar Assessment Scale (POSAS). Objective assessments included measurements to assess redness, water loss and elasticity. Forty patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group (the device simulated the sound of an ESWT treatment but no real shocks were applied), and were tested at four timepoints up to six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks.The objective assessments showed a significant improvement of elasticity in the intervention group when compared with placebo but revealed no significant effects on redness and water loss. Results of the clinical assessments showed no differences between the groups for the POSAS Patient and Observer scores.ESWT can give added value to the non-invasive treatment of pathological scars more specifically to improve elasticity in the early phase of healing.

Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment

Calcific tendinopathy (CT) of the shoulder is a common, painful condition characterized by the presence of calcium deposits in the rotator cuff tendons. Current theories indicate that CT may be the result of a cell-mediated process in which, after a stage of calcium deposition, calcifications are spontaneously resorbed. However, in a minority of cases, this self-healing process is somehow disrupted, resulting in symptoms. Recent literature shows an emerging role of biological and genetic factors underlying CT. This new evidence could supplement the classic mechanical theory of rotator cuff tendinopathy complicated by calcium precipitation, and it may also explain why the majority of the therapies currently in use are only able to provide partially satisfactory outcomes. This review aims to summarize the current knowledge about the pathological processes underlying CT of the shoulder and thereby justify the quest for advanced biological treatments of this condition when it becomes symptomatic.

Stimulation of angiogenesis using single-pulse low-pressure shock wave treatment

Endothelial cells respond to mechanical stimuli such as stretch. This property can be exploited with caution to induce angiogenesis which will have immense potential to treat pathological conditions associated with insufficient angiogenesis. The primary aim of this study is to test if low-pressure shock waves can be used to induce angiogenesis. Using a simple diaphragm-based shock tube, we demonstrate that a single pulse of low pressure (0.4 bar) shock wave is enough to induce proliferation in bovine aortic endothelial cells and human pulmonary microvascular endothelial cells. We show that this is associated with enhanced Ca⁺⁺ influx and phosphorylation of phosphatidylinositol-3-kinase (PI3K) which is normally observed when endothelial cells are exposed to stretch. We also demonstrate the pro-angiogenic effect of shock waves of single pulse (per dose) using murine back punch wound model. Shock wave treated mice showed enhanced wound-induced angiogenesis as reflected by increased vascular area and vessel length. They also showed accelerated wound closure compared to control mice. Overall, our study shows that just a single pulse/shot (per dose) of shock waves can be used to induce angiogenesis. Importantly, we demonstrate this effect using a pulse of low-pressure shock waves (0.4 bar, in vitro and 0.15 bar, in vivo). KEY MESSAGES: Low-pressure single-pulse shock waves can induce endothelial cell migration and proliferation. This effect is endothelial cell specific. These shock waves enhance wound-induced angiogenesis in vivo. These shock waves can also accelerate wound healing in vivo.

Platelet-Rich Plasma Injections as a Treatment for Refractory Patellar Tendinosis: A Meta-Analysis of Randomised Trials

Purpose

Patellar tendinosis (PT) is a common condition amongst athletes. In this study, we perform a meta-analysis on randomised controlled trials (RCTs) to evaluate the use of platelet-rich plasma (PRP) for refractory PT.

Methods

A literature search was undertaken in various databases from their year of inception to October 2015. The primary outcome measure was the Victorian Institute of Sports Assessment-Patella (VISA-P) score.

Results

We identified 2 RCTs comparing PRP injections to alternative treatment options (extracorporeal shockwave therapy [ESWT] and dry needling of the tendon). Meta-analysis showed no significant difference in mean VISA-P scores between PRP injection and control at early assessment (2 or 3 months; estimated difference in means, 11.9; standard error [SE], 7.4; 95% confidence interval [CI], -2.7 to 26.4; p=0.109). However, PRP was statistically better than control with regards to VISA-P scores at longer follow-up (6 months or longer; estimated difference in means, 12.7; SE, 4.4; 95% CI, 4.1 to 21.3; p=0.004).

Conclusions

There is a paucity of RCTs evaluating the role of PRP in PT. Our results suggest that, based on limited evidence, PRP is superior over other established non-surgical treatments (dry needling and ESWT) for refractory PT. Larger RCTs may allow better characterisation of the role of PRP in this condition.

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.

In-vitro cell treatment with focused shockwaves-influence of the experimental setup on the sound field and biological reaction

Background

To improve understanding of shockwave therapy mechanisms, in vitro experiments are conducted and the correlation between cell reaction and shockwave parameters like the maximum pressure or energy density is studied. If the shockwave is not measured in the experimental setup used, it is usually assumed that the device’s shockwave parameters (=manufacturer’s free field measurements) are valid. But this applies only for in vitro setups which do not modify the shockwave, e.g., by reflection or refraction. We hypothesize that most setups used for in vitro shockwave experiments described in the literature influence the sound field significantly so that correlations between the physical parameters and the biological reaction are not valid.

Methods

To reveal the components of common shockwave in vitro setups which mainly influence the sound field, 32 publications with 37 setups used for focused shockwave experiments were reviewed and evaluated regarding cavitation, cell container material, focal sound field size relative to cell model size, and distance between treated cells and air. For further evaluation of the severity of those influences, experiments and calculations were conducted.

Results

In 37 setups, 17 different combinations of coupling, cell container, and cell model are described. The setup used mainly is a transducer coupled via water to a tube filled with a cell suspension. As changes of the shockwaves’ maximum pressure of 11 % can already induce changes of the biological reaction, the sound field and biological reactions are mainly disturbed by use of standard cell containers, use of coupling gel, air within the 5 MPa focal zone, and cell model sizes which are bigger than half the −6 dB focal dimensions.

Conclusions

Until now, correct and sufficient information about the shockwave influencing cells in vitro is only provided in 1 of 32 publications. Based on these findings, guidelines for improved in vitro setups are proposed which help minimize the influence of the setup on the sound field.

Electronic supplementary material

The online version of this article (doi:10.1186/s40349-016-0053-z) contains supplementary material, which is available to authorized users.

Fractionated Repetitive Extracorporeal Shock Wave Therapy: A New Standard in Shock Wave Therapy?

Background. ESWT has proven clinical benefit in dermatology and plastic surgery. It promotes wound healing and improves tissue regeneration, connective tissue disorders, and inflammatory skin diseases. However, a single treatment session or long intervals between sessions may reduce the therapeutic effect. The present study investigated the effects of fractionated repetitive treatment in skin microcirculation. Methods. 32 rats were randomly assigned to two groups and received either fractionated repetitive high-energy ESWT every ten minutes or placebo shock wave treatment, applied to the dorsal lower leg. Microcirculatory effects were continuously assessed by combined laser Doppler imaging and photospectrometry. Results. In experimental group, cutaneous tissue oxygen saturation was increased 1 minute after the first application and until the end of the measuring period at 80 minutes after the second treatment (P < 0.05). The third ESWT application boosted the effect to its highest extent. Cutaneous capillary blood flow showed a significant increase after the second application which was sustained for 20 minutes after the third application (P < 0.05). Placebo group showed no statistically significant differences. Conclusions. Fractionated repetitive extracorporeal shock wave therapy (frESWT) boosts and prolongs the effects on cutaneous hemodynamics. The results indicate that frESWT may provide greater benefits in the treatment of distinct soft tissue disorders compared with single-session ESWT.

Treatment Outcomes of Corticosteroid Injection and Extracorporeal Shock Wave Therapy as Two Primary Therapeutic Methods for Acute Plantar Fasciitis: A Prospective Randomized Clinical Trial

The outcome of corticosteroid injection (CSI) and extracorporeal shock wave therapy (ESWT) as primary treatment of acute plantar fasciitis has been debated. The purpose of the present study was to evaluate and compare the therapeutic effects of CSI and ESWT in patients with acute (<6-week duration) symptomatic plantar fasciitis. Of the 116 eligible patients, 68 were randomized to 2 equal groups of 34 patients, each undergoing either ESWT or CSI. The ESWT method included 2000 impulses with energy of 0.15 mJ/mm(2) and a total energy flux density of 900 mJ/mm(2) for 3 consecutive sessions at 1-week intervals. In the CSI group, 40 mg of methyl prednisolone acetate plus 1 mL of lidocaine 2% was injected into the maximal tenderness point at the inframedial calcaneal tuberosity. The success and recurrence rates and pain intensity measured using the visual analog scale, were recorded and compared at the 3-month follow-up visit. The pain intensity had reduced significantly in all patients undergoing either technique. However, the value and trend of pain reduction in the CSI group was significantly greater than those in the ESWT group (p < .0001). In the ESWT and CSI groups, 19 (55.9%) and 5 (14.7%) patients experienced treatment failure, respectively. Age, gender, body mass index, and recurrence rate were similar between the 2 groups (p > .05). Both ESWT and CSI can be used as the primary and/or initial treatment option for treating patients with acute plantar fasciitis; however, the CSI technique had better therapeutic outcomes.

Prognostic factors of extracorporeal shock wave therapy for tendinopathies

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

Polyhydroxybutyrate-co-hydroxyvalerate structures loaded with adipose stem cells promote skin healing with reduced scarring

Currently available skin substitutes are still associated with a range of problems including poor engraftment resulting from deficient vascularization, and excessive scar formation, among others. Trying to overcome these issues, this work proposes the combination of poly(3-hydroxybutyrate-co-hydroxyvalerate) (PHBV) structures with adipose-derived stem cells (ASCs) to offer biomechanical and biochemical signaling cues necessary to improve wound healing in a full-thickness model. PHBV scaffold maintained the wound moisture and demonstrated enough mechanical properties to withstand wound contraction. Also, exudate and inflammatory cell infiltration enhanced the degradation of the structure, and thus healing progression. After 28 days all the wounds were closed and the PHBV scaffold was completely degraded. The transplanted ASCs were detected in the wound area only at day 7, correlating with an up-regulation of VEGF and bFGF at this time point that consequently led to a significant higher vessel density in the group that received the PHBV loaded with ASCs. Subsequently, the dermis formed in the presence of the PHBV loaded with ASCs possesses a more complex collagen structure. Additionally, an anti-scarring effect was observed in the presence of the PHBV scaffold indicated by a down-regulation of TGF-β1 and α-SMA together with an increase of TGF-β3, when associated with ASCs. These results indicate that although PHBV scaffold was able to guide the wound healing process with reduced scarring, the presence of ASCs was crucial to enhance vascularization and provide a better quality neo-skin. Therefore, we can conclude that PHBV loaded with ASCs possesses the necessary bioactive cues to improve wound healing with reduced scarring.

Efficacy of shock wave therapy on chronic diabetic foot ulcer: a single-blinded randomized controlled clinical trial

OBJECTIVE

This study was conducted to evaluate the efficacy of extracorporeal shock wave therapy (ESWT) on the healing rate, wound surface area and wound bed preparation in chronic diabetic foot ulcers (DFU).

METHODS

Thirty eight patients with 45 chronic DFU were randomly assigned into; the ESWT-group (19 patients/24 ulcers) and the control-group (19 patients/21 ulcers). Blinded therapist measured wound surface area (WSA), the percentage of reduction in the WSA, rate of healing and wound bed preparation at baseline, after the end of the interventions (W8), and at 20-week follow-up (W20). The ESWT group received shock wave therapy twice per week for a total of eight treatments. Each ulcer was received ESWT at a frequency of 100 pulse/cm(2), and energy flux density of 0.11mJ/cm(2). All patients received standardized wound care consisting of debridement, blood-glucose control agents, and footwear modification for pressure reduction.

RESULTS

The overall clinical results showed completely healed ulcers in 33.3% and 54% in ESWT-groups and 14.28% and 28.5% in the control group after intervention (W8), and at follow-up (W20) respectively. The average healing time was significantly lower (64.5 ± 8.06 days vs 81.17 ± 4.35 days, p<0.05) in the ESWT-group compared with the control group.

CONCLUSION

ESWT-treated ulcers had a significant reduction in wound size and median time required for ulcer healing, with no adverse reactions. So, the ESWT is advocated as an adjunctive therapy in chronic diabetic wound.

Experimental studies on the biological effects of extracorporeal shock wave therapy on tendon models. A review of the literature

Encouraging results using extracorporeal shock wave therapy (ESWT) for treating chronic tendinopathies were recently obtained, although the specific mechanisms by which it induces therapeutic effects remain largely unknown. In order to provide possible explications of such clinical efficacy, several reports have investigated the effects of ESWT on animal models and different kind of cultured cells. Our contribute in establishing the potential outcome of ESWT on human primary cultured tenocytes, derived from healthy compared to ruptured tendons, have supported the growing evidence that shock waves may supply faster post-injury recovery. The purpose of this review was to summarize and evaluate the available basic scientific evidences for using ESWT in tendon pathologies, suggesting possible shock waves-induced mechanisms of tissue repair.

Extracorporeal shockwave enhanced regeneration of fibrocartilage in a delayed tendon-bone insertion repair model

Fibrous tissue is often formed in delayed healing of tendon bone insertion (TBI) instead of fibrocartilage. Extracorporeal shockwave (ESW) provides mechanical cues and upregulates expression of fibrocartilage-related makers and cytokines. We hypothesized that ESW would accelerate fibrocartilage regeneration at the healing interface in a delayed TBI healing model. Partial patellectomy with shielding at the TBI interface was performed on 32 female New Zealand White Rabbits for establishing this delayed TBI healing model. The rabbits were separated into the control and ESW group for evaluations at postoperative week 8 and 12. Shielding was removed at week 4 and a single ESW treatment was applied at week 6. Fibrocartilage regeneration was evaluated histomorphologically and immunohistochemically. Vickers hardness of the TBI matrix was measured by micro-indentation. ESW group showed higher fibrocartilage area, thickness, and proteoglycan deposition than the control in week 8 and 12. ESW increased expression of SOX9 and collagen II significantly in week 8 and 12, respectively. ESW group showed a gradual transition of hardness from bone to fibrocartilage to tendon, and had a higher Vickers hardness than the control group at week 12. In conclusion, ESW enhanced fibrocartilage regeneration at the healing interface in a delayed TBI healing model.

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.

Extracorporeal shockwave therapy for treatment of delayed tendon-bone insertion healing in a rabbit model: a dose-response study

BACKGROUND

Tendon-bone insertion (TBI) consists of both hard and soft tissues. TBI injury with delayed repair is not uncommon. High-dose extracorporeal shockwave (ESW) is effective for treating nonunion fracture, whereas low-dose ESW is used for tendinopathy therapy. The dosing effect of ESW on delayed TBI healing is lacking.

HYPOTHESIS

Low-dose ESW might have a healing enhancement effect comparable to that of high-dose ESW in treating delayed TBI healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Partial patellectomy was adopted to create a delayed TBI healing model by shielding the healing interface between tendon and bone. Ninety-six female New Zealand White rabbits with unilateral delayed TBI healing at the knee joint were divided into 3 groups: controls, low-dose ESW (LD-ESW; 0.06 mJ/mm(2), 4 Hz, 1500 impulses), and high-dose ESW (HD-ESW; 0.43 mJ/mm(2), 4 Hz, 1500 impulses). The TBI shielding was removed at week 4 after partial patellectomy, followed by treatment with control or ESW at week 6. The rabbits were euthanized at week 8 and week 12 for radiological, microarchitectural, histological, and mechanical assessments of healing tissues.

RESULTS

Radiologically, both the LD-ESW group and the HD-ESW group showed larger new bone area than the controls at week 8 and week 12. Microarchitectural measurements showed that the LD-ESW and HD-ESW groups had larger new bone volume than the controls at week 12. Histological assessments confirmed osteogenesis enhancement. Both the LD-ESW and HD-ESW groups showed significantly higher failure load at the TBI healing complex than the control group at week 12. No significant difference was detected between the 2 ESW treatment groups at week 8 or week 12.

CONCLUSION

Extracorporeal shockwave, a unique noninvasive physical modality, had similar effects between the low and high dose for treating delayed TBI healing.

CLINICAL RELEVANCE

Low-dose ESW for TBI delayed healing might be more desirable and have better compliance in clinical applications.

Extracorporeal Shock Wave Treatment (ESWT) improves in vitro functional activities of ruptured human tendon-derived tenocytes

In vitro models of human tenocytes derived from healthy as well as from ruptured tendons were established, characterized and used at very early passage (P1) to evaluate the effects of Extracorporeal Shock Wave Treatment (ESWT). The molecular analysis of traditional tenocytic markers, including Scleraxis (Scx), Tenomodulin (Tnm), Tenascin-C (Tn-C) and Type I and III Collagens (Col I and Col III), permitted us to detect in our samples the simultaneous expression of all these genes and allowed us to compare their levels of expression in relationship to the source of the cells and treatments. In untreated conditions, higher molecular levels of Scx and Col I in tenocytes from pathological compared to healthy samples have been detected, suggesting – in the cells from injured tendon – the natural trigger of an early differentiation and repairing program, which depends by Scx and requires an increase in collagen expression. When ESWT (at the dose of 0.14 mJ/mm²) was applied to cultured tenocytes explanted from injured source, Scx and Col I were significantly diminished compared to healthy counterpart, indicating that such natural trigger maybe delayed by the treatment, in order to promote cellular repair. Herein, we show for the first time that ESWT enhances in vitro functional activities of ruptured tendon-derived tenocytes, such as proliferation and migration, which could probably contributes to tendon healing in vivo.

Long-Term Results of Rehabilitative Management with Extracorporeal Shockwave Therapy in Rotator Cuff Disease with Partial Tears

The purpose of this study is to evaluate the effects of rehabilitative approach using MJS and dynamic antigravity postural system (SPAD) with extracorporeal Shockwave therapy (ESWT) on rotator cuff syndrome associated tendon supraspinatus and infraspinatus medium tear (1–3 cm) of the tendons. In the last few years, ESWT has been proposed as an elective treatment in somatic diseases with encouraging short-term results. For this study the authors enrolled 108 patients who underwent 3 treatments with ESWT associated with 24 rehabilitation sessions over 3 weeks. Outcome measures were the VAS for pain and the Constant Murley Scale. The outcomes were measured pre-training, post-training and at 2, 4, 6 month follow-ups. Additional follow-up evaluation sessions were performed every year for 5 years by a telephone interview to evaluate changes in pain and function and the efficacy of treatment. Our study shows that the therapeutic efficacy of rehabilitative approach with ESWT in the rotator cuff syndrome with medium tears persists over time and significantly improves the patient's quality of life. The results obtained are certainly to be attributed to the biological mechanisms that ESWT are able to engage in tissues of the rotator cuff. The results seen at the conclusion of the treatment were maintained over the following years, thanks to the use of MJS and SPAD. In our opinion a conservative treatment with extracorporeal shock-wave (ESW), dynamic antigravity postural system (SPAD) and multi joint system (MJS) should be considered as an alternative and effective treatment for rotator cuff syndromes with medium tears.

Extracorporeal shock wave treatment improves incisional wound healing in diabetic rats

Impaired wound healing in surgical patients with diabetes increases the incidence of infection, prolongs hospitalization, and even increases the rate of mortality. Low-energy extracorporeal shock wave treatment (ESWT) was reported to accelerate chronic wound healing by promoting revascularization and tissue regeneration; however, it is not known if ESWT could also improve healing of acute surgical incisional wounds in diabetes. In this study, using a rat model of diabetes, we investigated the effect of low-energy ESWT on collagen content in wound tissues and its efficacy in incisional wound healing. A single dorsal incisional wound was inflicted in streptozotocin-induced diabetic rats, and they received ESWT at different time post-wounding. Rats were sacrificed on days 7 and 14 post-wounding. Wound breaking strength, hydroxyproline content, histological characteristics and the expression of transforming growth factor beta 1 (TGF-β1) were analyzed. As a result, the wound breaking strength was significantly enhanced and the hydroxyproline content in wound tissues was increased at each time point examined. The number of fibroblasts was signicantly increased, and the new collagen fibers were more abundant at the wound site after ESWT. Furthermore, the expression of TGF-β1 was up-regulated after ESWT on day 7 post-wounding. These results suggest that low-energy ESWT can increase collagen content, enhance wound breaking strength and improve the healing of incisional wound in diabetic rats. The increased collagen content may be attributed, at least in part, to the up-regulation of TGF-β1 expression in wound tissues.

The biological effects of extracorporeal shock wave therapy (eswt) on tendon tissue

There is currently great interest in the use of Extracorporeal Shock Wave Therapy (ESWT) and in clarifying the mechanisms of action in tendon pathologies. The success rate ranges from 60% to 80% in epicondylitis, plantar fasciitis, cuff tendinitis, trocanteritis, Achilles tendinitis or jumper's knee. In contrast to urological treatments (lithotripsy), where shockwaves are used to disintegrate renal stones, in musculoskeletal treatments (orthotripsy), shockwaves are not being used to disintegrate tissues, but rather to microscopically cause interstitial and extracellular biological responses and tissue regeneration. The researchers are interesting to investigate the biological effects which support the clinical successes. Some authors speculated that shockwaves relieve pain in insertional tendinopathy by hyper-stimulation analgesia. Many recent studies demonstrated the modulations of shockwave treatment including neovascularization, differentiation of mesenchymal stem cells and local release of angiogenetic factors. The experimental findings confirm that ESWT decrease the expression of high levels of inflammatory mediators (matrix metalloproteinases and inter-leukins). Therefore, ESWT produces a regenerative and tissue-repairing effect in musculoskeletal tissues, not merely a mechanical disintegrative effect as generally before assumed. Based on the encouraging results of clinical and experimental studies, the potential of ESWT appears to be emerging. The promising outcome after this non-invasive treatment option in tendinitis care justifies the indication of shockwave therapy. Further studies have to be performed in order or determine optimum treatment parameters and will bring about an improvement in accordance with evidence-based medicine. Finally, meta-analysis studies are necessary to demonstrate the efficacy and safety of ESWT in treating tendinopathies.

Extracorporeal shock wave therapy promotes cell proliferation and collagen synthesis of primary cultured human tenocytes

PURPOSE

The aim of this study was to investigate whether the effects of extracorporeal shock wave therapy (ESWT) could affect the behavior of primary cultured human tenocytes over a 12-day period.

METHODS

In this controlled laboratory study, primary human tenocytes were established from semitendinosus tendons collected from 3 patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. Cell viability, overall cell morphology, cell proliferation, and collagen synthesis following ESWT have been evaluated.

RESULTS

ESWT significantly interferes with the overall cell morphology, by impairing dedifferentiation of the cells. Furthermore, a shock wave-mediated growth-promoting effect was measured by the MTT (tetrazolium) colorimetric assay and by the proliferation marker Ki67. Lastly, a significant increase in collagen (mainly type I) synthesis by ESWT-tenocytes compared with control cells was found.

CONCLUSIONS

Shock wave treatment promoted cell growth and collagen synthesis of primary cultured human tenocytes. The clinical benefits of ESWT may be ascribed to an increased efficiency of tendon repair after injury.

Biological effects of extracorporeal shock waves on fibroblasts. A review

Tissue homeostasis is influenced by mechanical forces which regulate the normal function of connective tissues. Mechanotransduction, the process that transforms mechanical stimuli in chemical signals, involves mechanosensory units integrated in cell membrane. The mechanosensory units are able to activate gene expression for growth factors or cytochines as well as to induce a biological event which results in cell proliferation and/or differentiation. In connective tissue the fibroblasts are the cells more represented and are considered as a model of mechanosensitive cells. They are ubiquitous but specific for each type of tissue. Their heterogeneity consists in different morphological features and activity; the common function is the mechanosensitivity, the capacity to adhere to extracellular matrix (ECM) and to each other, the secretion of growth factors and ECM components. Extracorporeal shock waves (ESW) have been recently used to treat damaged osteotendineous tissues. Studies in vitro and in vivo confirmed that ESW treatment enhances fibroblast proliferation and differentiation by activation of gene expression for transforming growth factor β1 (TGF- β1) and Collagen Types I and III. In addition, an increase of nitric oxide (NO) release is even reported in early stage of the treatment and the subsequent activation of endothelial nitric oxide synthase (eNOS) and of vascular endothelial growth factor (VEGF) are related to TGF- β1 rise. The data have been related to the increase of angiogenesis observed in ESW treated tendons, an additional factor in accelerating the repairing process. A suitable treatment condition, characterized by a proper energy/shot number ratio, is the basis of treatment efficacy. Further ESWT applications are suggested in regenerative medicine, in all cases where fibroblast activity and the interaction with connective tissue can be positively influenced.

Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-year results of a single-blind randomized controlled trial

BACKGROUND

Evidence from a recent randomized controlled trial indicated that supervised exercises (SE) were more effective than radial extracorporeal shock-wave therapy (rESWT) for the treatment of subacromial shoulder pain in the short to medium term. Little knowledge exists about the long-term results of rESWT for subacromial pain.

OBJECTIVE

The aim of this study was to evaluate the results of rESWT and SE provided to patients with subacromial shoulder pain after 1 year.

DESIGN

This was a single-blind randomized controlled trial.

SETTING

The study was conducted in the outpatient clinic of the Physical Medicine and Rehabilitation Department at Oslo University Hospital, Ullevaal, Norway.

PATIENTS

One hundred four patients with subacromial shoulder pain lasting at least 3 months participated. Patients were randomly assigned to either an rESWT group (n=52) or an SE group (n=52).

INTERVENTION

The rESWT intervention consisted of one session weekly for 4 to 6 weeks. The SE intervention consisted of two 45-minute sessions per week for up to 12 weeks.

MEASUREMENTS

The primary outcome measure was the Shoulder Pain and Disability Index. Secondary outcome measures were questions regarding pain and function and work status.

RESULTS

After 1 year, an intention-to-treat analysis showed no significant differences between the 2 groups for the primary outcome measure (-7.6 points, 95% confidence interval=-16.6 to 0.5) and pain, function, and medication use. Twenty-nine participants (60%) in the SE group versus 24 participants (52%) in the rESWT group were categorized as clinically improved. Thirty-eight participants in the SE group were at work compared with 30 participants in the rESWT group (odds ratio=1.1, 95% confidence interval=1.0 to 1.2). Fewer patients in the SE group had received additional treatments between 18 weeks and 1 year.

LIMITATIONS

The lack of a placebo control group, the lack of a cost-benefit analysis, and the small sample size were limitations of the study.

CONCLUSION

No significant difference was found between the SE and rESWT groups at the 1-year follow-up. More participants in the SE group had returned to work.

Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy

BACKGROUND

Whether plantar fascia-specific stretching or shock-wave therapy is effective as an initial treatment for proximal plantar fasciopathy remains unclear. The aim of this study was to test the null hypothesis of no difference in the effectiveness of these two forms of treatment for patients who had unilateral plantar fasciopathy for a maximum duration of six weeks and which had not been treated previously.

METHODS

One hundred and two patients with acute plantar fasciopathy were randomly assigned to perform an eight-week plantar fascia-specific stretching program (Group I, n = 54) or to receive repetitive low-energy radial shock-wave therapy without local anesthesia, administered weekly for three weeks (Group II, n = 48). All patients completed the seven-item pain subscale of the validated Foot Function Index and a patient-relevant outcome questionnaire. Patients were evaluated at baseline and at two, four, and fifteen months after baseline. The primary outcome measures were a mean change in the Foot Function Index sum score at two months after baseline, a mean change in item 2 (pain during the first few steps of walking in the morning) on this index, and satisfaction with treatment.

RESULTS

No difference in mean age, sex, weight, or duration of symptoms was found between the groups at baseline. At two months after baseline, the Foot Function Index sum score showed significantly greater changes for the patients managed with plantar fascia-specific stretching than for those managed with shock-wave therapy (p < 0.001), as well as individually for item 2 (p = 0.002). Thirty-five patients (65%) in Group I versus fourteen patients (29%) in Group II were satisfied with the treatment (p < 0.001). These findings persisted at four months. At fifteen months after baseline, no significant between-group difference was measured.

CONCLUSIONS

A program of manual stretching exercises specific to the plantar fascia is superior to repetitive low-energy radial shock-wave therapy for the treatment of acute symptoms of proximal plantar fasciopathy.