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Liao PC, Chou SH, Shih CL. A systematic review of the use of shockwave therapy for knee osteoarthritis. J Orthop 2024; 56:18-25. [PMID: 38765896 PMCID: PMC11096685 DOI: 10.1016/j.jor.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Previous studies assessed the effect of extracorporeal shockwave therapy (ESWT) for knee osteoarthritis (OA) among different situations. Thus, results from a meta-analysis regarding this topic may not be reliable due to heterogeneity. Methods A systematic review was conducted on three internet databases, namely Cochrane Library, PubMed, and Embase, gathering pertinent papers from their establishment to March 2024. The search phrases were as follows: "shockwave" OR "shock wave" OR "extracorporeal shockwave" OR "Extracorporeal Shockwave Therapy [MeSH Term]" AND "knee" AND ("osteoarthritis" OR "arthritis" OR "arthritic" OR "osteoarthritis [MeSH term]"). Results Twenty-four articles (n = 888) were included, with the resulting conclusions demonstrating that ESWT was effective for knee OA compared with sham ESWT; however, ESWT was not effective for patients with severe knee OA. Patients receiving higher energy or higher shock number had significant improvement than those receiving lower energy or less shock number, respectively. Adding ESWT in isokinetic muscular strengthening exercises (IMSE) was more effective than IMSE alone. The efficacy of ESWT was better than other therapies, including intravenously applied prostacyclin and bisphosphonate, corticosteroid injection, kinesiotherapy, hyaluronic acid injection, platelet-rich plasma injection, and physiotherapy. Conclusions This review demonstrated that ESWT was effective for knee OA. Higher energy and more shock numbers could obtain better efficacy. ESWT could be used as a replacement for some other therapies.
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Affiliation(s)
- Po-Cheng Liao
- Surgical Intensive Care Unit, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, 600, Taiwan
| | - Shih-Hsiang Chou
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
| | - Chia-Lung Shih
- Clinical Research Center, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, 600, Taiwan
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Giaretta S, Magni A, Migliore A, Natoli S, Puntillo F, Ronconi G, Santoiemma L, Sconza C, Viapiana O, Zanoli G. A Review of Current Approaches to Pain Management in Knee Osteoarthritis with a Focus on Italian Clinical Landscape. J Clin Med 2024; 13:5176. [PMID: 39274389 PMCID: PMC11396710 DOI: 10.3390/jcm13175176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/24/2024] [Accepted: 08/11/2024] [Indexed: 09/16/2024] Open
Abstract
The global cases of knee osteoarthritis (KOA) are projected to increase by 74.9% by 2050. Currently, over half of patients remain dissatisfied with their pain relief. This review addresses unmet needs for moderate-to-severe KOA pain; it offers evidence and insights for improved management. Italian experts from the fields of rheumatology, physical medicine and rehabilitation, orthopedics, primary care, and pain therapy have identified several key issues. They emphasized the need for standardized care protocols to address inconsistencies in patient management across different specialties. Early diagnosis is crucial, as cartilage responds better to early protective and structural therapies. Faster access to physiatrist evaluation and reimbursement for physical, rehabilitative, and pharmacological treatments, including intra-articular (IA) therapy, could reduce access disparities. Concerns surround the adverse effects of oral pharmacological treatments, highlighting the need for safer alternatives. Patient satisfaction with corticosteroids and hyaluronic acid-based IA therapies reduces over time and there is no consensus on the optimal IA therapy protocol. Surgery should be reserved for severe symptoms and radiographic KOA evidence, as chronic pain post-surgery poses significant societal and economic burdens. The experts advocate for a multidisciplinary approach, promoting interaction and collaboration between specialists and general practitioners, to enhance KOA care and treatment consistency in Italy.
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Affiliation(s)
- Stefano Giaretta
- UOC Ortopedia e Traumatologia OC San Bortolo di Vicenza (AULSS 8 Berica), 36100 Vicenza, Italy
| | - Alberto Magni
- Local Health Department, Desenzano sul Garda, 25015 Brescia, Italy
| | - Alberto Migliore
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
| | - Silvia Natoli
- Department of Clinical-Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Pain Unit, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Filomena Puntillo
- Anaesthesia, Intensive Care and Pain Unit, Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Gianpaolo Ronconi
- Department of Rehabilitation, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | | | | | - Ombretta Viapiana
- Rheumatology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, University of Verona, 37126 Verona, Italy
| | - Gustavo Zanoli
- Orthopaedic Ward, Casa di Cura Santa Maria Maddalena, Occhiobello, 45030 Rovigo, Italy
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Cp A, Jayaraman K, Babkair RA, Nuhmani S, Nawed A, Khan M, Alghadir AH. Effectiveness of extracorporeal shock wave therapy on functional ability in grade IV knee osteoarthritis - a randomized controlled trial. Sci Rep 2024; 14:16530. [PMID: 39020015 PMCID: PMC11254909 DOI: 10.1038/s41598-024-67511-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 07/11/2024] [Indexed: 07/19/2024] Open
Abstract
Extracorporeal shockwave therapy (ESWT) is a non-invasive physical therapy intervention that has emerged in the recent past to address the upswing of osteoarthritis (OA). However, insufficient evidence is present to prove the efficacy of ESWT on grade IV knee osteoarthritis (KOA). The present study aimed to examine the effects of ESWT on functional ability in patients suffering from grade IV KOA. Thirty volunteers aged 45-60 years with grade IV primary KOA diagnosed by an orthopaedic surgeon based on the Kellgren-Lawrence score participated in the study. The participants were equally and randomly divided into two groups (i.e. experimental and control), with 15 participants in each group. The participants in the control group performed conventional physiotherapy (CPT) that included ultrasound therapy, isometric quadriceps, SLR and isometric hip adductor strengthening exercises. The participants in the experimental group received ESWT in addition to CPT. Lower extremity functional scale (LEFS) score was measured before and after the four weeks of intervention. In both groups, a statistically significant (p = 0.001) improvement in LEFS was observed. In the experimental groups, it improved by 81.92% and in the control groups by 48.15%. A statistically significant (p < 0.001) difference was observed in LEFS post-intervention values between both groups. As demonstrated by our trial results, the addition of ESWT to the CPT program will yield beneficial results in ameliorating the functional disability in patients with primary KOA (grade IV). Further studies are needed to confirm and apply these findings to a larger cohort.
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Affiliation(s)
- Arshed Cp
- Department of Physiotherapy, AWH Special College, Kozhikode, Affiliated to Kerala University of Health Sciences, Kozhikode, India
| | - Kavitha Jayaraman
- Department of Physiotherapy, AWH Special College, Kozhikode, Affiliated to Kerala University of Health Sciences, Kozhikode, India
| | | | - Shibili Nuhmani
- Department of Physical Therapy, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alvina Nawed
- Department of Rehabilitation Science, Jamia Hamdard, New Delhi, India
| | - Masood Khan
- Rehabilitation Research Chair, Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.
| | - Ahmad H Alghadir
- Rehabilitation Research Chair, Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
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Yang F, Guo J, Kang N, Yu X, Ma Y. rESWT promoted angiogenesis via Bach1/Wnt/β-catenin signaling pathway. Sci Rep 2024; 14:11733. [PMID: 38777838 PMCID: PMC11111732 DOI: 10.1038/s41598-024-62582-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 05/20/2024] [Indexed: 05/25/2024] Open
Abstract
Previous reports have established that rESWT fosters angiogenesis, yet the mechanism by which rESWT promotes cerebral angiogenesis remains elusive. rESWT stimulated HUVECs proliferation as evidenced by the CCK-8 test, with an optimal dosage of 2.0 Bar, 200 impulses, and 2 Hz. The tube formation assay of HUVECs revealed that tube formation peaked at 36 h post-rESWT treatment, concurrent with the lowest expression level of Bach1, as detected by both Western blot and immunofluorescence. The expression level of Wnt3a, β-catenin, and VEGF also peaked at 36 h. A Bach1 overexpression plasmid was transfected into HUVECs, resulting in a decreased expression level of Wnt3a, β-catenin, and VEGF. Upon treatment with rESWT, the down-regulation of Wnt3a, β-catenin, and VEGF expression in the transfected cells was reversed. The Wnt/β-catenin inhibitor DKK-1 was utilized to suppress Wnt3a and β-catenin expression, which led to a concurrent decrease in VEGF expression. However, rESWT treatment could restore the expression of these three proteins, even in the presence of DKK-1. Moreover, in the established OGD model, it was observed that rESWT could inhibit the overexpression of Bach1 and enhance VEGF and VEGFR-2 expression under the OGD environment.
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Affiliation(s)
- Fan Yang
- Department of Rehabilitation Medicine, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Juan Guo
- Department of Rehabilitation Medicine, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China
| | - Nan Kang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China
| | - Xiaotong Yu
- Institute of Meta-Synthesis Medicine, Beijing, 100097, China
| | - Yuewen Ma
- Department of Rehabilitation Medicine, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China.
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Somaiya KJ, Samal S, Boob MA. Physiotherapeutic Intervention Techniques for Knee Osteoarthritis: A Systematic Review. Cureus 2024; 16:e56817. [PMID: 38654798 PMCID: PMC11037114 DOI: 10.7759/cureus.56817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/24/2024] [Indexed: 04/26/2024] Open
Abstract
Globally, knee osteoarthritis (KOA) is the leading cause of disability. The most prevalent complaints associated with KOA are knee pain, joint stiffness, and weakness in the muscles of the lower limbs. These symptoms impede movement and result in functional limitations. As a result, people with KOA have a lower quality of life. For all patient groups with knee OA, an effective rehabilitation program focuses on improving knee range of motion, isometric quadriceps strength, and productivity level while reducing discomfort. The American College of Rheumatology (ACR) categorization criteria for KOA, research on KOA physiotherapy, and reviews covering various physical therapy interventions, including exercise, physical modalities, and patient education, were used to narrow down the pool of 180 systematic reviews to 15 articles. Google Scholar, PubMed, the Cochrane Library, and EMBASE were the databases that were used. The following keyword combinations were included in our search: KOA and physiotherapy or interventions or exercises, strengthening and stretching, concentric and eccentric training. Through our analysis, we identified a few methods that, in addition to standard therapy, could be used in clinical settings for people with osteoarthritis in the knee. It has been shown that Mulligan, Pilates, Kinesiotaping, Aquatic Therapy, and other current therapies are effective. The study employed a broad range of results. This review concludes that rather than relying solely on conventional therapy, it is preferable to combine a number of the most current physiotherapy techniques with it.
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Affiliation(s)
- Kamya J Somaiya
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Subrat Samal
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Manali A Boob
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Wu L, Zhang X, Yi C, Ren H. CD146-positive adipose-derived stem cells subpopulation enriched by albumin magnetic sphere ameliorates knee osteoarthritis pain and promotes cartilage repair. J Orthop Surg Res 2023; 18:969. [PMID: 38102700 PMCID: PMC10724978 DOI: 10.1186/s13018-023-04434-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND The use of adipose stem cell (ADSCs) subpopulations in cartilage repair remains poorly characterized. In this study, we constructed an albumin magnetic sphere with specific targeting of CD146 (CD146-AMs) for sorting a subpopulation of CD146-positive ADSCs (CD146 + ADSCs) and explored the role of CD146 + ADSCs on joint pain and cartilage repair in rats with knee osteoarthritis (KOA). METHODS CD146-AMs were prepared and analyzed in materialistic characterization tests. Subpopulations of CD146 + ADSCs were sorted using CD146-AMs. Surface labeling, viability, and proliferation of a subpopulation of CD146 + ADSCs were evaluated in vitro. Molecular characterization of mRNA and protein expression profiles was analyzed by microarray. A rat KOA pain model was established by the iodoacetic acid method, and KOA pain and the promotion of cartilage repair were assessed after treatment with bilateral joint cavity injections of CD146 + ADSCs. RESULTS The CD146-AMs prepared in this study had an average particle size of 242.63 ± 6.74 nm, an average potential of 33.82 ± 3.53 mv, and high CD146 targeting and low cytotoxicity. The positive rate of enriched CD146 + ADSCs was 98.21% and showed a high level of stem cell marker expression and good cell viability. Gene and protein expression profiles showed that CD146 + ADSCs have different cellular functions, especially in regulating inflammation. In the KOA model, low, medium and high concentrations of CD146 + ADSCs were able to improve KOA pain and promote cartilage repair in a concentration-dependent trend. CONCLUSIONS The CD146-AMs prepared in this study were able to safely and efficiently sort out the CD146 + ADSCs subpopulation. The subpopulation of CD146 + ADSCs has a unique molecular profile that ameliorates KOA pain and repairs cartilage damage in rats, providing a new idea for KOA treatment.
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Affiliation(s)
- Lianghao Wu
- Department of Orthopedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, Shanghai, 201399, China
| | - Xu Zhang
- Department of Orthopedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, Shanghai, 201399, China
| | - Chengqing Yi
- Department of Orthopedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, Shanghai, 201399, China.
| | - Hanru Ren
- Department of Orthopedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, Shanghai, 201399, China.
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Wang H, Shi Y. Extracorporeal shock wave treatment for post‑surgical fracture nonunion: Insight into its mechanism, efficacy, safety and prognostic factors (Review). Exp Ther Med 2023; 26:332. [PMID: 37346403 PMCID: PMC10280326 DOI: 10.3892/etm.2023.12031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/21/2023] [Indexed: 06/23/2023] Open
Abstract
Post-surgical fracture nonunion (PSFN) represents the failure to achieve cortical continuity at radiological examination after an orthopedic operation, which causes a considerable disease burden in patients with fractures. As one of the traditional treatment modalities, surgical therapy is associated with a high fracture union rate; however, post-surgical complications are not negligible. Therefore, less invasive therapies are needed to improve the prognosis of patients with PSFN. Extracorporeal shock wave treatment (ESWT) is a noninvasive method that presents a similar efficacy profile and favorable safety profile compared with surgical treatment. However, the application and detailed mechanism of ESWT in patients with PSFN remain unclear. The present review focuses on the mechanism, efficacy, safety and prognostic factors of ESWT in patients with PSFN, aiming to provide a theoretical basis for its application and improve the prognosis of these patients.
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Affiliation(s)
- Haoyu Wang
- Department of Orthopaedics, Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Yaxuan Shi
- Department of Internal Medicine (Bone Oncology), Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
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Liu K, Zhang Q, Chen L, Zhang H, Xu X, Yuan Z, Dong J. Efficacy and safety of extracorporeal shockwave therapy in chronic low back pain: a systematic review and meta-analysis of 632 patients. J Orthop Surg Res 2023; 18:455. [PMID: 37355623 DOI: 10.1186/s13018-023-03943-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/19/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Extracorporeal shock wave therapy (ESWT) has been widely used for pain control in musculoskeletal disorders. Whether ESWT can relieve chronic low back pain (CLBP) and improve lumbar function is still unclear. Therefore, we conducted a meta-analysis of relevant studies to comprehensively analyse and determine the efficacy and safety of ESWT for chronic low back pain. METHODS Four databases were systematically searched for randomized controlled trials (RCTs) on ESWT for CLBP. The quality of the included studies was evaluated according to Cochrane systematic review criteria, relevant data were extracted, and meta-analysis was performed using RevMan 5.4 software. The primary outcomes were pain intensity, disability status, and mental health. The data were expressed as standardized mean differences (SMD) or weighted mean difference (WMD) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 statistic. If I2 ≥ 50%, a random effects model was applied; otherwise, a fixed effects model was used. RESULTS Twelve RCTs involving 632 patients were included in this meta-analysis. The ESWT group reported significantly more pain relief than the control group at 4 weeks (WMD = - 1.04; 95% CI = - 1.44 to - 0.65; P < 0.001) and 12 weeks (WMD = - 0.85; 95% CI = - 1.30 to - 0.41; P < 0.001). Regarding the dysfunction index, ESWT led to significant improvement in lumbar dysfunction compared with the control group at 4 weeks (WMD = - 4.22; 95% CI = - 7.55 to - 0.89; P < 0.001) and 12 weeks (WMD = - 4.51; 95% CI = - 8.58 to - 0.44; P = 0.03). For mental health, there was no significant difference between the ESWT group and the control group after 4 weeks of intervention (SMD = 1.17; 95% CI = - 0.10 to 2.45; P = 0.07). CONCLUSION This systematic review and meta-analysis found that ESWT provided better pain relief and improved lumbar dysfunction compared with the other interventions included, and no serious adverse effects were found. There was no significant effect of ESWT on the mental health of patients, but we hope to obtain more RCTs for further analysis in the future. Based on the pooled results, we suggest that ESWT is effective and safe for treating chronic low back pain.
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Affiliation(s)
- Kun Liu
- Shandong Sport University, No.10600, Road Century, Jinan, 250102, Shandong, China
| | - Qingyu Zhang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Lili Chen
- Shandong Sport University, No.10600, Road Century, Jinan, 250102, Shandong, China
| | - Haoran Zhang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Xiqiang Xu
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Zenong Yuan
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Jun Dong
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China.
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Şah V. The Short-Term Efficacy of Large-Focused and Controlled-Unfocused (Radial) Extracorporeal Shock Wave Therapies in the Treatment of Hip Osteoarthritis. J Pers Med 2022; 13:jpm13010048. [PMID: 36675709 PMCID: PMC9865373 DOI: 10.3390/jpm13010048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
Although the classical treatments listed in the guidelines for osteoarthritis are widely used, the majority of patients do not fully recover from their pain. It is a fact that new treatment methods are needed both to relieve pain and restore deteriorated joint function. No study has been found to date that evaluated the efficacy of ESWT in hip OA. This pilot trial is the first in the literature to investigate the comparative effects of the two ESWT types (f-ESWT and r-ESWT) in the treatment of hip OA. Briefly, 148 patients were randomly distributed into the three ESWT groups: focused (f-ESWT), radial (r-ESWT), and sham (s-ESWT). Patients were assessed with the Visual Analog Scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores just before the treatment (0 week), just after the treatment (4th week), and 1 month after completion of the treatment (8th week). VAS and all WOMAC scores were significantly reduced at follow-up points (4th and 8th weeks) in both the f-ESWT and r-ESWT groups compared with baseline (0 week) (for all, p < 0.001). Statistical comparisons between the f-ESWT and r-ESWT groups showed that f-ESWT was superior to r-ESWT for the decrease in VAS and WOMAC scores from baseline to the 4th and 8th weeks (p < 0.001 or p < 0.002). Both r-ESWT and f-ESWT were found to have significant treatment efficacy compared with s-ESWT. However, f-ESWT produced a superior improvement in follow-up parameters compared to r-ESWT.
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Affiliation(s)
- Volkan Şah
- Department of Sports Medicine, University of Yüzüncü Yıl, Van 65040, Turkey
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