Defocused and Radial Shock Wave Therapy, Mesotherapy, and Kinesio Taping Effects in Patients with Lipedema: A Pilot Study

The aim of this pilot study was to investigate the effects of defocused and radial shock wave therapy, mesotherapy, and kinesio taping on pain, circumferences of lower limbs, echographic/ elastosonographic pattern of subcutaneous adipose tissue (SAT), and quality of life in patients with lipedema. Fifteen women affected by lower limb lipedema in stage II were treated with shock wave therapy, mesotherapy, and kinesio taping on thighs and legs (eight sessions, twice a week). The primary outcome was pain, as assessed by Numeric Rating Scale (NRS). Secondary outcomes included the limb circumferences measurements, the SF-12 Health Survey for quality of life, the International Classification of Functioning (ICF) for disability, and echographic/ elastosonographic changes of SAT. Significant reductions of pain and circumference measurements were seen in patients at each follow up. This was associated with significant reduction of thickness, echographic pattern improvement, and increased elasticity of SAT, with consequent positive impact on the quality of life and disability reported by the patients. The results demonstrate improved clinical and functional ultrasound findings in patients affected by lipedema in the early stages of lower limbs, and this combination therapy needs to be investigated in larger populations at multiple centers to confirm the findings.

Can platelet-rich plasma have a role in Achilles tendon surgical repair?

PURPOSE

Our hypothesis was that the Achilles tendon healing process after surgical treatment would be promoted by PRP with a faster return to sports activities.

METHODS

Thirty patients with Achilles tendon rupture and surgically treated with a combined mini-open and percutaneous technique were prospectively enroled in the study. Patients were alternately case-by-case assigned to Group A (control group; 15 patients) or Group B (study group; 15 patients). In Group B, PRP was locally infiltrated both during surgery and 14 days after surgery. Patients in both groups were followed up at 1, 3, 6 and 24 months post-operatively via physical examination, VAS, FAOS and VISA-A scales; ultrasonography (US) and MRI were also conducted at one and 6 months; at the 6-month follow-up, isokinetic and jumping capacity tests were also performed.

RESULTS

The VAS, FAOS and VISA-A scale showed no difference between the two groups at 1, 3, 6 and 24 months post-operatively. Isokinetic evaluation showed no differences at both angular speeds. Jumping evaluation showed no difference at 6 months. Also US evaluation showed no differences. MRI data analysis before administration of gadolinium did not reveal significant differences between the two groups. Moreover, after intravenous injection of gadolinium, patients in Group B showed signal enhancement in 30 % of patients compared to 80 % in Group A at 6 months, as indirect evidence of better tendon remodelling (P < 0.05).

CONCLUSIONS

A substantial equivalence in structural and functional results in Achilles tendon ruptures surgically treated with and without addition of PRP is shown by present study. Clinical results, morphological features and jumping capability were similar in both groups. The addition of PRP to the surgical treatment of Achilles tendon rupture does not appear to offer superior clinical and functional results.

LEVEL OF EVIDENCE

IV.

Extracorporeal shockwaves as regenerative therapy in orthopedic traumatology: a narrative review from basic research to clinical practice

Extracorporeal Shock Wave Therapy (ESWT), after its first medical application in the urological field for lithotripsy, nowadays represents a valid therapeutical tool also for many musculoskeletal diseases, as well as for regenerative medicine applications. This is possible thanks to its mechanisms of action, which in the non-urological field are not related to mechanical disruption (as for renal stones), but rather to the capacity, by mechanotransduction, to induce neoangiogenesis, osteogenesis and to improve local tissue trophism, regeneration and remodeling, through stem cell stimulation. On the basis of these biological assumptions, it becomes clear that ESWT can represent a valid therapeutic tool also for all those pathological conditions that derive from musculoskeletal trauma, and are characterized by tissue loss and/or delayed healing and regeneration (mainly bone and skin, but not only). As a safe, repeatable and non–invasive therapy, in many cases it can represent a first–line therapeutic option, as an alternative to surgery (for example, in bone and skin healing disorders), or in combination with some other treatment options. It is hoped that with its use in daily practice also the muscle–skeletal field will grow, not only for standard indications, but also in post–traumatic sequelae, in order to improve recovery and shorten healing time, with undoubted advantages for the patients and lower health service expenses.

Cross-cultural adaptation and reliability of the Italian version of the Foot Function Index (FFI-I) for patients with plantar fasciitis

AIM

The aim of this paper was to translate and cross-culturally adapt the FFI to the Italian language, and to assess the reliability of the Italian version of the FFI (FFI-I) for plantar fasciitis.

METHODS

Fifty symptomatic patients affected by plantar fasciitis completed the FFI-I scale twice, at interval of one week. The translation of the FFI was performed according to international standards for translation of questionnaires. Test-retest reliability was evaluated using intraclass correlation coefficient (ICC). Internal consistency was measured by Cronbach α coefficient. Ceiling and floor effects were assessed.

RESULTS

The process resulted in an intelligible version of the questionnaire. The reliability of the FFI-I was adequate, with an ICC ranging from 0.86 to 0.98 for test-retest reliability. The FFI-I showed an excellent internal consistency, ranging from 0.93 to 0.99 for all subscales. Three items involving disability and four items involving activities restrictions had highest proportion of floor score.

CONCLUSION

The FFI-I is a reliable and valid instrument to assess clinical severity in patients with plantar fasciitis and it is suitable for daily practice. We suggest evaluating the total FFI-I score along with the distinct scores of the three subscales of the FFI-I in order to interpret more correctly minor changes in patient status during repetitive outcome assessments.

Neurocognitive therapeutic exercise improves pain and function in patients with shoulder impingement syndrome: a single-blind randomized controlled clinical trial

BACKGROUND

Traditional rehabilitation improves pain and function in patients with shoulder impingement syndrome. Neurocognitive rehabilitation has shown to be highly effective after surgical reconstruction of the anterior cruciate ligament. However, its effects in patients with shoulder impingement syndrome have not yet been established.

AIM

The aim of the study was to compare the effects of neurocognitive therapeutic exercise, based on proprioception and neuromuscular control, on pain and function in comparison to traditional therapeutic exercise in patients with shoulder impingement syndrome.

DESIGN

Single-blind randomized, non-inferiority clinical trial.

SETTING

Outpatient clinic of Geriatrics and Physiatrics, University Hospital.

POPULATION

Forty-eight patients with shoulder impingement syndrome (Neer stage I) and pain lasting for at least three months.

METHODS

Participants were randomly allocated (1:1) to either neurocognitive therapeutic exercise or traditional therapeutic exercise. Both treatments were provided one-hour session, three times a week for five weeks. The primary outcome measure was the short form of the Disability of the Arm, Shoulder and Hand Questionnaire (Quick-DASH questionnaire) for the assessment of physical ability and symptoms of the upper extremity.

SECONDARY OUTCOME MEASURES

Constant-Murley shoulder outcome score for the determination of range of motion, pain and strength; American Shoulder and Elbow Surgeons Society standardized shoulder assessment form for the evaluation of physical ability in daily-living tasks; a visual analogue scale for pain assessment at rest and during movements; Likert score for the estimation of participant satisfaction.

ENDPOINTS

before treatment, end of treatment, 12 and 24 weeks after the completion of each intervention for all outcome measures, except for the Likert score that was evaluated only at the end of treatment.

FOLLOW-UP

24 weeks.

RESULTS

At the end of treatment and at follow-up, both treatment groups experienced improvements in all outcomes measures relative to baseline values, except for the visual analogue scale at rest that was unaffected by traditional therapeutic exercise. For all outcome measures, changes over time were greater in the neurocognitive therapeutic exercise group relative to the traditional therapeutic exercise group. The level of satisfaction with treatment was higher for participants in the neurocognitive therapeutic exercise group.

CONCLUSION

Neurocognitive rehabilitation is effective in reducing pain and improving function in patients with shoulder impingement syndrome, with benefits maintained for at least 24 weeks.

CLINICAL REHABILITATION IMPACT

skills and function of the shoulder can greatly benefit from neurocognitive rehabilitation.

Cryoultrasound therapy in the treatment of chronic plantar fasciitis with heel spurs. A randomized controlled clinical study

BACKGROUND

Plantar fasciitis is one of the most common causes of pain in the inferior heel and is very frequent in some running sports. It affects up to 10% of general population and accounts for 11% to 15% of all foot pain symptomatology. Several treatments have been suggested, but there is no evidence supporting a specific conservative management strategy.

AIM

Evaluation of the efficacy of combined cryoultrasound therapy on chronic plantar fasciitis with heel spurs resistant to pharmacological and instrumental therapies.

DESIGN

Single-blind randomized clinical trial.

POPULATION

102 consecutive patients affected by chronic plantar fasciitis with painful symptomatology for at least 6 months, intensity of pain higher than 5 on the VAS score, presence of heel spurs, use of plantar orthoses and ineffectiveness of previous therapies.

METHODS

The patients were randomized into two groups: Group A treated with cryoultrasound therapy and Group B with cryotherapy. Our protocol was based on 10 daily treatments, lasting 20 minutes. Each participant was evaluated using VAS score before (T0) the treatment and 3 months (T1), 12 months (T2) and 18 months (T3) after. Effectiveness index was calculated from T1 to T3.

RESULTS

Both treatments have been found effective. The difference in pain intensity on the VAS scale between the two groups at T2 was 4.35 points in favor of Group A (IC 95% 3.75; 4.95; P<0.001), reaching the primary end point. The difference in pain intensity on the VAS scale between the two groups at T1, T2 and T3 was 3.00, 4.35 and 4.81 respectively, showing a statistically significant difference between VAS average scores at all follow-ups in favor of Group A. Scores of at least 66% at the effectiveness index were only achieved in Group A (P values <0.001).

CONCLUSION

Cryoultrasound therapy could be an efficient treatment option for chronic plantar fasciitis.

CLINICAL REHABILITATION IMPACT

Cryoultrasound therapy promises an effective and long-lasting clinical improvement in patients with chronic plantar fasciitis, granted its high therapeutic efficiency, patients' satisfaction, its limited cost and its short and repeatable protocol of use.

Chronic pain and motor imagery: a rehabilitative experience in a case report

BACKGROUND

The "neuromatrix" theory of Melzack and the studies of Decety on motor imagery have opened the way to an alternative rehabilitation method in chronic pain.

AIM

To evaluate the role of motor imagery in chronic shoulder pain rehabilitation.

DESIGN

Case report.

SETTING

University outpatient rehabilitation.

POPULATION

A 49-year-old female with chronic shoulder pain.

METHODS

Neurocognitive approach, which involves the use of a new tool called "naval battle" to achieve chronic pain relief as assessed by the Visual Analogic Scale (VAS) and McGill Pain Questionnaire (MPQ). The Shoulder Rating Questionnaire (SRQ) and Constant Scale (CS) were used to measure functional improvement.

RESULTS

The results indicate significant pain relief (71%) and improvement in functionality (50%).

CONCLUSION

The results seem to confirm the accuracy of the hypothesis on the genesis of chronic pain as a perceptive "discoherency" and that motor imagery can remake a coherence of afferences at central level in chronic pain.

CLINICAL REHABILITATION IMPACT

The use of motor imagery in rehabilitation can be a viable alternative in chronic shoulder pain resistant to other rehabilitation protocols.

Perceptive rehabilitation of patients with non-specific chronic low back pain: the role of body midline. A randomized controlled trial

BACKGROUND

Surface for perceptive rehabilitation (Su-Per treatment) is a hopeful therapeutic system in the treatment of non-specific chronic low back pain (CLBP). During treatment, some patients poorly tolerate the presence of the less elastic cones at the back midline.

AIM

To assess the importance of an increased awareness of body midline through higher stimulus at interspinous line during Su-Per treatment for non-specific CLBP.

DESIGN

Single-blind, randomized, controlled trial.

SETTING

Outpatient academic hospital.

POPULATION

Forty patients with non-specific CLBP, for at least 12 weeks before treatment.

METHODS

The patients were distributed in 2 groups: Group A (20 patients) received standard Su-Per treatment; Group B (20 patients) received Su-Per treatment without higher stimulus at interspinous line. Pain was assessed using the Visual Analogue Scale and the Present Pain Intensity and Pain Rating Index of the McGill Pain Questionnaire. Disability was evaluated using the Oswestry Disability Index.

RESULTS

In both groups, a significant reduction of pain and disability scores was observed at the first follow-up (end of treatment), and was maintained at later evaluations (4-weeks, and 12-weeks follow up). No significant difference was observed between the two groups in all outcome measures at all time points (P>0.05 for all).

CONCLUSION

Su-Per treatment is a valid modality in a cognitive-perceptive therapeutic concept for non-specific CLBP. It does not necessarily require external stimulation of the body midline to be effective.

CLINICAL REHABILITATION IMPACT

Modifying the standard distribution of the cones, without less deformable cones along interspinous line, makes the Su-Per treatment more acceptable to patients.

Early rehabilitation reduces the onset of complications in the upper limb following breast cancer surgery

BACKGROUND

Breast cancer (BC) is currently the most frequent tumor in women. Through the years, BC management has evolved towards conservative surgery. However, even minimally invasive surgery can cause neuromotor and/or articular impairments which can lead to permanent damage, if not adequately treated.

AIM

To clinically evaluate upper ipsilateral limb function and the impact of certain post-surgical consequences arising after invasive or breast-conserving surgery for early BC, by intervening, or not intervening, with an early rehabilitation program. To investigate physical morbidity after sentinel (SLND) or axillary lymph node dissection (ALND) and after reconstructive surgery in the treatment of early BC.

DESIGN

Observational prospective trial.

SETTING

Inpatient and outpatient treatment.

POPULATION

Eighty-three females participated in the study: 25 patients did not begin physiotherapy during hospitalization (Group A), 58 patients received early rehabilitation treatment (Group B).

METHODS

The patients of Groups A and B were compared with respect to the following criteria: shoulder-arm mobility, upper limb function, and presence of lymphedema. All patients were assessed at 15-30, 60 and 180 days after surgery.

RESULTS

Statistically significant differences, in favor of Group B, were encountered at the 180-day follow-up visit, especially with respect to articular and functional limitation of the upper limb.

CONCLUSION AND CLINICAL REHABILITATION IMPACT

The results of the present study show that early assisted mobilization (beginning on the first postoperative day) and home rehabilitation, in conjunction with written information on precautionary hygienic measures to observe, play a crucial role in reducing the occurrence of postoperative side-effects of the upper limb.

Quality of life improved by multidisciplinary back school program in patıents with chronic non-specific low back pain: a single blind randomized controlled trial

STUDY DESIGN

A three and six months follow-up in a randomized controlled trial.

BACKGROUND

Back School has become a widespread exercise program for low back pain (LBP), since its introduction in 1969. Back School could improve quality of life (QoL), but there are controversial data regarding its effectiveness.

AIM

To evaluate the effects of the Back School program on quality of life (primary outcome), disability and pain perceptions (secondary outcomes) in patients with chronic and non-specific low back pain.

SETTING

Rehabilitative specialized centre.

POPULATION

Seventy four patients with chronic non-specific LBP.

METHODS

Patients were randomly placed in a 3:2 form and were allocated into 2 groups (treated-control). Treatment group participated in a intensive multidisciplinary Back School program including brief education and active back exercises (BSG, N.=41), while the control group received medical assistance (CG, N.=29). Medication was the same in both groups. The Short Form 36 Health Status Survey, Waddel Index, Oswestry Disability Index and Visual Analogue Scale were collected at baseline, at the end of treatment, and at the three and six month follow-up.

RESULTS

Quality of life significantly improved along time more in BSG, both in Physical and Mental Composite Score (repeated measure Anova: interaction time per group: P<0.001 and P=0.002, respectively). We also observed a significant improvement in disability scores along time (P<0.001) in BSG with significant differences between groups at three and at six months for Waddell Index (P=0.006 and P=0.009 respectively) and for Oswestry Disability Index (P=0.018 and 0.011 respectively). Moreover, pain perception score VAS showed a reduction in both groups, but it was significantly lower in BSG at end of treatment and both follow-ups (P<0.001).

CONCLUSION

Our Back School program can be considered an effective treatment in people with chronıc non-specıfıc LBP.

Surgical access and damage extent after total hip arthroplasty influence early gait pattern and guide rehabilitation treatment

AIM

Different surgical approaches are used in total hip arthroplasty. The present study confronted two surgical techniques, analysing functional recovery in terms of activities of daily living, and ambulation using gait analysis, after a standardized rehabilitation protocol. Our hypothesis was that the increased surgical damage could modify the gait pattern and functional recovery.

METHODS

Thirty patients were randomly assigned to two homogeneous groups: Group A was treated with intermuscular minimally invasive surgery (MIS); Group B was treated with standard lateral transmuscular approach. Follow up was planned at 30 and 90 days. Instrumental evaluation using gait analysis and functional evaluation using validated scales were performed at follow up.

RESULTS

No differences could be found as for functional scales. At the first follow up, the MIS approach proved to be the most favourable: data showed a longer duration of the swing phase, an improved range of motion of the non-treated hip, a reduced adduction (all P<0.005) and a correct timing of activation of the gluteus medium muscle on the treated side. At the second evaluation, gait analysis demonstrated some benefits of the intermuscular approach (a better flexion of both hips, and a minor obliquity of the pelvis during the terminal stance), but also advantages in the transmuscular group (better hip extension).

CONCLUSION

Gait pattern after THA seems to be strictly dependent on surgical access and on the extent and location of surgical damage. It appears important to consider these elements in order to correctly manage the rehabilitation treatment after surgery.

Extracorporeal shockwave therapy (ESWT) in Achilles tendinopathy. A long-term follow-up observational study

AIM

The etiology, pathogenesis and natural course of Achilles tendinopathy are not yet completely known. Various forms of therapies, either conservative or surgical, have been proposed for its treatment. In the last few years, extracorporeal shockwave therapy (ESWT) has been proposed in the treatment of these tendinopathies and has shown encouraging short-term results. The purpose of this type-C study was to evaluate the effectiveness of ESWT in the symptomatic treatment of Achilles tendinopathies over time.

METHODS

One hundred five patients (127 tendons) aged between 18 and 74 years (mean age 47.8) were enrolled in this study. All patients underwent clinical and instrumental diagnosis (ultrasonography, magnetic resonance imaging and X-rays) in order to identify presence, location and seriousness of the specific tendinopathy. The symptomatology was classified using the Visual Analogical Scale (VAS) and according to a five-stage clinical evaluation range. Shock wave treatment was applied with an electromagnetic shock wave generator. The protocol consisted in an average of four sessions (minimum three, maximum five), at a 2/7-day interval. In each session 1 500-2 500 impulses were administered with an energy varying between 0.08 and 0.40 mJ/mm2. All patients were evaluated before therapy and two months after the last ESWT session. Also, all patients were assessed and evaluated at medium-term (6 to 12 months), and 121 patients also at long-term (13 to 24 months).

RESULTS

Authors obtained satisfactory results in 47.2% of cases (60 out of 127 tendons) at two-months follow-up, which increased to 73.2% at medium-term follow-up (93 out of 127 tendons), and then reaching 76% in the last evaluation (92 out of 121 tendons).

CONCLUSIONS

The outcome of the described shock wave treatment appears to be satisfactory and confirms the role of this alternative treatment in the management of the tendon disorders.

Jumper's knee treatment with extracorporeal shock wave therapy: a long-term follow-up observational study

AIM

Jumper's knee affects more frequently athletes participating in jumping activities. This pathology is very difficult to treat: various therapeutic treatments are used, often based on the physician's personal experience rather than clinical evidence. The aim of this prospective study is to present our experience with the treatment of jumper's knee using extracorporeal shock wave therapy (ESWT) in a group of patients followed up for 2 years after treatment.

METHODS

In this study, we included 73 sports patients (83 knees), 54 males and 19 females, aged between 15 and 69 years (mean age: 32 years). All patients underwent clinical and instrumental diagnosis (ultrasonography, magnetic resonance imaging and X-rays) in order to identify presence, location and seriousness of the specific tendinopathy. The symptomatology was classified using the visual analogical scale and according to a 6-stage clinical evaluation range. Shock wave treatment was applied with an electromagnetic shock wave generator. The protocol consisted in an average of 4 sessions (minimum 3, maximum 5), at a 2/7-day interval. In each sessions, 1,500-2,500 impulses were administered with an energy varying between 0.08 and 0.44 mJ/mm(2).

RESULTS

We obtained satisfactory results in 73.5% of cases (54.2% excellent results and 19.3 good results). In performing athletes (16 tendons), treatment was satisfactory in 87.5% of cases, with an average time of resuming sport of approximately 6 weeks.

CONCLUSION

The outcome of the described shock wave treatment appears to be satisfactory and confirms the role of this alternative treatment in the management of the tendon disorders.

Regeneration of the semitendinosus tendon harvested for anterior cruciate ligament reconstruction. Evaluation using ultrasonography

In a prospective study, 40 consecutive patients who underwent anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendon autografts were examined pre- and postoperatively by ultrasound to investigate the anatomy of the donor site before and after the harvest of the tendons. The patients underwent ultrasonography at 2 weeks and 1, 2, 3, 6, 12, 18, and 24 months postoperatively. A total of 298 postoperative sonographic evaluations were performed. The semitendinosus tendon was imaged in the sagittal and axial planes: structure and margins were evaluated with the sagittal views; thickness and width were measured with the axial views. In all cases the following sequence of healing was documented: 2 weeks after surgery the semitendinosus tendon site was occupied by an area of increased thickness and decreased echogenicity, suggesting the presence of traumatic edema of the soft tissue surrounding the tenotomy. At 1 month, an irregular hypoechoic structure appeared in a near-anatomic position; at 2 months after surgery, thickness, width, and cross-sectional area of this structure were significantly greater than preoperatively. The amount of regenerated tissue increased up to that seen in the tissue of the 6-month examinations, which also showed a more uniform echostructure. The scans performed at 1 year showed distinct edges and reduction in thickness and width. At 18 and 24 months the echogenicity of the structure occupying the donor site was very similar to that of the normal semitendinosus tendon. However, this structure was clearly identified about 4 cm proximal to the pes anserinus, revealing a more proximal insertion of the regenerated semitendinosus tendon.