High-energy Extracorporeal Shock Wave Therapy Research Articles

Radiometry in a comprehensive assessment of the effectiveness of extracorporeal shock wave therapy of calcifying tendinobursopathy of the shoulder

Introduction. Uncomfortable working conditions and excessive professional loads on the shoulder joints cause a high prevalence of degenerative-dystrophic changes in the periarticular tissues. Calcifying tendinitis and bursitis occupy a special place, characterized by multifocal accumulation of calcium phosphate crystals in tendons, mucous bags and muscles. The study is devoted to solving the problem of optimizing the X-ray diagnostics of the evolution of calcifying tendinobursopathy of the shoulder (CTS) in the dynamic assessment of the effectiveness of extracorporeal shock wave therapy.
 The aims of the study to optimize the X–ray diagnosis of calcifying tendinobursopathy of the shoulder in people working under the influence of adverse production factors.
 Materials and methods. The authors conducted a comparative retrospective analysis of the results of a comprehensive dynamic clinical and X-ray examination of 155 able-bodied men aged 35-57 years with an average work experience of 14.5±2.7 years (miners, loaders, bricklayers) examined for pain syndrome and dysfunction in the shoulder joint. The main group (65 people) are patients with CTS clinic, the presence of calcifications in the periaricular tissues of the rotator cuff and in the biceps muscle of the shoulder, evaluated in dynamics after shock wave therapy (SWT) of the shoulder in the phases of rest, resorption and recovery. The comparison group (90 people) consisted of patients with the absence of instrumentally detectable signs of multifocal accumulation of calcium phosphate crystals in the periarticular tissues of the shoulder. The study included patients whose routine conservative treatment proved ineffective. The following criteria for the effectiveness of therapy were identified: pain at rest, measured using a visual analog scale (VAS); dimensions (calcification area (in mm2)); optical density and calcification density gradient. Specialists evaluated the data at the initial stage of the study before the use of therapy, immediately after treatment and 12 months after the final SWT session.
 Results. In patients of the main group with the presence of CTS, the main manifestations of shoulder-scapular periarthritis (SSP) both in the main group and in the comparison group were moderately pronounced, however, the frequency of detection of the main SSP syndromes, primarily rotator cuff lesion, as well as background pathology (arthrosis of the shoulder joint) and acromioclavicular joint) were significantly higher in the main group. The effectiveness of SWT was demonstrated by regression of pain syndrome and positive dynamics of density characteristics of periarticular tissues of shoulder joints in areas of interest (in anatomotopographic projections of localization of tendons, mucous bags and muscles). In all patients of the main group, the decalcification process was characterized by both a visually perceptible pattern of disintegration and a decrease in its area, and a decrease in optical density immediately after the end of treatment. In 36.9% of patients, 12 months after the start of SWT, the X-ray and X-ray densitometric picture confirmed the prolongation of the decalcification process up to complete lysis of foci and calcification sites.
 Conclusions. In a comprehensive assessment of the effectiveness of CTS therapy, along with traditional X-ray diagnostics, special methodological techniques of radiometry (X-ray diffraction and X-ray densitometry in areas of interest) can be used, allowing for more accurate and more objective reflection of the direction of the dynamics of changes.
 The use of X-ray calcifications in the arsenal of methodological techniques, such as area, optical density and optical density gradient, can significantly improve the quality of diagnosis and avoid the use of computed tomography and an increase in radiation exposure to the patient.
 High-energy extracorporeal shockwave therapy is largely able to solve the problem of treating resistant forms of calcifying tendinobursopathy of the shoulder.

Double screw versus angular stable plate fixation of scaphoid waist nonunions in combination with intraoperativeextracorporeal shockwave therapy (ESWT).

Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT. Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41mJ/mm2 intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed. Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant.However, at a mean follow-up interval of 34months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative. Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.

A Novel Treatment Method for Ankylosing Spondylitis Combined With Sacroiliac Joint Bone Marrow Edema

Objective: To investigate whether high-energy extracorporeal shock wave therapy (ESWT) combined with conventional oral medicine as a potential novel therapeutic approach for the treatment of ankylosing spondylitis (AS)combined with sacroiliac joint bone marrow edema. Materials & Methods: 40 patients were divided into two groups and were treated with or without ESWT in combination with conventional oral medicine. A visual analog scale (VAS) score of spinal pain, as well as indicators of spinal mobility, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) scores, inflammatory index (C-reactive protein, blood cell sedimentation rate), and other indicators were compared between the two groups. The Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system was used to evaluate pain and structural damage in the sacroiliac joint. Results: (1) After one month of treatment (T1), VAS, BASDAI, BASFI, and SPARCC scores were lower in both groups than at the start of treatment (T0) (P < 0.05), with greater decreases observed in the treatment group (P < 0.05). (2) Also, at T1, indicators of spinal mobility for the two groups were improved (P < 0.05). (3) ESR and C-reactive protein levels for the two groups decreased significantly at T1 versus T0 (P < 0.05). Conclusion: ESWT combined with oral medication can significantly relieve pain and improve clinical functional symptoms for patients with AS. It can also reduce sacroiliac joint bone marrow edema and control the inflammatory reaction in the sacroiliac joint, which represents a novel, effective, reliable, and safe clinical treatment therapeutic method. Keywords: Ankylosing spondylitis, Sacroiliac joint, extracorporeal shock wave therapy, oral medicine.

High Energy Focused Extracorporeal Shock Wave therapy for early and mid stage femoral head necrosis: A single center Retrospective Cohort Study

Background: Research has shown that extracorporeal shock wave therapy has a certain therapeutic effect on the osteonecrosis of the femoral head (ONFH). However, the sample sizes are relatively small. The aim of this study is to evaluate and investigate the clinical efficacy and safety of high-energy extracorporeal shock wave treatment (ESWT) in the management of early and mid-stage ONFH by observing a large size clinical sample. Materials & Methods: 453 patients with stage I–III ONFH treated ESWT in our hospital between June 2019 to August 2021, are included. The visual analog pain scale (VAS), Harris hip score, radiography, and magnetic resonance imaging were used to estimate treatment results. The progression of ONFH was evaluated by imaging examination and clinical outcomes. Results: The mean follow-up was 39.81±7.94 months (range 26 to 50 months). The mean VAS decreased from 5.54 ± 1.19 before ESWT treatment to 1.92 ± 0.43 points at the 12 months follow-up (p < 0.001). The mean Harris hip score improved from 75.51 ± 5.14 before ESWT treatment, to 92.21 ± 4.53 at the 12 months follow-up (p < 0.001). The clinical success(improvement) was observed in 85.71% of ARCO stage I patients, 48.09% of ARCO stage II patients, and 49.15% of ARCO stage III patients. Imaging success (no worsening of clinical images) was observed in 12.38% stage I hips, 28.37% of stage II hips, and 27.12% of stage III hips, respectively. The hip joint survival rate of stage Ⅱ and stage Ⅲ patients was 86.51% and 77.97% (P<0.05). Conclusions: The result of the current study suggests that ESWT definitely represents an effective, reliable, and safe therapeutic method for early and middle stages of ONFH with bone marrow edema syndrome (BMES), and should be recommended as a therapeutic option. Keywords: High-energy extracorporeal shock wave therapy, Osteonecrosis, Femoral head, Bone marrow edema.

Effects of High-Energy Extracorporeal Shockwave Therapy on Pain, Functional Disability, Quality of Life, and Ultrasonographic Changes in Patients with Calcified Rotator Cuff Tendinopathy.

Objective The current trial was designed to evaluate the effects of high-energy shockwave therapy on objective and subjective outcomes among participants with calcified rotator cuff tendinopathy. Methods This parallel-group, randomized trial consists of 42 patients affected by calcific tendinopathies divided into two groups of 21 participants. Patients having calcified tendinopathy aged between 30 and 65 years with type A or B calcification were selected in the trial after signing the written consent form. Participants in the ESWT+RPT group received eight sessions of shockwaves, while the RPT group was treated by routine physical therapy. About 2000 shockwaves of 0.32 mJ/mm2, 120 Hz per treatment, were given as 12 sessions for the first six weeks (2 sessions/week). Pain intensity and shoulder functional ability, ultrasonographic changes, and quality of life were assessed with the numeric pain rating scale (NPRS), Constant-Murley score (CMS), ultrasonography, and Western Ontario rotator cuff index (WORC). Results There were significant differences regarding NPRS and CMS between the two groups, at baseline and 6th and 12th weeks after intervention (p < 0.05). Within-group differences also showed statistically significant results after treatment (all p < 0.05). Significant results were seen in the WORC and ultrasonographic results pre- and posttreatment; more significant findings were found in the experimental group as compared to others. Conclusion High-energy shockwave therapy has been proved to be effective and thus strongly recommended for the management of calcified rotator cuff tendinopathy, improving the pain, functionality, and quality of life of these participants and decreasing the size of calcified deposits. Shockwave therapy is proved to be superior to routine physiotherapy.

The Effects of Three and Six Sessions of Low Energy Extracorporeal Shockwave Therapy on Graft Incorporation and Knee Functions Post Anterior Cruciate Ligament Reconstruction.

Introduction:One session of high energy extracorporeal shockwave therapy (ESWT) was found to improve the healing of anterior cruciate ligament (ACL) after reconstruction in animal and human studies. This study investigated the effects of three and six sessions of low energy ESWT on graft incorporation and knee functions post ACL reconstruction in humans.Materials and methods:Thirty participants with ACL injuries were recruited and assigned equally into three groups with 10 participants per group (n=10). Participants in the control group received physiotherapy alone without low energy ESWT. Participants in the 3ESWT group underwent three sessions of low energy ESWT (one session per week) combined with physiotherapy, and participants in the 6ESWT group received six sessions of low energy ESWT (one session per week) combined with physiotherapy. However, five participants were lost to follow-up. Evaluations of graft incorporation of the tibial tunnel using magnetic resonance (MRI) and Lysholm score were carried out before ACL reconstruction and after six months post ACL reconstruction.Results:The number of grafts with partial incorporation in the tibia tunnel in 6ESWT was significantly higher compared with the number of grafts with non-incorporation at six months post-operatively, X2 (1, N=9) =5.44, p =0.02. However, there was no significant difference between frequencies of graft incorporation in tibia tunnel in the control and 3ESWT groups, X2 (1, N=7) =3.57, p =0.06 and X2 (1, N=9) =2.78, p =0.10, respectively at 6 months postoperatively. Lysholm scores were significantly higher at 6 months post ACL reconstruction compared to the baseline value for each group (p<0.002, respectively). However, there was no significant difference in the Lysholm score between each group (F = 2.798, p = 0.083).Conclusions:Six sessions of low energy ESWT improved graft incorporation in the tibial tunnel. Both three and six sessions of low energy of ESWT does not affect the knee function score at six months post ACL reconstruction.

Evaluating the efficacy of High-energy Extracorporeal Shockwave Therapy Aimed at Treating Calcified Shoulder (ESWT-CS): a study protocol for a randomized controlled trial

Shockwave therapy is a solid scientifically based medical tool used to manage calcified shoulder. This therapy, along with its pros and cons, is paving its way among armamentarium of interventions for musculoskeletal disorders. Objective: To determine efficacy of extracorporeal shockwave therapy on subjective and objective measures in patients with calcified shoulder. Methods: Single-blinded, parallel-group, randomized trial will be conducted on sample of 48 participants recruited through convenient sampling. Patients with calcified shoulder tendinopathy, aged between 30-55 years and both gender will be included. Outcome measures will be numeric pain rating scale, Constant and Murley score, Western Ontario rotator cuff index, shoulder ROM and radiological outcomes. Current study has been initiated in June 2020 till enrollment in December 2020.The quantitative data would present in the form of mean and standard deviation. After fulfilling the parametric assumptions, data will be analyzed using independent sample t-test/Mann Whitney test. Repeated measure ANOVA/Friedman test for pair-wise comparisons for follow-ups will be used to determine the effects of treatment within the groups at baseline, in 6th week and 12th week after commencement of treatment. Discussion: Evidence reported related to shockwave therapy for tendinopathy shows less quality and less number of randomized trials done, with no comparable groups and methodological deficiencies of studies. Trial registration: Approval was obtained from Institutional Review Board Committee (ref: IRB-UOL-FAHS/693/2020). The study was registered on 28th March 2020 in Iranian Registry of Clinical trials (IRCT), its registration reference number is IRCT20200204046373N1 https://irct.ir/trial/45657.

Pain Management Optimisation by an Ultrasound-Guided Analgesic Technique in Outpatients with Plantar Fasciitis during High-Energy Extracorporeal Shock Wave Therapy.

Several studies have demonstrated the efficacy of high-energy extracorporeal shock wave therapy (HESWT) for the treatment of painful foot diseases. A crucial complication of HESWT is the appearance of pain with the subsequent interruption of the procedure. The aim of this study was the evaluation of ultrasound (US)-guided posterior tibial nerve block (PTNB) efficacy in outpatients who discontinued the first application of HESWT due to surge of moderate-severe pain. Twenty-one patients, scheduled for HESWT due to plantar fasciitis, who interrupted the treatment for surge of pain (numeric rating scale [NRS] 5), were enrolled. After interruption of the first treatment, the patients received US-guided PTNB for every subsequent HESWT session. The same skilled anaesthesiologist performed an US-guided PTNB all the times. Once the nerve was identified, the needle was inserted and 5ml mepivacaine 1% were injected. Intensity of pain during each procedure by NRS and evaluation of patient's adherence to the treatment were detected. The HESWT was split into only three applications giving in average about 0.25 mJ mm-2, and all patients completed the treatment sessions. US-guided PTNB showed a significant reduction of NRS (P < 0.01) between the first HEWST without anaesthesia and the three subsequent treatments under peripheral block. US-guided PTNB resulted a valid support for the HEWST in outpatients with plantar fasciitis because it reduced the pain during the procedure, allowing to minimise the patient discomfort and to give the therapeutic doses just in three sessions.

High-energy extracorporeal shockwave therapy in humeral delayed and non-unions.

Within the last few decades, focused high-energy extracorporeal shockwave therapy (ESWT) has proven to be an effective alternative to standard of care revision surgery in delayed healing fractures or manifest non-unions in various anatomical regions. A retrospective multi-variant analysis of an open prospective, single-armed clinical study was conducted. Patients receiving focused high-energy ESWT for a delayed healing or an apparent non-union of a humeral fracture between January 1999 and December 2015 at a single trauma center were included in the study. Bony healing was defined as cortical continuity in three of four cortices and pain-free force loading and evaluated using CT scans and clinical examination at three- and six-month follow-ups after ESWT. A total of 236 patients were included. N = 93 (43.8%) showed bony consolidation three months after ESWT and n = 105 (52.5%) after six months. Sub-group analysis showed significantly better healing for the proximal metaphyseal humerus (66.7% after six months, n = 42) compared to the diaphyseal region (48.1%, n = 133) and distal metaphyseal humerus (48.1%, n = 25). Regression analysis indicated significantly increased healing rates for patients of younger ages (p = 0.001) and a fracture diastasis of less than 5mm (p = 0.002). The findings of this study indicate that ESWT can be considered as a treatment option for a well-selected patient population despite the lower healing rates compared to other anatomical regions.

Electronic focusing high-nergy extracorporeal shockwave combined with conventional oral medicine for the treatment of ankylosing spondylitis

To observe the progress of disease activity and sacroiliac joint imaging in patients with ankylosing spondylitis treated by extracorporeal shockwave combined with conventional oral medicine, and find a new safe and effective therapeutic method. The clinical data of 30 patients with ankylosing spondylitis treated from January 2018 to December 2018 were retrospectively analyzed. Including 20 males and 10 females, aged from 18 to 50 years with an average of (34.50±9.60) years. All 30 patients had different degrees of sacroiliac joint bone marrow edema on MRI before treatment. Thirty patients were divided into treatment group and control group according to different treatment methods. Among them, 15 cases in control group were treated with non-steroidal anti-inflammatory drugs and sulfasalazine enteric-coated tablets, for the 15 cases in treatment group, in addition to oral medicine in line with control group, electronic focusing high-energy extracorporeal shockwave therapy was added. The course of disease, age, pre- and post-treatment erythrocyte sedimentation rate, C-reactive protein in the two groups were analyzed; and visual analogue scale (VAS) and spondyloarthritis research consortium Canada (SPARCC) scoring system were used to evaluate the pain of the sacroiliac joint and the structural damage of the sacroiliac joint;Bath ankylosing spondylitis disease activity index (BASDAI) was calculated. All patients were followed up for at least 3 months. One month after treatment, VAS, and SPARCC scores in treatment group were significantly better than in control group (P<0.05). After 1 month of treatment, there was no significant difference in BASDAI, erythrocyte sedimentation rate and C-reactive protein between two groups(P>0.05). VAS, BASDAI, SPARCC, erythrocyte sedimentation rate, and C-reactive protein of all patients after treatment were significantly improved compared with those before treatment (P< 0.01). Electronic focusing high-energy extracorporeal shockwave combined with conventional oral medicine in the treatment of ankylosing spondylitis has a good clinical effect in rapidly relieving pain, improving disease activity, and preventing imaging progress. In addition, it is safe and non-invasive, which is worthy of clinical application.

Extracorporeal Shockwave Therapy in the Treatment of Trigger Finger: A Randomized Controlled Study

ObjectivesTo determine the efficacy of extracorporeal shockwave therapy (ESWT) and to determine the ideal energy flux density of wide-focused ESWT in the treatment of trigger finger (TF). DesignDouble-blind randomized controlled trial. SettingA university hospital. ParticipantsA total of 60 patients (N=60) with grade II TF according to the Quinnell classification were randomly and evenly allocated to 3 treatment groups. InterventionsThree treatment groups included a high-energy ESWT (HS) group (energy flux density of 0.01 mJ/mm2, 5.8 bar, 1500 impulses, once per week for 4wk), a low-energy ESWT (LS) group (energy flux density of 0.006 mJ/mm2, 3 bar, 1500 impulses, once per week for 4wk), and a sham intervention group (sham group). All participants received 6 months of follow-up after intervention when only painkillers were allowed as concomitant treatment. Main Outcome MeasuresClinical outcomes were followed at baseline and 1, 3, and 6 months after intervention, including pain score, frequency of triggering, severity of triggering, functional impact of triggering, and quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH). ResultsAll groups showed significant improvements from baseline in all clinical parameters, except for functional impact of triggering, 6 months after the interventions. However, the HS group demonstrated a higher magnitude of improvement than the LS and sham groups. In addition, the HS group reported significantly lower pain (P=.01) and lower qDASH (P=.008) than the sham group 6 months after the interventions. No adverse effects were reported in the HS and LS groups within 6 months of follow-up. ConclusionsWide-focused ESWT is a safe and effective but dose-dependent alternative facilitating pain relief and functional improvement in the treatment of grade II TF according to the Quinnell classification.

Antibiofilm efficacy of focused high-energy extracorporeal shockwaves and antibiotics in vitro.

AimsBiofilm formation is one of the primary reasons for the difficulty in treating implant-related infections (IRIs). Focused high-energy extracorporeal shockwave therapy (fhESWT), which is a treatment modality for fracture nonunions, has been shown to have a direct antibacterial effect on planktonic bacteria. The goal of the present study was to investigate the effect of fhESWT on Staphylococcus aureus biofilms in vitro in the presence and absence of antibiotic agents.Methods S. aureus biofilms were grown on titanium discs (13 mm × 4 mm) in a bioreactor for 48 hours. Shockwaves were applied with either 250, 500, or 1,000 impulses onto the discs surrounded by either phosphate-buffered saline or antibiotic (rifampin alone or in combination with nafcillin). The number of viable bacteria was determined by quantitative culture after sonication. Representative samples were taken for scanning electron microscopy.ResultsThe application of fhESWT led to a ten-fold reduction in bacterial counts on the metal discs for all impulse numbers compared to the control (p < 0.001). Increasing the number of impulses did not further reduce bacterial counts in the absence of antibiotics (all p > 0.289). Antibiotics alone reduced the number of bacteria on the discs; however, the combined application of the fhESWT and antibiotic administration further reduced the bacterial count compared to the antibiotic treatment only (p = 0.032).ConclusionThe use of fhESWT significantly reduced the colony-forming unit (CFU) count of a S. aureus biofilm in our model independently, and in combination with antibiotics. Therefore, the supplementary application of fhESWT could be a helpful tool in the treatment of IFIs in certain cases, including infected nonunions.Cite this article: Bone Joint Res 2021;10(1):77–84.

Novel extracorporeal magnetotransduction therapy with Magnetolith and high-energy focused electromagnetic extracorporeal shockwave therapy as bone stimulation therapy for scaphoid nonunion

Abstract Introduction: The case report describes a non-invasive combination of novel Magnetolith Extracorporeal magnetotransduction therapy (EMTT) with high-energy focused extracorporeal shockwave therapy (ESWT) for scaphoid nonunion. Patient concern: In March 2020, a 31-year-old male presented with significant left wrist pain with the epicenter in the radial fossa, limiting daily activities and sports. Initial injury happened in 2005 when the patient was 16-years-old which was neglected. The first scaphoid non-union surgery took place in 2012 with bone-grafting and Herbert-screw. The second revision surgery took place in December 2019. Diagnosis: CT scan showed a non-healing atrophic bone graft in the scaphoid region. Intervention: In March/April 2020, combined novel Magnetolith (EMTT, 8 Hertz, 6000 shots, energy level 6/8) with high-energy focused electromagnetic ESWT (0.35mJ/mm2, 4000 shots, 4 Hertz) was performed in 3 sessions on a weekly interval to accelerate bony healing. Outcomes: Cone-beam CT in May 2020 (5 weeks after the last combined EMTT/ESWT treatment) revealing bony consolidation. Conclusion: The combination of novel non-invasive Magnetolith (EMTT) with focused high-energy ESWT for 3 sessions on a weekly interval can significantly improve bony healing in scaphoid nonunion. To the best of my knowledge, this is the first report to apply EMTT &amp; ESWT for scaphoid nonunion after failed surgeries.

Extracorporeal shock wave therapy: an update.

Extracorporeal shock wave therapy (ESWT) is a safe therapy and there are only a few side effects known (such as pain during ESWT and minor haematomata), but no severe complications are to be expected if it is performed as recommended.Contraindications are severe coagulopathy for high-energy ESWT, and ESWT with focus on the foetus or embryo and focus on severe infection.The effect mechanism of ESWT is still a component of diverse studies, but as far as we can summarize today, it is a similar process to a cascade triggered by mechano-transduction: mechanical energy causes changes in the cellular skeleton, which provokes a reaction of the cell core (for example release of mRNA) to influence diverse cell structures such as mitochondria, endoplasmic reticulum, intracellular vesicles, etc., so the enzymatic response leads to the improvement of the healing process.The usage of ESWT should be taught, to improve the outcome. Courses should be organized by national societies, since the legal framework conditions are different from one country to another.In this update the musculoskeletal indications are addressed (mainly bone and tendons): pseudoarthrosis, delayed fracture healing, bone marrow oedema and osteonecrosis in its early stages, insertional tendinopathies such as plantar fasciitis and Achilles tendon fasciitis, calcifying tendonitis of the rotator cuff, tennis elbow, and wound healing problems.Cite this article: EFORT Open Rev 2020;5:584-592. DOI: 10.1302/2058-5241.5.190067

High-energy extracorporeal shock wave therapy for early stage femoral head osteonecrosis: A protocol of systematic review.

Background:Published trials reported that high-energy extracorporeal shock wave therapy (HEEPSWT) can effectively treat early stage femoral head osteonecrosis (ESFHO). However, their results are still inconsistent. Thus, this study will systematically and comprehensively explore the effectiveness and safety of HEEPSWT for ESFHO.Methods:We will retrieve the electronic databases of Cochrane Library, EMBASE, PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, VIP database, and China National Knowledge Infrastructure from inception to the present. All randomized controlled trials that focusing on the effectiveness and safety of HEEPSWT for ESFHO will be considered. Two researchers will undertake literature selection, information collection, and risk of bias evaluation separately. If disagreements occur, we will invite a third researcher for consultation and a final decision will be made. Cochrane risk of bias tool, and Grades of Recommendation, Assessment, Development and Evaluation will be utilized to assess the risk of bias and quality of evidence, respectively. We will perform statistical analysis using RevMan 5.3 software.Results:This study will provide a detailed summary of exist evidence related to the effectiveness and safety of HEEPSWT for ESFHO.Conclusion:The results of this study synthesize the evidence regarding the HEEPSWT for ESFHO, which may help to guide clinical management in the future.Systematic review registration:INPLASY202060055.

Quantifying the minimal and substantial clinical benefit of the Constant-Murley score and the Disabilities of the Arm, Shoulder and Hand score in patients with calcific tendinitis of the rotator cuff

BackgroundTo aid the interpretation of clinical outcome scores, it is important to determine the measurement properties. The aim of this study was to establish the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score in patients with long-lasting rotator cuff calcific tendinitis treated with high-energy extracorporeal shockwave therapy and ultrasound guided needling. The secondary purpose was to assess the responsiveness of both questionnaires and to identify variables associated with achieving the MCID and SCB.MethodsA prospective cohort of 80 patients with rotator cuff calcific tendinitis was analyzed. Two anchor-based methods were used to calculate the MCID and SCB. Effect sizes and standardized response means were calculated to assess the responsiveness. Additional univariate logistic regression analyses were performed to identify factors associated with the achievement of the MCID and SCB.ResultsFor the Constant-Murley score, we found an MCID and SCB of 9.8 and 19.9, respectively, based on the mean change method and 5.5 and 10.5, respectively, based on receiver operating characteristic analysis. For the Disabilities of the Arm, Shoulder and Hand score, we found an MCID and SCB of –8.2 and –19.6, respectively, with the former and –11.7 and –12.5, respectively, with the latter. The responsiveness of both outcome measures was good, with large effect sizes and standardized response means. The radiographic resorption after 6 weeks and after 6 months appeared to be the most important positive predictor for achieving the MCID and SCB after 6 months.ConclusionThis study established the MCID, SCB, and responsiveness for patients with long-lasting rotator cuff calcific tendinitis who were treated with minimally invasive treatment options. With this information, physicians can distinguish between a statistically significant difference and a clinically relevant benefit. Successful radiographic resorption after 6 weeks and after 6 months was associated with achieving clinically significant improvement after treatment.

The Therapeutic Effects of Extracorporeal Shock Wave Therapy (ESWT) on the Rotator Cuff Lesions with Shoulder Stiffness: A Prospective Randomized Study.

Aim We wish to investigate the therapeutic potential of a single-session high-energy extracorporeal shock wave therapy (ESWT) on the rotator cuff lesions with shoulder stiffness. Patients and Methods. Thirty-seven patients afflicted with rotator cuff lesions with shoulder stiffness were randomized to receive either shockwave or sham treatment based on statistical randomization. In the shockwave group, we used Orthospec™ Extracorporeal Shock Wave Therapy 3000 impulse 24 kV (0.32 mJ/mm2) focused at two points as one session. The sham intervention entailed the use of the device in which the silicone pad was removed from the stand-off device. The visual analogue scale (VAS), muscle power of the shoulder, Constant and Murley score (CMS), and range of motion (ROM) of the shoulder were assessed for all patients. Ten milliliters of peripheral venous blood was obtained from every participant for the measurements of markers for inflammation, tissue regeneration, angiogenesis, and substance P before and at 1 week and 4 weeks after intervention. Results The ESWT group has significantly better VAS, muscle power, CMS, and ROM at 6 and 12 months after intervention. No between-group differences were observed before as well as 1 and 4 weeks after intervention in the selected biomarkers. Conclusion ESWT may be a good adjuvant for the treatment of rotator cuff lesions with shoulder stiffness.

High-Energy Flux Density Extracorporeal Shock Wave Therapy Versus Traditional Physical Therapy Modalities in Myofascial Pain Syndrome: A Randomized-controlled, Single-Blind Trial.

This study aims to investigate the effects of extracorporeal shock wave therapy (ESWT) on pain, sleep, fatigue, disability, depression, and quality of life (QoL) in patients with myofascial pain syndrome (MPS). Between March 2018 and September 2018, a total of 94 patients (16 males, 78 females; mean age 44.2±11.94 years; range, 19 to 74 years) with the diagnosis of MPS were included in the study. The patients were divided into two groups. The treatment group consisted of 49 patients and a total of seven sessions of high-energy flux density ESWT (H-ESWT) (0.26 mJ/mm2) were given with three days interval. The control group consisted of 45 patients and the treatment of hot pack, transcutaneous electrical nerve stimulation, and ultrasound was given for five days for two weeks. At baseline and one month after treatment, the visual analog scale (VAS), Short Form-36 (SF-36), Pittsburgh Sleep Quality Index (PSQI), Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale, Neck Disability Index (NDI), and Beck Depression Inventory (BDI) scores were compared between the groups. There were no statistically significant differences in the age, sex, demographic characteristics, and baseline VAS, SF-36, NDI, BDI, FACIT, and PSQI scores between the groups (p>0.05). In the ESWT group, there was a statistically significant decrease in the VAS, SF-36, NDI, BDI, FACIT, and PSQI scores after treatment compared to the baseline scores, while only the SF-36 subscale scores were statistically significantly higher (p<0.05). There was a statistically significant correlation between the VAS and SF-36 scores and the BDI, NDI, FACIT and PSQI scores after the treatment. Our study results suggest that H-ESWT is more effective than traditional physical therapy methods on pain, QoL, sleep, fatigue, depression, and disability in patients with MPS.

Comparing Ultrasound-Guided Needling Combined With a Subacromial Corticosteroid Injection Versus High-Energy Extracorporeal Shockwave Therapy for Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial

To compare clinical and radiographic outcomes after treatment with standardized high-energy extracorporeal shock wave therapy (ESWT) and ultrasound-guided needling (UGN) in patients with symptomatic calcific tendinitis of the rotator cuff who were nonresponsive to conservative treatment. The study was designed as a randomized controlled trial. The ESWT group received ESWT (2000 pulses, energy flux density 0.35 mJ/mm2) in 4 sessions with 1-week intervals. UGN was combined with a corticosteroid ultrasound-guided subacromial bursa injection. Shoulder function was assessed at standardized follow-up intervals (6 weeks and 3, 6, and 12 months) using the Constant Murley Score (CMS), the Disabilities of the Arm, Shoulder, and Hand questionnaire, and visual analog scale for pain and satisfaction. The size, location, and morphology of the deposits were evaluated on radiographs. The a priori sample size calculation computed that 44 participants randomized in each treatment group was required to achieve a power of 80%. Eighty-two patients were treated (56 female, 65%; mean age 52.1 ± 9 years) with a mean baseline CMS of 66.8 ± 12 and mean calcification size of 15.1 ± 4.7 mm. One patient was lost to follow-up. At 1-year follow-up, the UGN group showed similar results as the ESWT group with regard to the change from baseline CMS (20.9 vs 15.7; P= .23), Disabilities of the Arm, Shoulder, and Hand questionnaire (-20.1 vs -20.7; P= .78), and visual analog scale for pain (-3.9 and -2.6; P= .12). The mean calcification size decreased by 13 ± 3.9 mm in the UGN group and 6.7 ± 8.2 mm in the ESWT group (<P= .001). In total, 22% of the UGN and 41% of the ESWT patients received an additional treatment during follow-up because of persistent symptoms. This RCT compares the clinical and radiographic results of UGN and high-energy ESWT in the treatment of calcific tendinitis of the rotator cuff. Both techniques are successful in improving function and pain, with high satisfaction rates after 1-year follow-up. However, UGN is more effective in eliminating the calcific deposit, and the amount of additional treatments was greater in the ESWT group. II, randomized controlled trial.

Effectiveness of non-surgical interventions for rotator cuff calcific tendinopathy: A systematic review.

To evaluate the effectiveness of non-surgical interventions for rotator cuff calcific tendinopathy. Medline, EMBASE, CINAHL, Cochrane Register of Clinical Trials, PEDro and SPORTDiscus from inception to March 2018, and accompanying reference lists. Peer-reviewed randomized clinical trials of non-surgical interventions for adults with rotator cuff calcific tendinopathy were included. The same 2 reviewers independently evaluated eligibility, extracted data and evaluated risk of bias of the included randomized clinical trials. A system to resolve any disagreements was established a priori. Short-term, medium-term and long-term outcomes for pain, shoulder function and calcific morphology related to rotator cuff calcific tendinopathy were extracted. Due to diversity in outcome measures a meta-analyses was not conducted. Of the 2,085 articles identified, 18 met the inclusion criteria, all of which had high risk of bias. Five non-surgical interventions were identified (extracorporeal shockwave therapy, ultrasound-guided percutaneous intervention, pulsed ultrasound, acetic acid iontophoresis, and transcutaneous electrical nerve stimulation). There was moderate evidence for high-energy extracorporeal shockwave therapy over low-energy extracorporeal shockwave therapy for pain and function between 3 and 6 months, and over placebo for function in the first 6 months. There was moderate evidence for ultrasound-guided percutaneous intervention over medium/high-energy extracorporeal shockwave therapy for reduced pain and calcific morphology over a 1-year period. Methodological concerns preclude definitive recommendations.