Midsubstance Tendinopathy, Percutaneous Techniques (Platelet-Rich Plasma, Extracorporeal Shock Wave Therapy, Prolotherapy, Radiofrequency Ablation)

Contribution of Shockwave Therapy in the Functional Rehabilitation Program of Patients with Patellofemoral Pain Syndrome

Background: Patellofemoral pain syndrome is a condition with an increasing incidence in recent years, being known as the most common cause of knee pain in adults and adolescents. Undiagnosed and untreated, this condition can worsen over time. The aggravation leads to an increase in the intensity of the pain and the risk of injury, along with an increase in stress on the other joints of the lower limb. The objective of this study was to evaluate the contribution of shockwave therapy to a functional rehabilitation programme for patients with patellofemoral pain syndrome. Materials and Methods: The study was carried out on a group of 64 subjects (32 males and 32 females), aged between 20 and 39 years. The subjects were divided into two groups: 32 subjects who followed a program of functional rehabilitation based on low- and medium-frequency electrotherapy, ultrasound and laser therapy, along with a physical therapy program lasting approximately 3 weeks, and 32 subjects who followed a functional rehabilitation program based on shockwave therapy and specific physical therapy exercises lasting approximately 3 weeks. Results: Following the protocols applied to the two groups, the pain reported by the patients decreased, while the functional parameters of the knee improved, better results being obtained in the group that performed shock wave therapy together with specific physical therapy programs (Cohen Index 5916, p < 0.001). Conclusions: This study indicates that radial shockwave therapy combined with physiotherapy may provide additional benefits for patellofemoral syndrome, including greater pain reduction and improved joint mobility, compared to traditional treatments. However, further research is needed to confirm these findings and their broader clinical applicability.

Outcomes After Extracorporeal Shockwave Therapy for Chronic Noninsertional Achilles Tendinopathy Compared With Chronic Insertional Achilles Tendinopathy: A Retrospective Review

BACKGROUND

Extracorporeal shockwave therapy (ESWT) is a noninvasive treatment modality that is used in the treatment of chronic Achilles tendinopathy (AT).

PURPOSES

To (1) retrospectively assess outcomes after ESWT for both noninsertional AT (NAT) and insertional AT (IAT) at >1-year follow-up and (2) identify potential predictors of outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Chart review was conducted to identify patients who underwent ESWT for AT with a minimum of 1-year follow-up. Data collected and assessed included patient demographic characteristics, pathological characteristics including the location of AT (NAT or IAT), presence of a Haglund deformity, and severity of tendon degeneration on magnetic resonance imaging (MRI), in addition to treatment characteristics including number of sessions and intensity of ESWT. The Victorian Institute of Sports Assessment-Achilles (VISA-A) and visual analog scale (VAS) pain scores were obtained before ESWT, 6 months after ESWT, and at final follow-up. Failures were also recorded, which were defined as no improvement in VISA-A or VAS scores or need for surgical intervention. Linear regression was performed to identify potential predictors of inferior subjective clinical outcomes and failures. Survival analysis was conducted using Kaplan-Meier curves.

RESULTS

The study included 52 patients with IAT and 34 patients with NAT. The mean follow-up in the NAT cohort was 22.3 ± 10.2 months and the mean follow-up in the IAT cohort was 26.8 ± 15.8 months. Improvements in VISA-A and VAS scores were observed in the NAT cohort at 6-month follow-up and at final follow-up (P < .05). Improvements in VISA-A and VAS scores were recorded in the IAT cohort at 6-month follow-up, which subsequently deteriorated at final follow-up. In the NAT cohort, the failure rate at 6-month follow-up was 11.8%, which increased to 29.4% at final follow-up. In the IAT cohort, the failure rate at 6-month follow-up was 32.7%, which increased to 59.6% at final follow-up. Predictors of inferior subjective clinical outcomes and failures in the NAT cohort included pre-ESWT subjective clinical score, male sex, presence of a cardiovascular risk factor, and more severe MRI grading of tendinopathy. Predictors of inferior subjective clinical outcomes and failures in the IAT cohort included pre-ESWT subjective clinical score and more severe MRI grading of tendinopathy.

CONCLUSION

Superior subjective clinical outcomes together with a lower failure rate were maintained for >1 year in the NAT cohort compared with the IAT cohort, calling into question the long-term benefit of ESWT for patients with IAT.

The Effectiveness of Adding Transvaginal Radiofrequency to Pelvic Floor Muscle Training for 6 Weeks in Women with Stress Urinary Incontinence. A Double-Blind Randomised Controlled Trial

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the clinically beneficial effect of adding transvaginal monopolar non-ablative radiofrequency (RF) to pelvic floor muscle training (PFMT) on leakage severity, quality of life and urinary incontinence-related symptoms in women with stress urinary incontinence (SUI).

METHODS

A double-blind randomised controlled trial was conducted, with a 6-week intervention and a 6-month follow-up. Participants were randomly assigned to the experimental group (PFMT plus RF; n = 18) or the control group (PFMT plus placebo; n = 20). The primary outcome was the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF). Secondary outcomes included the Pelvic Floor Distress Inventory-20 (PFDI-20) and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), self-efficacy, female sexual function, pelvic floor muscle dynamometry, 1-h pad test and number of SUI episodes per week. Inferential analyses of the data were performed using a two-factor analysis of variance.

RESULTS

Both groups achieved a statistically significant improvement in ICIQ-SF over time. However, the differences observed in the experimental group exceeded the minimal clinically important differences by 4 points (MD = -9.4, 95% CI = -12.6 to -6.3), which was not observed in the control group (MD = -3.9, 95% CI = -6.9 to -1.0). This was maintained at the 6-month follow-up with a significant time*group interaction (p < 0.001, ηp2 = 0.150). There was no time*group interaction in the other variables (p > 0.05). Additionally, a significant difference in favour of the experimental group was observed in the 1-h pad test and episodes of SUI per week (p < 0.05).

CONCLUSIONS

This study highlights the beneficial effects of adding transvaginal RF to PFMT on the severity and amount of leakage, as well as on the quality of life and urinary incontinence-related symptoms in women with moderate SUI. Future trials are needed to assess the effects of this intervention in women with severe SUI.

Does additional extracorporeal shock wave therapy improve the effect of isolated percutaneous radiofrequency coblation in patients with insertional Achilles tendinopathy? Study protocol for a randomized controlled clinical trial

BACKGROUND

No conclusive evidence recommends a prior treatment for insertional Achilles tendinopathy (IAT). It is theorized that both percutaneous radiofrequency coblation and extracorporeal shockwave therapy (ESWT) relieve pain within the insertion. However, no clinical evidence shows that either treatment promotes the regeneration of the tendon or if the combination of these 2 interventions offers better function and less pain than one therapy.

METHODS

The study is a randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients with insertional Achilles tendinopathy who are not satisfied with the effect of conservative treatment will be screened. A minimum of 38 patients will be enrolled after deciding to participate in the trial on an informed basis. Then the intervention group and the control group perform radial ESWT and sham-ESWT respectively at 6 months after percutaneous radiofrequency coblation. The primary outcome will be the Victorian Institute of Sports Assessment Achilles (VISA-A) Score. Secondary outcome measures will be Foot and Ankle Outcome Score (FAOS) scale, visual analog scale (VAS), Tegner Score, and MRI ultra-short echo time (UTE) T2* value. The assessments will occur in 6 months, 1 year, and 2 years, post-operatively. The differences between the 2 groups will be conducted as intention-to-treat basis.

DISCUSSION

We aim to investigate if radiofrequency coblation associated with ESWT can provide more encouraging imaging findings as well as functional and clinical outcomes regarding the treatment of the IAT comparing to the single radiofrequency coblation treatment.

TRIAL REGISTRATION

ChiCTR1800017898; pre-results. Registered on 20 August 2018.

Relative Effect of Extracorporeal Shockwave Therapy Alone or in Combination with Noninjective Treatments on Pain and Physical Function in Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials

Extracorporeal shockwave therapy (ESWT) has been recommended for managing pain in patients with knee osteoarthritis (KOA). The difference in therapeutic effects between radial shockwave characteristics (RaSW) and focused shockwave characteristics (FoSW) with different energy levels for KOA remains controversial. The purpose of this network meta-analysis (NMA) was to identify the effects relative to the different ESWT regime and combination treatments on pain and functional outcomes in individuals with KOA. The randomized controlled trials (RCTs) which investigated the efficacy of RaSW, FoSW, and combination treatments in patients with KOA were identified by searches of electronic databases. The included RCTs were analyzed through NMA and risk-of-bias assessment. We analyzed 69 RCTs with a total of 21 treatment arms in the NMA. Medium-energy FoSW plus physical therapy, medium-energy acupoint RaSW plus Chinese medicine, and high-energy FoSW alone were the most effective treatments for reducing pain [standard mean difference (SMD) = -4.51], restoring function (SMD = 4.97), and decreasing joint inflammation (SMD = -5.01). Population area and study quality influenced the treatment outcomes, particularly pain. Our findings indicate that medium-energy ESWT combined with physical therapy or Chinese medicine is beneficial for treating pain and increasing function in adults with KOA.

Efficacy of Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Meta-analysis

Background:

Achilles tendinopathy is a frequent sports injury, and extracorporeal shock wave therapy (ESWT) has been proposed as a treatment.

Purpose:

To compare outcomes between ESWT and other nonsurgical intervention (including sham shock wave therapy) in Achilles tendinopathy patients.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

We included 5 randomized controlled trials and 3 case-control studies published between 2005 and 2018. We analyzed pain scores and other outcomes that were reported in more than 3 of the 8 studies.

Results:

ESWT was associated with significantly better scores than comparison therapy on the visual analog scale for pain (P < .01), American Orthopaedic Foot & Ankle Society scale (P = .01), Likert scale for satisfaction (P = .03), Roles and Maudsley scale (P < .01), Victorian Institute of Sports Assessment–Achilles questionnaire (P < .01), and numerical rating scale (P = .02). The 2 patient groups did not differ significantly in tenderness (P = .34) or pain threshold (P = .24). Subgroup analysis showed that ESWT led to better VAS pain scores than comparison treatments at both low-energy level (0.06-0.11 mJ/mm²) and medium-energy level (0.12-0.25 mJ/mm²) and at both shorter (<6 months) and longer (≥6 months) follow-up.

Conclusion:

ESWT improves pain and functional outcomes in patients with Achilles tendinopathy. Further research is needed to determine the optimal energy level.

New concept for treating urinary incontinence after radical prostatectomy with radiofrequency: phase 1 clinical trial

To describe the clinical response and side effects of radiofrequency treatment in patients with urinary incontinence after radical prostatectomy. This is a phase 1 clinical trial with 10 men up to 65 years of age who had urinary incontinence after radical prostatectomy, post void residual volume < 50 ml verified by ultrasonography, pad test ≥ 1 g, and PSA < 0.2 ng/ml. pad test and self-administered questionnaires were used to assess clinical response. Scales were used to measure treatment satisfaction and improvement in symptoms. Participants underwent five sessions of 2 min of non-ablative endoanal radiofrequency (41 °C). The evaluated co-primary endpoints were urinary incontinence volume and urinary symptoms, analyzed by the Wilcoxon nonparametric test; residual volume, and self-reports to assess safety. The participants' mean age was 57.5 ± 4.9. The initial pad test score was 6.5 g (1.7-50.0) with a final score of 2.0 g (0.0-9.0) (p < 0.01). Ultrasonography showed no alteration of residual volume. A decrease of urinary loss was found in nine patients, three of them showed a complete resolution of urinary loss. A decrease in irritative micturition symptoms was found as well, but no improvement in the quality of life was shown. Regarding treatment satisfaction, two patients were neutral, six satisfied, and two very satisfied. Limitations included pain while the endoanal electrode was inserted. Four patients indicated pain during treatment, but overall results were positive. The reduction of urinary loss and irritative micturition symptoms increased patients' satisfaction scores, without improving their perception of quality of life.

[Experimental study of platelet-rich plasma in treatment of Achilles tendinopathy in rabbits]

OBJECTIVE

To explore the effect of platelet-rich plasma (PRP) in treatment of Achilles tendinopathy in rabbits, and provide experimental evidence for the clinical application of PRP in treatment of Achilles tendinopathy.

METHODS

Forty-eight adult New Zealand white rabbits, weighing 2.5-3.0 kg, male or female, were randomly divided into model group (group A), model control group (group B), model+treatment control group (group C), model+treatment group (group D), with 12 in each group. The rabbits were injected with type Ⅰ collagenase to prepare Achilles tendinopathy models in groups A, C, and D, and with an equal dose of normal saline in group B. The blood from the central artery of rabbit ear was taken to preprare PRP by secondary centrifugation in group D. The results of platelet counts showed that PRP platelets reached 3 to 5 times the whole blood. After the model was prepared, the rabbits in groups C and D were injected with physiological saline and autologous PRP at the molding site respectively, once a week, 0.8 mL each time for 4 weeks. At 1 week after PRP injection, the relative hardness (expressed as HRD%) of Achilles tendon was evaluated by ultrasound elastic quantitative imaging detection technique; the maximum breaking load of Achilles tendon was measured by universal electronic tensile testing machine; the contents of collagen type Ⅰ and Ⅲ were determined by ELISA; and the morphology of Achilles tendon collagen fibers was observed by HE and Masson stainings.

RESULTS

All animals survived during the experiment. The results of ultrasound elastic quantitative imaging and mechanical tests showed that the HRD% and the maximum breaking load were significantly lower in group A than in group B ( P<0.05) and in group C than in group D ( P<0.05). The results of ELISA showed that the content of collagen type Ⅰ was significantly lower in group A than in group B ( P<0.05) and in group C than in group D ( P<0.05); the content of collagen type Ⅲ was significantly higher in group A than in group B ( P<0.05) and in group D than in group C ( P<0.05). HE and Masson stainings showed that the Achilles tendon collagen fibers were irregularly curled and the structure was severely damaged in group A; the fibers were parallel and ordered, and the structure was complete in group B; the fibers were irregularly curled and structurally disordered in group C; the fibers were slightly curled and the structure was relatively complete in group D.

CONCLUSION

A rabbit model of Achilles tendinopathy can be reconstructed by type Ⅰ collagenase injection. PRP treatment can increase the Achilles tendon hardness and maximum breaking load, up-regulate the expression level of collagen type Ⅰ and Ⅲ, improve the structure of Achilles tendon collagen fiber, and promote the repair in rabbit Achilles tendinopathy model.

Efficacy of extracorporeal shock wave therapy for knee tendinopathies and other soft tissue disorders: a meta-analysis of randomized controlled trials

Background

Extracorporeal shock-wave therapy (ESWT), which can be divided into radial shock-wave therapy (RaSWT) and focused shock-wave therapy (FoSWT), has been widely used in clinical practice for managing orthopedic conditions. The aim of this study was to determine the clinical efficacy of ESWT for knee soft tissue disorders (KSTDs) and compare the efficacy of different shock-wave types, energy levels, and intervention durations.

Methods

We performed a comprehensive search of online databases and search engines without restrictions on the publication year or language. We selected randomized controlled trials (RCTs) reporting the efficacy of ESWT for KSTDs and included them in a meta-analysis and risk of bias assessment. The pooled effect sizes of ESWT were estimated by computing odds ratios (ORs) with 95% confidence intervals (CIs) for the treatment success rate (TSR) and standardized mean differences (SMDs) with 95% CIs for pain reduction (i.e., the difference in pain relief, which was the change in pain from baseline to the end of RCTs between treatment and control groups) and for restoration of knee range of motion (ROM).

Results

We included 19 RCTs, all of which were of high or medium methodological quality and had a Physiotherapy Evidence Database score of ≥5/10. In general, ESWT had overall significant effects on the TSR (OR: 3.36, 95% CI: 1.84–6.12, P < 0.0001), pain reduction (SMD: − 1.49, 95% CI: − 2.11 to − 0.87, P < 0.00001), and ROM restoration (SMD: 1.76, 95% CI: 1.43–2.09, P < 0.00001). Subgroup analyses revealed that FoSWT and RaSWT applied for a long period (≥1 month) had significant effects on pain reduction, with the corresponding SMDs being − 3.13 (95% CI: − 5.70 to − 0.56; P = 0.02) and − 1.80 (95% CI: − 2.52 to − 1.08; P < 0.00001), respectively. Low-energy FoSWT may have greater efficacy for the TSR than high-energy FoSWT, whereas the inverse result was observed for RaSWT.

Conclusions

The ESWT exerts an overall effect on the TSR, pain reduction, and ROM restoration in patients with KSTDs. Shock-wave types and application levels have different contributions to treatment efficacy for KSTDs, which must be investigated further for optimizing these treatments in clinical practice.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2204-6) contains supplementary material, which is available to authorized users.