Nitric oxide mediates anti-inflammatory action of extracorporeal shock waves

Impact of low-intensity extracorporeal shockwave therapy on vascular parameters and sexual function in patients with arteriogenic erectile dysfunction

ABSTRACT

Previous published studies have shown an improvement of penile hemodynamic parameters after low-intensity extracorporeal shockwave therapy (Li-ESWT). However, the clinical significance of these findings remains unclear, and definitive selection criteria for Li-ESWT based on preexisting comorbidities have yet to be established. This was an observational study of 113 patients with ED, evaluated between January 2019 and December 2021 in Andrology Unit at the Department of Urology and Renal Transplantation, University of Foggia (Foggia, Italy). Penile dynamic Doppler was performed to evaluate vascular parameters and 5-item version of the International Index of Erectile Dysfunction (IIEF-5) questionnaire was administered to assess the severity of ED. This was repeated 1 month after treatment. Patients with a peak systolic velocity (PSV) <30 cm s-1 were considered eligible for Li-ESWT. Our protocol consisted of 8 weekly sessions with 1500 strokes distributed in 5 different locations along the penis. After treatment, a significant mean (±standard deviation [s.d.]) PSV increase of 5.0 (±3.4) cm s-1 was recorded and 52/113 (46.0%) patients reached a PSV >30 cm s-1 at posttherapeutic penile dynamic Doppler. A clinically significant IIEF-5 score improvement was observed in 7 patients, 21 patients, and 2 patients with mild-to-moderate, moderate, and severe pretreatment ED, respectively. No different outcomes were assessed based on smoking habits, previous pelvic surgery, or use of oral phosphodiesterase-5 inhibitor (PDE5i). On the other side, only 1 (6.7%) in 15 patients with diabetes mellitus showed an IIEF-5 score improvement after Li-ESWT. Shockwave treatment determined a significant increase in PSV and correlated IIEF-5 improvement in ED patients. This advantage seemed particularly evident for moderate ED and was not affected by smoking habits, previous pelvic surgery, and use of PDE5i. Conversely, diabetic patients did not benefit from the treatment.

Efficacy of focused shockwave therapy in patients with moderate-to-severe carpal tunnel syndrome: a preliminary study

OBJECTIVE

To evaluate the efficacy of focused extracorporeal shockwave therapy for symptoms and function in patients with moderate-to-severe carpal tunnel syndrome.

DESIGN

A single-blind randomized controlled trial.

SUBJECTS

Twenty-four outpatients with moderate-to-severe carpal tunnel syndrome.

METHODS

Patients were randomly allocated into 2 groups: a focused extracorporeal shockwave therapy group and a control group. The focused extracorporeal shockwave therapy group received conservative treatment in addition to focused extracorporeal shockwave therapy with an energy flux density ranging from 0.01 to 0.15 mJ/mm2, a frequency of 4-5 Hz, and 1500 pulses per session once a week for a total of 3 sessions. The control group received only conservative treatment, which comprised gliding exercises for carpal tunnel syndrome, a night wrist splint, and lifestyle modification. The Thai version of the Boston Carpal Tunnel Questionnaire (T-BCTQ), a nerve conduction study, and ultrasonography of the median nerve cross-sectional area were performed before treatment and at 3 and 6 weeks after baseline.

RESULTS

The T-BCTQ symptom and function scores had significantly decreased in both groups, favouring focused extracorporeal shockwave therapy at all time-points. In addition, distal sensory and motor latency were significantly different between the groups at 3 weeks from baseline.

CONCLUSION

Focused extracorporeal shockwave therapy plus conservative treatment effectively provided short-term improvement in symptoms, hand function, and nerve conduction in patients with moderate-to-severe carpal tunnel syndrome compared with conservative treatment alone.

Therapeutic implications of extracorporeal shock waves in burn wound healing

Burns are a common type of trauma that seriously affect not only the physical health, but also the mental health and quality of life of the patient. Extracorporeal shock wave therapy (ESWT) is an emerging treatment that has been used in clinical treatment. It has many advantages, including safety, non-invasiveness, efficiency, short treatment duration, fewer complications, and relatively low prices. In clinical settings, ESWT has played an important role in the healing process of burns and the prevention of sequelae. This article reviews the history of ESWT, the mechanism of ESWT to promote burn healing, and the application of ESWT in burns. Current status of ESWT treatment for burns as well as future perspectives for research have been summarized and proposed. However, patients with burns cannot be considered recovered when the wounds have healed, we need some new technology to adjust to the challenges of the future.

Non-surgical local treatments of digital ulcers in systemic sclerosis: a systematic literature review

INTRODUCTION

Digital ulcers (DUs) are difficult to treat in patients with systemic sclerosis (SSc) and systemic (i.e., pharmacological) therapy is currently considered the 'standard of care'. Our aim was to examine the safety and efficacy of local, non-surgical treatment for SSc-DUs.

METHODS

A systematic literature review (SLR) of original research articles up to August, 29 2022 was performed according to the PICO framework. References were independently screened by two reviewers and risk of bias was assed using validated tools. Due to study heterogeneity narrative summaries are used to present data.

RESULTS

Among 899 retrieved references, 14 articles were included (2 randomised trials (RTs), and 12 observational (OBS) studies). The most frequently studied procedure (5 studies) was botulin A toxin (hand or single finger) injection with a reported healing rate (HR) of 71%-100%. Amniotic and hydrocolloid membranes were examined in one study each and associated with a good HR. Tadalafil 2% cream was studied in a single study with a reduction in the number of DUs. Vitamin E gel was associated with a reduction in ulcer healing time. Low-level light therapy, hydrodissection and corticosteroid injection, extracorporeal shock wave (ESW) and photobiomodulation were evaluated in a single study each and showed a positive trend. Dimethyl sulfoxide was associated with significant local toxicity.

CONCLUSIONS

A range of non-surgical, local treatments for SSc-DUs have been explored and showed efficacy to some extent. We have identified methodological flaws that should be avoided in the design of future studies to explore locally-acting treatments for SSc-DUs.

Radial extracorporeal shock wave therapy as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients. A randomized controlled study

PURPOSE

To evaluate the effectiveness of radial extracorporeal shock wave therapy (r ESWT) as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients.

METHODS

100 eligible stroke patients with calf muscles spasticity were randomized into 2 groups. Group I: 50 patients exposed to rESWT 1.500 pulses, 0.10 mJ to 0.3mJ/mm2, with a frequency 4 Hz once weekly for one month. Group II: 50 patients exposed to Sham rESWT once weekly for one month. Clinical, electrophysiological & musculoskeletal ultrasound assessments were done for all patients.

RESULTS

After controlling baseline as covariate, the trend for modified Ashworth scale (MAS), Passive ankle dorsiflexion motion (PADFM), 10 meters walk test (10-MWT), and Ratio of maximum H reflex to maximum M response (H/M ratio) after one & two months was significantly different between the two groups, with improvement of all clinical and electrophysiological parameters in group I.

CONCLUSION

ESWT represents a useful non-invasive, additional modality for the reduction of foot spasticity and equinus deformity in stroke patients.

Multimodal treatment, including extracorporeal shock wave therapy, for refractory chronic tension-type headache: a case report

BACKGROUND

Few reports have described multidisciplinary treatment, including extracorporeal shock wave therapy, for patients with refractory chronic tension-type headache. In this study, we conducted multidisciplinary treatment for a patient with chronic tension-type headache who suffered from chronic headache refractory to treatment.

CASE PRESENTATION

The patient was a 45-year-old Japanese male suffering from 20 years of headache. As his headache had worsened recently, he visited a local clinic. With the diagnosis of suspected tension-type headache, its treatment was unsuccessful and he was referred to our hospital. The neurology department confirmed the tension-type headache and prescribed another medication, but he showed no improvement. Then, the patient was referred to the rehabilitation medicine department for consultation. At the initial visit, we identified multiple myofascial trigger points in his bilateral posterior neck and upper back regions. At the initial visit, he was prescribed 10 mL of 1% lidocaine injected into the muscles in these areas. In addition, he received 2000 extracorporeal shock wave therapy into bilateral trapezius muscles, and was instructed to take oral Kakkonto extract granules, benfotiamine, pyridoxine hydrochloride, and cyanocobalamin. Cervical muscle and shoulder girdle stretches and exercises were also recommended. At follow-up treatment visits, we used extracorporeal shock wave therapy to bilateral trapezius muscles, which led to immediate pain relief. After 11 weeks, he was not taking any medication and his headache was subjectively improved and his medical treatment ended.

CONCLUSION

A patient with chronic tension-type headache refractory to regular treatment was successfully treated with a multimodal approach including extracorporeal shock wave therapy in addition to standard treatment. For patients with tension-type headache accompanied by myofascial trigger points, it may be recommended to promptly consider aggressive multimodal treatment that includes extracorporeal shock wave therapy.

Emerging theory of sensitization in post-stroke muscle spasticity

Spasticity, characterized by a velocity-dependent increase in muscle tone and exaggerated reflexes, is a common complication in individuals with upper motor neuron syndrome, such as stroke survivors. Sensitization, the heightened responsiveness of the nervous system to sensory stimuli, has emerged as a potential cause of spasticity. This perspective article explores three emerging treatments targeting sensitization. Recent studies have investigated novel treatment modalities for spasticity, including Extracorporeal Shockwave Therapy (ESWT), repetitive peripheral magnetic stimulation (rPMS), and needling. ESWT has shown promising results in reducing spasticity in both the upper and lower extremities, potentially through mechanisms such as nitric oxide production, rheological property changes, and neuromuscular transmission dysfunction. rPMS offers a non-invasive approach that may reduce spasticity by increasing sensory input, enhancing cortical activation, and exerting tissue-softening effects. Needling has also demonstrated positive effects on spasticity reduction. The high heterogeneity observed indicates the need for more rigorous research to confirm these findings. Recently, mechanical needling and sterile water injection invented by the author is also promising for reducing spasticity through removing sensitization. In conclusion, the emerging treatment options discussed in this perspective article provide promising avenues for addressing sensitization in spasticity and improving motor function. However, further research is needed to validate their findings, optimize treatment protocols, and investigate their long-term effects on motor recovery and overall quality of life in individuals with spasticity.

Radiofrequency energy in the treatment of erectile dysfunction-a novel cohort pilot study on safety, applicability, and short-term efficacy

The erectile mechanism depends, in part on the intactness of the collagen components in the penis. As such, impaired collagen may have a deleterious effect on erectile function. Radiofrequency energy has been shown to renew and restore spatial structural arrangement of collagen fibers; therefore, treatment of erectile dysfunction with radiofrequency could lead to anatomical and physiological changes at the penile tissue level and could lead to improvement in the erectile mechanism. We conducted this study to assess the effect of radiofrequency treatment on erection quality. We evaluated the safety, applicability, and efficacy of a self-applied, handheld, low-intensity radiofrequency device (Vertica®) in men with moderate and mild-to-moderate organic erectile dysfunction. The treatment protocol consisted of 12 treatments (twice a week during the 1st month, and once a week during the 2nd month), and each participant treated himself individually. Treatment outcomes were evaluated using the International Index of Erectile Function, Erection Hardness Scale, Erectile Dysfunction Index of Treatment Satisfaction, Benefit, Satisfaction & Willingness to continue, Quality of Erection Questionnaire, Sexual Quality of Life questionnaires and specific questions addressing side effects and ease of use. Twenty-eight out of 32 men (mean age 59.5 ± 9.8, range: 41-78 years) completed a one-month follow-up after treatment. Mean International Index of Erectile Function (43.7. ± 7.8 vs. 60.9 ± 10.8, p < 0.01), International Index of Erectile Function -Erection Function domain (16.8 ± 3.1 vs. 24.4 ± 4.4, p < 0.001), and Erection Hardness Scores (2.2 ± 0.8 vs. 3.2 ± 0.5, p = 0.01) were all significantly improved. Fifty percent of patients achieved normal erectile function parameters according to the International Index of Erectile Function -Erection Function domain score >25. High mean scores were achieved in the Erectile Dysfunction Index of Treatment Satisfaction (76.8 ± 20.3), Benefit, Satisfaction & Willingness to continue (4.83 ± 1.1), Quality of Erection Questionnaire (73.4 ± 23.8), and Sexual Quality of Life (67 ± 29.4) questionnaires. No side effects were reported and participants rated the device as very comfortable, simple, and easy to operate.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Clinical significance

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

Synergistic effect of LCI with ESWT on treating patients with mild to moderate CTS: a randomized controlled trial

BACKGROUND

Applying radial extracorporeal shock wave therapy (R-ESWT) with LCI(local corticosteroid injection) in carpal tunnel syndrome (CTS) management is gaining momentum. The objective is to actualize the topic of this study.

METHODS

In this prospective randomized controlled trial, forty patients with mild to moderate CTS are divided into two sham- R-ESWT and R-ESWT groups subject to LCI(local corticosteroid injection). The first group received four sessions of sham-ESWT weekly, which involved sound but no energy; the second group received R-ESWT at equal intervals and were assessed for pain score (VAS score) and symptoms (GSS) baseline, 1st month, 3rd month, and 6th month.

RESULTS

A considerable improvement is observed in both groups for pain at (P < 0.05) and symptoms at (P < 0.05) in the 3rd month. The second group revealed more significant symptom improvement at (P < 0.05) in the 6th month.

CONCLUSION

The R-ESWT + LCI combined therapy course is the first line of treatment in patients with mild to moderate symptoms and leads to control and reduction of symptoms and the need for surgery, thus a primary concern in CTS treatment with an orthopedist.

Effectiveness of Extracorporeal Shockwave Therapy on Controlling Spasticity in Cerebral Palsy Patients: A Meta-Analysis of Timing of Outcome Measurement

Extracorporeal shockwave therapy (ESWT) has been suggested as an alternative treatment for reducing spasticity in patients with cerebral palsy (CP). However, the duration of its effect was rarely known. A meta-analysis was performed to investigate the effectiveness of ESWT at controlling spasticity in patients with CP according to the follow-up period. We included studies in which ESWT was used to manage spasticity in patients with CP, and the effect was compared with that in a control group. Finally, three studies were included. In the meta-analysis, spasticity, measured using the modified Ashworth scale (MAS), was significantly reduced after ESWT compared with that in the control group; however, it was sustained for only 1 month. After ESWT, significant increases in passive ankle range of motion (ROM) and plantar surface area in the standing position were observed compared with those in the control group and sustained for up to 3 months. Although spasticity measured using MAS was significantly reduced for only 1 month, improvement in spasticity-associated symptoms, such as ankle ROM and plantar surface area contacting the ground, persisted for over 3 months. ESWT appears to be a useful and effective therapeutic option for managing spasticity in patients with CP.

Research progress in extracorporeal shock wave therapy for upper limb spasticity after stroke

Spasticity is one of the most common complications after stroke. With the gradual intensification of spasticity, stroke patients will have a series of problems such as joint ankylosis and movement restriction, which affect the daily activities and increase the burden on patients' families, medical staff and society. There are many ways to treat post-stroke spasticity before, including physical therapy and exercise therapy, drug therapy, surgery and so on, but not satisfied because of a few shortcomings. In recent years, many researchers have applied extracorporeal shock wave therapy (ESWT) for the treatment of post-stroke spasm and achieved good clinical effect, because it is non-invasive, safe, easy to operate, low cost and other advantages compared with other treatment methods. This article reviews the research progress and existing problems of ESWT in the treatment of post-stroke spasticity.

Shock waves modulate corticospinal excitability: A proof of concept for further rehabilitation purposes?

Background

Focal extracorporeal shock wave therapy (fESWT) is a physical therapy vastly studied and used for various musculoskeletal disorders. However, the effect of fESWT on central nervous system is still to be determined.

Objective

To elucidate spinal and supra-spinal mechanisms of fESWT in healthy subjects, in order to widen the spectrum of its clinical applications.

Methods

In this quasi-experimental, unblinded, proof-of-concept clinical study, 10 voluntary healthy subjects underwent fESWT and were assessed immediately before (T0), immediately after (T1) and seven days after (T2) the intervention. As neurophysiological outcomes, motor evoked potentials (resting motor threshold, maximal motor evoked potential and maximal compound muscle action potential ratio, cortical silent period, total conduction motor time, direct and indirect central motor conduction time), F-waves (minimal and mean latency, persistence and temporal dispersion) and H-reflex (threshold, amplitude, maximal H reflex and maximal compound muscle action potential ratio, latency) were considered.

Results

Resting motor threshold and F-waves temporal dispersion significantly decreased, respectively, from T1 and T2 and from T0 and T2 (for both, p <  0.05). H-reflex threshold increase between T0 and T1. Analysis disclosed a strong negative correlation between Δ3 cortical silent period (i.e., T2 -T1 recordings) and Δ1 Hr threshold (i.e., T1 -T0 recordings) (r = -0.66, p <  0.05), and a positive strong relationship between Δ3 cortical silent period and Δ3 Hr threshold (r = 0.63, p <  0.05).

Conclusions

fESWT modulates corticospinal tract excitability in healthy volunteers, possibly inducing an early inhibition followed by a later facilitation after one week.

Placebo-Controlled Study of Effects of Low-Energy Shockwave Therapy (LE-ESWT) on Erectile Tissue in a Diabetic Animal Model

Objective

Low-energy extracorporeal shockwave therapy (LE-ESWT) has been shown to induce organ repair and neo-vascularization. The ability of LE-ESWT to improve erectile function in rodents as measured by improvements in intracavernosal pressure is well-established in various pathological situations. The underlying molecular mechanism are unclear and likely vary between different disorders, making rational drug design for synergetic effects with LE-ESWT difficult, without further research. In this placebo-controlled study, we aim to establish whether LE-ESWT can activate neovascularization biomarkers in diabetic tissues.

Material and Methods

Forty Wistar rats, aged 8 weeks, were randomly divided into 4 groups: 8 untreated controls, 12 controls that underwent LE-ESWT treatment, 8 controls with induced diabetes mellitus (DM) and 12 with DM underwent LE-ESWT treatment. DM was induced by streptozotocin. LE-ESWT treatment was performed with a Duolith SD1 machine (Storz), with a total amount of energy of 6.4 J per treatment. The rats received a total of three LE-ESWT treatments with 2-week intervals between treatments.

Results

Diabetic rats had significantly elevated blood glucose concentrations compared to control rats (P < 0.001) and experienced significant weight loss compared to controls (P < 0.001). Diabetic rats had elevated creatinine and urea and lower albumin (P < 0.001). Histologic analysis of penile tissue showed significant levels of vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF) expression in the LE-ESWT groups compared to controls (P< 0.01).

Conclusion

LE-ESWT induces neo-angiogenesis as expressed by VEGF and FGF in erectile tissue in normal and diabetic rats.

The association of catestatin and endocan with the effects of cardiac shock wave therapy: Biomarker sub-study of the randomized, sham procedure-controlled trial

Introduction

Cardiac shock-wave therapy (CSWT) is a non-invasive regenerative treatment method based on low-frequency ultrasound waves, which stimulate angiogenesis. Current data about the effects of revascularization procedures on angiogenesis biomarkers is limited. Recently, an association of catestatin and endocan with coronary collateral development was shown in several trials. In this study, we aimed to evaluate the impact of CSWT on the dynamics of catestatin and endocan levels and to assess their correlation with parameters of myocardial perfusion and function.

Methods

Prospective, randomized, triple-blind, sham procedure-controlled study enrolled 72 adult subjects who complied with defined inclusion criteria (NCT02339454). We measured biomarkers in 48 patients with stable angina (24 patients of CSWT group, 24 patients of sham-procedure group). Additionally, patients were divided into responders and non-responders according to improvement in myocardial perfusion and/or contractility assessed by myocardial scintigraphy and dobutamine echocardiography (30 and 13 patients, respectively). The blood samples were collected at baseline, after the last treatment procedure (9th treatment week) and at 6-month follow-up to evaluate biomarkers concentration and stored at -80° until analysis. Serum catestatin and endocan levels were determined by commercially available ELISA kits.

Results

Serum catestatin concentration significantly increased in all patients. While endocan levels significantly decreased in the responders sub-group. The increase in catestatin levels at 9th week and 6 months was positively associated with improvement in summed difference score (rho = 0.356, p = 0.028) and wall motion score, WMS (rho = 0.397, p = 0.009) at 6 months in the whole study population. Meanwhile, the decrease in endocan levels over 6 months was positively correlated with improvement in WMS at 3- and 6- months (r = 0.378, p = 0.015 and r = 0.311, p = 0.045, respectively). ROC analysis revealed that a change at 6 months in catestatin and endocan levels significantly predicted improvement in myocardial perfusion and contractile function with 68.9% sensitivity and 75.0% specificity (p = 0.039) and 51.7% sensitivity, and 91.7% specificity (p = 0.017), respectively. Baseline endocan concentration and its change at 6 months predicted response to CSWT with 68.8% sensitivity and 83.3% specificity (p = 0.039) and 81.3% sensitivity and 100% specificity (p < 0.0001), respectively.

Conclusion

This study demonstrates the association of increase in catestatin and decrease in endocan levels with the improvement of myocardial perfusion and contractile function. The potential predictive value of catestatin and endocan dynamics for the response to regenerative therapy is shown.

Efficacy and patient satisfaction of low-intensity shockwave treatment for erectile dysfunction in a retrospective real-world study in Japan

OBJECTIVES

To clarify the efficacy of low-intensity extracorporeal shockwave therapy for patients with erectile dysfunction, compare the efficacy between two types of lithotripters (ED1000 [focused type] and Renova [linear type]), and detect factors indicative of therapeutic gain with the treatment.

METHODS

This retrospective study included 76 patients (52.8 ± 11.7 years) treated by ED1000 (12 times over 9 weeks) and 484 patients (52.5 ± 11.6 years) treated by Renova (4 times over 4 weeks). Age, sexual symptoms scores, and blood examinations were assessed. Efficacy was judged by improvement of the scores and patient satisfaction and compared between patients at 1 month after treatment with the lithotripters. Independent factors influencing efficacy by Renova were also assessed.

RESULTS

Sexual symptom scores were improved significantly by both lithotripters, although the changes in the scores did not differ significantly between them. Efficacy rate as judged by patient satisfaction was 65.8% with the ED1000 and 71.1% with Renova, also without significant difference. Among several factors including age, sexual symptoms scores, endocrinological factors, metabolic factors, and the rate of phosphodiesterase type 5 inhibitor use, only age was found to be an independent factor influencing the efficacy of Renova.

CONCLUSION

We clearly showed the high efficacy of both lithotripters. Although the efficacy rate did not differ between them, we speculated that the fewer treatment sessions needed with the Renova versus the ED1000 would be a great advantage for patients. We also suggest that Renova should be recommended for patients younger than 70 years of age.

Comparison of Extracorporeal Shock Wave Therapy and Ultrasound-Guided Shoulder Injection Therapy in Patients with Supraspinatus Tendinitis

BACKGROUND

The present study compared the clinical effect of extracorporeal shock wave therapy (ESWT) with that of ultrasound (US)-guided shoulder steroid injection therapy in patients with supraspinatus tendinitis. We hypothesized that the two treatments would show comparable results.

METHODS

The inclusion criteria were age over 20 years and diagnosis of supraspinatus tendinitis using US. Ultimately, 26 patients were assigned using blocked randomization: 13 in the US-guided shoulder injection group and 13 in the ESWT group. Treatment outcomes were evaluated using the pain visual analog scale (pVAS), the American Shoulder and Elbow Society (ASES) score, and the Constant score at baseline and at 1 and 3 months after the procedure.

RESULTS

At 1 month after the intervention, pVAS, ASES, and constant score were significantly higher in the US-guided shoulder injection group than in the ESWT group, but not at 3 months after the intervention. Both groups showed clinically significant treatment effects at 3 months after the intervention compared to baseline. No significance was shown using equivalence testing.

CONCLUSIONS

US-guided shoulder injection therapy was not superior to ESWT therapy. Considering the complications and rebound phenomenon of steroid injections, interventions using ESWT may be a good alternative to treat patients with supraspinatus tendinitis.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of the effectiveness of conventional physical therapy and extracorporeal shock wave therapy on pain, disability, functional status, and depression in patients with chronic low back pain

Objectives: The aim of this study was to compare the effectiveness of conventional physical therapy (transcutaneous electrical nerve stimulation, hot pack, and therapeutic ultrasound) and extracorporeal shock wave therapy (ESWT) on pain, disability, functional status, and depression in patients with chronic low back pain (LBP).

Patients and methods: Ninety-one patients with chronic LBP were included in the study and randomized to groups that received ESWT or conventional physiotherapy; of these, 70 completed the study (37 males, 33 females; mean age: 46.4±13.3 years; range, 18 to 65 years). Outcome measures included the Visual Analog Scale, the pressure pain algometer, Oswestry Disability Index (ODI), Health Assessment Questionnaire (HAQ), fingertip-to-floor distance, and the Beck Depression Inventory. The assessments were made before treatment and at the first and 12th weeks after treatment.

Results: Extracorporeal shock wave therapy was more effective than conventional physical therapy in terms of Visual Analog Scale scores, the pressure algometer, ODI, HAQ, and fingertip-to-floor distance at the first and 12th week.

Conclusion: Extracorporeal shock wave therapy is superior to conventional physical therapy in terms of improving pain, spinal mobility, and functional status in patients with chronic LBP.

Extracorporeal shockwave therapy in an immobilized knee model in rats prevents progression of joint contracture

Joint immobilization, which ensures rest and accelerates tissue recovery in musculoskeletal disorders, often causes joint contracture, for which there is still no effective prevention. To address this, we investigated the effects of extracorporeal shockwave therapy (ESWT) in preventing joint contracture, in a unilaterally immobilized knee rat model. Under general anesthesia, ESWT (0.25 mJ/mm² , 3000 shot, 4 Hz, 3 days/week) was administered from 1 day after immobilization up to 2, 4, and 6 weeks. The immobilized control group received general anesthesia without ESWT. We evaluated joint angle, tissue elasticity, and gene and protein expression related to fibrosis, inflammation, and angiogenesis in the joint capsule. Relative to the control, the ESWT group had greater joint angle at 4 and 6 weeks, and lower posterior-capsule elasticity at 6 weeks. In the ESWT group, at 6 weeks, gene expression of collagen type I (col1α1), connective tissue growth factor (CTGF), and α-smooth muscle actin (α-SMA) was significantly downregulated, whereas interleukin-6 (IL-6) and hypoxia-inducible factor-1α (HIF-1α) gene expression was upregulated, relative to that in the control. Compared with that in the control, at 4 and 6 weeks, the ratio of CTGF⁺ cells was significantly lower in the ESWT group; at 4 weeks, the ESWT group had significantly fewer CD68⁺ cells in the adhesion area, and at 6 weeks, significantly more blood vessels. Statement of Clinical Significance: In a rat model, ESWT counteracted fibrosis, suppressed macrophage infiltration, and promoted neovascularization, reducing elasticity, and increasing joint range-ofmotion. ESWT offers a potential new strategy to prevent progression in joint contracture.

Spasticity Management after Spinal Cord Injury: The Here and Now

Spasticity is a common comorbidity of spinal cord injury (SCI) that is characterized by velocity dependent tone and spasms manifested by uninhibited reflex activity of muscles below the level of injury. For some, spasticity can be beneficial and facilitate functional standing, transfers, and some activities of daily living. For others, it may be problematic, painful, and interfere with mobility and function. This manuscript will address the anatomy and physiology of neuromuscular reflexes as well as the pathophysiology that occurs after SCI. Spasticity assessment will be discussed in terms of clinical history and findings on physical examinations, including responses to passive and active movement, deep tendon reflexes, and other long tract signs of upper motor neuron injury, as well as gait and function. Management strategies will be discussed including stretch, modalities, pharmacotherapy, neurolysis, and surgical options.

Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors

In recent years, extracorporeal shock wave therapy (ESWT) has received increasing attention for its potential beneficial effects on various bone and soft-tissue pathologies, yielding promising outcomes for pain relief and functional recovery. In fact, ESWT has emerged as an alternative, non-invasive, and safe treatment for the management of numerous musculoskeletal disorders, including myofascial pain syndrome (MPS). In particular, MPS is a common chronic painful condition, accounting for the largest proportion of patients affected by musculoskeletal problems. Remarkably, sensory innervation and nociceptors of the fascial system are emerging to play a pivotal role as pain generators in MPS. At the same time, increasing evidence demonstrates that application of ESWT results in selective loss of sensory unmyelinated nerve fibers, thereby inducing long-lasting analgesia. The findings discussed in the present review are supposed to add novel viewpoints that may further enrich our knowledge on the complex interactions occurring between disorders of the deep fascia including changes in innervation, sensitization of fascial nociceptors, the pathophysiology of chronic musculoskeletal pain of MPS, and EWST-induced analgesia. Moreover, gaining mechanistic insights into the molecular mechanisms of pain-alleviating effects of ESWT may broaden the fields of shock waves clinical practice far beyond the musculoskeletal system or its original application for lithotripsy.

Cardiac Shockwave Therapy – A Novel Therapy for Ischemic Cardiomyopathy?

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

The effect of radial shockwave on the median nerve pathway in patients with mild-to-moderate carpal tunnel syndrome: a randomized clinical trial

Background

This study aimed to evaluate the short-term effect of radial shockwave on the median nerve pathway as a new model method in patients with mild-to-moderate carpal tunnel syndrome.

Methods

In this randomized clinical trial, 60 patients were randomly allocated into three equal groups. The first group received 1500 shocks on the carpal tunnel, the second group received 1500 shocks on the carpal tunnel and median nerve pathways, and the third group was the control group. In all three groups, patients received conventional physiotherapy for ten sessions. In addition, patients in experimental groups received four sessions of radial shockwave. Pain and paresthesia intensity, sensory and motor distal latency were evaluated as primary outcomes. Boston carpal tunnel Questionnaire scores were evaluated as secondary outcomes. Evaluations were performed at baseline, 1 and 4 weeks after the end of the treatment.

Results

Pain and paresthesia intensity and Boston questionnaire score significantly decreased in all three groups, but the greater improvement was noted in shockwave groups. Sensory and motor distal latency were only improved in shockwave groups. In terms of clinical and electrophysiological parameters, two groups of shockwaves showed similar results.

Conclusions

Radial shockwave combined with conventional physiotherapy is an effective noninvasive treatment for mild-to-moderate carpal tunnel syndrome that produces greater and longer-lasting results than conventional physiotherapy alone. There were no differences observed between utilizing radial shockwave on the carpal tunnel or median nerve pathways on the palmar surface of the hand, in terms of clinical and electrophysiological measurements.

Clinical Trial registration number The study was registered at https://fa.irct.ir/user/trial/49490/view (20200706048028N1) in date of 08/24/2021.

Pharmaceutical and Energy-Based Management of Sexual Problems in Women

This article summarizes and critiques the evidence for use of available pharmacotherapies (vasoactive, psychoactive, and hormonal medications) and energy-based therapies (laser, radiofrequency, shockwave, and neurostimulation) for treatment of female sexual dysfunction. The enthusiasm with which energy-based treatments for sexual dysfunction have been adopted is disproportionate to the amount of data currently available to support their clinical use. Pharmacotherapy for female sexual dysfunction has considerably more research evidence to justify its use. Patients must be empowered to make an informed, autonomous determination as to whether the risk/reward ratio favors the use of pharmacotherapy, energy-based therapy, or some other treatment intervention.

Cardiac Shock Wave Therapy Ameliorates Myocardial Ischemia in Patients With Chronic Refractory Angina Pectoris: A Randomized Trial

Background: Cardiac shock wave therapy (CSWT) is a non-invasive new option for the treatment of chronic refractory angina pectoris (CRAP). This study aimed to evaluate the safety and efficiency of CSWT in the treatment of CRAP. Methods: Eighty-seven patients with CRAP were randomly allocated into CWST group (n = 46) and Control group (n = 41). Canadian Cardiovascular Society (CCS) grade of angina pectoris, Seattle Angina Questionnaire (SAQ) score, 6-min walk test (6MWT), weekly dosage of nitroglycerin, and myocardial perfusion on D-SPECT were determined at baseline and during the follow-up period. Adverse events were also evaluated. Results: CSWT was well-tolerated in the CSWT patients. CSWT significantly improved the CCS grade, SAQ score, and 6MWT (p < 0.05). Imaging examinations showed that the ischemic area was reduced after CSWT. However, no significant changes were observed in the Control group. Conclusions: CSWT may improve the myocardial perfusion and reduce clinical symptoms without increasing adverse effects in CRAP patients. It provides a non-invasive and safe clinical therapy for CRAP patients. Clinical Trial registration: www.ClinicalTrials.gov, identifier: NCT03398096.

Shockwave therapy associated with progressive exercises in rotator cuff tendinopathy: a clinical trial protocol

The aim of the present study is to determine whether adding shockwave therapy (SWT) to a progressive exercise program improves shoulder pain and function in individuals with rotator cuff tendinopathy (RC tendinopathy). Ninety patients diagnosed with rotator cuff tendinopathy will be randomly allocated into two groups: active SWT plus a progressive exercise program or placebo SWT plus a progressive exercise program. Primary outcomes will be measured using the Constant-Murley Score function questionnaire and by assessing patient-reported pain intensity with the numerical pain rating scale. The secondary outcomes will be measured using the Global Perceived Effects Scale and Shoulder Pain and Disability Index. All the outcomes will be measured immediately after the end of treatment and at 3-month follow-up.

Mechanical Stimulation of Fibroblasts by Extracorporeal Shock Waves: Modulation of Cell Activation and Proliferation Through a Transient Proinflammatory Milieu

Extracorporeal shock waves (ESWTs) are “mechanical” waves, widely used in regenerative medicine, including soft tissue wound repair. Although already being used in the clinical practice, the mechanism of action underlying their biological activities is still not fully understood. In the present paper we tried to elucidate whether a proinflammatory effect may contribute to the regenerative potential of shock waves treatment. For this purpose, we exposed human foreskin fibroblasts (HFF1 cells) to an ESWT treatment (100 pulses using energy flux densities of 0.19 mJ/mm² at 3 Hz), followed by cell analyses after 5 min, up to 48 h. We then evaluated cell proliferation, reactive oxygen species generation, ATP release, and cytokine production. Cells cultured in the presence of lipopolysaccharide (LPS), to induce inflammation, were used as a positive control, indicating that LPS-mediated induction of a proinflammatory pattern in HFF1 increased their proliferation. Here, we provide evidence that ESWTs affected fibroblast proliferation through the overexpression of selected cytokines involved in the establishment of a proinflammatory program, superimposable to what was observed in LPS-treated cells. The possibility that inflammatory circuits can be modulated by ESWT mechanotransduction may disclose novel hypothesis on their biological underpinning and expand the fields of their biomedical application.

Combined Melatonin and Extracorporeal Shock Wave Therapy Enhances Podocyte Protection and Ameliorates Kidney Function in a Diabetic Nephropathy Rat Model

(1) Background: Diabetic nephropathy (DN) is common complication of diabetes. Current therapy for DN does not include promotion of podocyte protection. Therefore, we investigated the therapeutic effect of melatonin (Mel) combined extracorporeal shock wave (SW) therapy on a DN rat model. (2) Methods: The DN rats were treated with Mel (5 mg/kg) twice a week for 6 weeks and SW treatment once a week (0.13 mJ/mm²) for 6 weeks. We assessed urine microalbumin, albumin to creatinine ratio (ACR), glomerular hypertrophy, glomerular fibrosis, podocyte markers (Wilm’s tumor protein-1, synaptopodin and nephrin), cell proliferation, cell survival, cell apoptosis, renal inflammation and renal oxidative stress. (3) Results: The Mel combined SW therapy regimen significantly reduced urine microalbumin excretion (3.3 ± 0.5 mg/dL, p < 0.001), ACR (65.2 ± 8.3 mg/g, p < 0.001), glomerular hypertrophy (3.1 ± 0.1 × 10⁶ μm³, p < 0.01) and glomerular fibrosis (0.9 ± 0.4 relative mRNA fold, p < 0.05). Moreover, the Mel combined SW therapy regimen significantly increased podocyte number (44.1 ± 5.0% area of synaptopodin, p < 0.001) in the Mel combined SW group. This is likely primarily because Mel combined with SW therapy significantly reduced renal inflammation (753 ± 46 pg/mg, p < 0.01), renal oxidative stress (0.6 ± 0.04 relative density, p < 0.05), and apoptosis (0.3 ± 0.03 relative density, p < 0.001), and also significantly increased cell proliferation (2.0 ± 0.2% area proliferating cell nuclear antigen (PCNA), p < 0.01), cell survival, and nephrin level (4.2 ± 0.4 ng/mL, p < 0.001). (4) Conclusions: Mel combined SW therapy enhances podocyte protection and ameliorates kidney function in a DN rat model. Mel combined SW therapy may serve as a novel noninvasive and effective treatment of DN.

Reviewing the evidence for shockwave- and cell-based regenerative therapies in the treatment of erectile dysfunction

Erectile dysfunction (ED) is both a common and complex disease process. Existing ED treatments do not always achieve adequate results. There is clinical interest in employing regenerative therapies, including low-intensity extracorporeal shockwave therapy (Li-ESWT), platelet rich plasma (PRP), and stem cell therapy (SCT), in the treatment of ED as adjunct or alternative treatments. Here, we present evidence for emerging shockwave- and cell-based regenerative therapies for the treatment of ED following a thorough review of the existing PubMed literature pertaining to Li-ESWT, PRP, and SCT in relation to the treatment of ED. Li-ESWT causes microtrauma in tissue that hypothetically upregulates angiogenesis and recruits stem cells. Several large-scale systematic reviews and meta-analyses have reported that Li-ESWT improved ED in humans. Additionally, evidence has commenced to show that Li-ESWT may be effective against two recognized and complex etiologies of ED: diabetic and neurogenic. PRP delivers an autologous sample rich in growth factors to damaged tissue. Animal model studies have demonstrated improved erectile function recovery as well as preservation of cavernous nerve axons. Studies with PRP in humans are limited. SCT utilizes the regenerative potential of stem cells for healing of damaged tissue. In the treatment of ED, SCT has been used in the setting of diabetic and post-prostatectomy ED. Results of human studies are varied, although SCT treatments did result in increased erectile rigidity with some patients recovering the ability to achieve penetration. While these regenerative therapies show potential to augment the current treatment regimen for ED, there is a paucity of evidence to support the safety and efficacy of these treatments. Further research is necessary to define the role of these alternative therapies in the treatment of ED.

The Acceleration of Diabetic Wound Healing by Low-Intensity Extracorporeal Shockwave Involves in the GSK-3β Pathway

Previous studies have demonstrated that extracorporeal shock wave therapy (ESWT) could accelerate diabetic wound healing and that the inhibition of glycogen synthase kinase-3β (GSK-3β) is involved in epithelial differentiation during wound healing. This study investigated whether the enhancement of diabetic wound healing by ESWT is associated with the GSK-3β-mediated Wnt/β-catenin signaling pathway. A dorsal skin wounding defect model using streptozotocin-induced diabetic rodents was established. Rats were divided into 4 groups: group 1, normal controls without diabetes; group 2, diabetic controls without treatment; group 3, diabetic rats receiving ESWT; and group 4, rats receiving 6-bromoindirubin-3′oxime (BIO), a GSK-3β inhibitor, to trigger Wnt/β-catenin signaling. Tissue samples were collected and analyzed by immunohistochemical (IHC) staining and quantitative RT-PCR. The ESWT and BIO-treated groups both exhibited significant promotion of wound healing compared to the healing in controls without treatment. RT-PCR analysis of Wnt-1, -3a, -4, -5a, and -10 and β-catenin expression showed significantly increased expression in the ESWT group. The IHC staining showed that Wnt-3a and -5a and β-catenin levels were significantly increased in the ESWT and BIO treatment groups compared to the control groups. ESWT enhancement of diabetic wound healing is associated with modulation of the GSK-3β-mediated Wnt/β-catenin signaling pathway.

Extracorporeal shock wave therapy versus local corticosteroid injection for the treatment of carpal tunnel syndrome: a meta-analysis

BACKGROUND

Many studies have demonstrated the effectiveness of extracorporeal shock wave therapy (ESWT) and local corticosteroid injection (LCI) for the treatment of carpal tunnel syndrome (CTS), and some studies showed that the effect of ESWT was superior to LCI. We performed this meta-analysis to compare the clinical effects across the two therapies.

METHODS

Relevant randomized controlled trials (RCTs) comparing ESWT and LCI for the treatment of CTS were searched in electronic database. The Cochrane risk bias tool was used for quality assessment. After data extraction and quality assessment of the included studies, a meta-analysis was performed using RevMan 5.3 software. Mean differences (MDs), odds ratios (ORs), and 95% confidence intervals (CIs) were analyzed. The protocol for this systematic review was registered on INPLASY (202080025) and is available in full on the inplasy.com ( https://doi.org/10.37766/inplasy2020.8.0025 ) RESULTS: A total of 5 RCT studies with 204 patients were included from the electronic database. The meta-analysis results showed that two therapies were not significantly different in terms of visual analog scale (VAS) score (P = 0.65), Boston Carpal Tunnel Questionnaire (BQ) score (P = 0.14), sensory distal latency (P = 0.66), and nerve conduction velocity (NCV) of the sensory nerve (P = 0.06). There were significant differences between the results of motor distal latency (P < 0.0001), compound muscle action potential (CMAP) amplitude (P < 0.00001), and sensory nerve action potential (SNAP) amplitude (P = 0.004).

CONCLUSIONS

In terms of pain relief and function improvement, the effects of ESWT and LCI are not significantly different. In terms of electrophysiological parameters, LCI has a stronger effect on shortening motor distal latency; ESWT is superior to LCI in improving action potential amplitude. ESWT is a noninvasive treatment with fewer complications and greater patient safety. In light of the heterogeneity and limitations, these conclusions require further research for definitive conclusions to be drawn.

A Narrative Review of Metatarsal Bone Stress Injury in Athletic Populations: Etiology, Biomechanics, and Management

Metatarsal bone stress injuries (BSIs) are common in athletic populations. BSIs are overuse injuries that result from an accumulation of microdamage that exceeds bone remodeling. Risk for metatarsal BSI is multifactorial and includes factors related to anatomy, biology, and biomechanics. In this article, anatomic factors including foot type, metatarsal length, bone density, bone geometry, and intrinsic muscle strength, which each influence how the foot responds to load, are discussed. Biologic factors such as low energy availability and impaired bone metabolism influence the quality of the bone. Finally, the influence of biomechanical loads to bone such as peak forces, load rates, and loading cycles are reviewed. General management of metatarsal BSI is discussed, including acute care, rehabilitation, treatment of refractory metatarsal BSI, and evaluation of healing/return to sport. Finally, we identify future research priorities and emerging treatments for metatarsal BSI.

In Vivo Modulation of Angiogenesis and Immune Response on a Collagen Matrix via Extracorporeal Shockwaves

The effective management of tissue integration and immunological responses to transplants decisively co-determines the success of soft and hard tissue reconstruction. The aim of this in vivo study was to evaluate the eligibility of extracorporeal shock wave therapy (ESWT) with respect to its ability to modulate angiogenesis and immune response to a collagen matrix (CM) for tissue engineering in the chorioallantoic membrane (CAM) assay, which is performed with fertilized chicken eggs. CM were placed on the CAM on embryonic development day (EDD) 7; at EDD-10, ESWT was conducted at 0.12 mJ/mm² with 500 impulses each. One and four days later, angiogenesis represented by vascularized area, vessel density, and vessel junctions as well as HIF-1α and VEGF gene expression were evaluated. Furthermore, immune response (iNOS2, MMP-9, and MMP-13 via qPCR) was assessed and compared between ESWT- and non-ESWT-groups. At EDD-14, the vascularized area (+115% vs. +26%) and the increase in vessel junctions (+751% vs. +363%) were significantly higher in the ESWT-group. ESWT significantly increased MMP-9 gene expression at EDD-11 and significantly decreased MMP-13 gene expression at EDD-14 as compared to the controls. Using the CAM assay, an enhanced angiogenesis and neovascularization in CM after ESWT were observed. Furthermore, ESWT could reduce the inflammatory activity after a latency of four days.

Radial shock waves prevent growth retardation caused by the clinically used drug vismodegib in ex vivo cultured bones

In childhood medulloblastoma patients, the hedgehog antagonist vismodegib is an effective anti-cancer treatment but unfortunately induces irreversible growth arrests and growth impairment limiting its use in skeletally immature patients. We hypothesized that radial shock wave treatment (rSWT) may protect drug-induced growth impairment owing to its osteogenic effects. Fetal rat metatarsal bones were exposed to vismodegib (day 0–5; 100 nM) and/or rSWT (single session); other bones from day 1 were continuously exposed to a Gli1 antagonist (GANT61; 10 µM) and/or rSWT (single session). Control bones were untreated. The bone length was measured at intervals; histomorphometric analysis and immunostaining for PCNA, Gli1, and Ihh were performed on the sectioned bones. Bones treated with vismodegib showed impaired bone growth, reduced height of the resting-proliferative zone and reduced hypertrophic cell size compared to control. In vismodegib treated bones, a single session of rSWT partially rescued bone growth, increased the growth velocity, hypertrophic cell size, and restored growth plate morphology. Bones exposed to GANT61 showed impaired bone growth and disorganized growth plate while when combined with rSWT these effects were partially prevented. Locally applied rSWT had a chondroprotective effect in rat metatarsal bones and suggest a novel strategy to prevent growth impairment caused by vismodegib.

Penile low intensity shock wave treatment for PDE5I refractory erectile dysfunction: a randomized double-blind sham-controlled clinical trial

PURPOSE

Over the last decade, penile low-intensity extracorporeal shockwave therapy (LI-ESWT) has emerged as a promising alternative for the treatment of erectile dysfunction (ED). The aim of this trial is to assess the effect of electromagnetic LI-ESWT on the erectile function of vascular phosphodiesterase type 5 inhibitor (PDE5I) refractory ED patients.

METHODS

Randomized, double-blind, sham-controlled study. 76 patients with vascular PDE5I-refractory ED completed the study. 40 men were treated with LI-ESWT (1 session/week for 4 weeks, 5000 shocks/session, 0.09 mJ/mm² energy density) and 36 were treated with a sham probe. Baseline and post-treatment (1, 3 and 6 months) evaluations were performed using validated erectile function questionnaires (IIEF-EF, EHS, SEP2, SEP3 and GAQ1). The groups were compared using Mann-Whitney-Wilcoxon and chi-squared tests, with results considered statistically significant at p < 0.05.

RESULTS

At the 3-month follow-up, median change in IIEF-EF score for active and sham groups was 3.5 (IQR 0-10) and - 0.5 (IQR - 11 to 1), respectively (p < 0.05). Six months after treatment, 52.5% of patients (21/40) in the active group and 27.8% of patients (10/36) in the sham group presented an EHS > 2 (p < 0.05). At the same evaluation, 40.0% (16/40) and 13.9% (5/36) of patients had positive answers to GAQ-1, in the treated and sham groups, respectively (p < 0.05). No adverse events were observed during the study.

CONCLUSION

This study showed that penile electromagnetic shockwave therapy may improve erectile function, to a modest extent, on certain patients that do not respond to PDE5I; making it an alternative for vascular ED patients that reject more invasive therapies.

Clinical Practice Guideline Recommendation on the Use of Low Intensity Extracorporeal Shock Wave Therapy and Low Intensity Pulsed Ultrasound Shock Wave Therapy to Treat Erectile Dysfunction: The Asia-Pacific Society for Sexual Medicine Position Statement

Published literature shows low intensity extracorporeal shock wave therapy (LIESWT) and low intensity pulsed ultrasound (LIPUS) therapy to improve erectile function and penile hemodynamic by inducing neovascularisation and promoting tissue regeneration. Key opinion leaders across the Asia Pacific region attended the recent biennial meeting of the Asia Pacific Society for Sexual Medicine in Australia, and presented the current evidence on LIESWT and LIPUS for erectile dysfunction (ED). The clinical findings were internally discussed, and the quality of evidence was graded based on the Oxford Centre for Evidence-Based Medicine recommendations. Existing literature supports the use of LIESWT and LIPUS in men with ED, with many clinical studies reported encouraging results with improved erectile function, good safety profile and short-term durability. However, controversial exists due to sampling heterogeneity, non-standardised treatment protocol and lack of large multiinstitutional studies. There is a need to better define which subgroup of ED population is best-suited, and specific treatment protocol to optimise shock wave energy delivery. More stringent and larger multi-institutional randomised placebo-controlled trials are warranted before clinical adoption of LIESWT and LIPUS as the new standard of care for men with ED.

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.

Extracorporeal shockwave therapy combined with alginate dressing for treatment of sacroiliac decubital necrosis in older adults: A case report

RATIONALE

Pressure sores are major clinical problems with limited treatment options.

PATIENT CONCERN

A 62-year-old man, admitted with unresponsive, indifferent mood, and malnutrition. A noval-shaped skin lesion deeping into the fascia was found in the sacrococcygeal region.

DIAGNOSIS

The patient was diagnosed with delayed carbon monoxide poisoning encephalopathy and stage IV sacrococcygeal pressure sores.

INTERVENTION

The patient received neurologic rehabilitation therapy and simple debridement dressing care followed by extracorporeal shockwave therapy.

OUTCOMES

The scores for the pressure ulcer healing scale were 17 points, 13 points, 9 points, and 5 points, respectively, before treatment and at the 4-, 8-, and 12-week follow-ups. At 2 weeks after discharging the total pressure ulcer healing scale score was 0, which signifies that the sacroiliac decubital necrosis healed without adverse reactions and side effects.

LESSONS

This study presents a therapeutic solution for treating older adults with pressure ulcers by using extracorporeal shockwave with alginate dressing, which proved effective and safe.

The Basic Science Behind Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction: A Systematic Scoping Review of Pre-Clinical Studies

INTRODUCTION

Despite recent promising clinical results, the underlying mechanism of action of low-intensity extracorporeal shockwave therapy (Li-ESWT) for erectile dysfunction (ED) is mostly unclear and currently under investigation.

AIM

To systematically identify and evaluate evidence regarding the basic science behind Li-ESWT for ED, discuss and propose a putative mechanism of action, address the limitations, and imply insights for further investigation in the field.

METHODS

Using Cochrane's methodologic recommendations on scoping studies and systematic reviews, we conducted a systematic scoping review of the literature on experimental research regarding Li-ESWT for ED and other pathologic conditions. The initial systematic search was carried between January and November 2017, with 2 additional searches in April and August 2018. All studies that applied shockwave treatment at an energy flux density >0.25 mJ/mm² were excluded from the final analysis.

MAIN OUTCOME MEASURE

We primarily aimed to clarify the biological responses in erectile tissue after Li-ESWT that could lead to improvement in erectile function.

RESULTS

59 publications were selected for inclusion in this study. 15 experimental research articles were identified on Li-ESWT for ED and 44 on Li-ESWT for other pathologic conditions. Li-ESWT for ED seems to improve erectile function possibly through stimulation of mechanosensors, inducing the activation of neoangiogenesis processes, recruitment and activation of progenitor cells, improving microcirculation, nerve regeneration, remodeling of erectile tissue, and reducing inflammatory and cellular stress responses.

CLINICAL IMPLICATIONS

Improving our understanding of the mechanism of action of Li-ESWT for ED can help us improve our study designs, as well as suggest new avenues of investigation.

STRENGTHS & LIMITATIONS

A common limitation in all these studies is the heterogeneity of the shockwave treatment application and protocol.

CONCLUSION

Li-ESWT for ED, based on current experimental studies, seems to improve erectile function by inducing angiogenesis and reversing pathologic processes in erectile tissue. These studies provide preliminary insights, but no definitive answers, and many questions remain unanswered regarding the mechanism of action, as well as the ideal treatment protocol. Sokolakis I, Dimitriadis F, Teo P, et al. The Basic Science Behind Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction: A Systematic Scoping Review of Pre-Clinical Studies. J Sex Med 2019;16:168-194.

The Effect of Extracorporeal Shock Wave Therapy in the Treatment of Patients with Trigger Finger

Introduction

Trigger finger disorder is a sudden release or locking of a finger during flexion or extension. Regarding the complications and disadvantages mentioned for the methods used in the treatment of trigger finger disorder, the aim of this study was to investigate the effect of extracorporeal shock wave therapy in the treatment of patients with trigger finger.

Methods

This study was an interventional study recruiting 19 patients with trigger finger disorder. Evaluation of pain severity, severity of triggering, and functional impact of triggering was carried out using the Visual Analogue Scale, Trigger Finger Score suggested by Quinnell, and Quick-Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, respectively, before intervention, immediately after intervention, and in 6 and 18 weeks after intervention. Each patient was treated with extracorporeal shock wave therapy in three sessions with a 1-week interval. Data were analyzed in Statistical Package for the Social Sciences (SPSS) software using ANOVA to monitor changes in pain severity, severity of triggering, and functional impact of triggering during follow-ups.

Results

There were statistically significant differences with regard to reduction of the pain severity, severity of triggering, and functional impact of triggering before intervention, immediately after intervention, and in 6 and 18weeks after intervention (P<0.01). However, the effect of extracorporeal shock wave therapy on reducing severity of triggering immediately after intervention did not yield a statistically significant difference compared to before intervention (P>0.01).

Conclusion

It seems that extracorporeal shock wave therapy leads to a reduction in pain severity, severity of triggering, and functional impact of triggering. These effects persisted until the 18th week after the intervention. It is recommended to use extracorporeal shock wave therapy in terms of a non-invasive intervention with no significant complications for patients with trigger finger.

Shock Waves as a Treatment Modality for Spasticity Reduction and Recovery Improvement in Post-Stroke Adults - Current Evidence and Qualitative Systematic Review

Purpose

This systematic review examines intervention studies using extracorporeal shock wave therapy (ESWT) application in post-stroke muscle spasticity with particular emphasis on the comparison of two different types of radial (rESWT) and focused shock waves (fESWT).

Methods

PubMed, PEDro, Scopus, and EBSCOhost databases were systematically searched. Studies published between the years 2000 and 2019 in the impact factor journals and available in the English full-text version were eligible for inclusion. All qualified articles were classified in terms of their scientific reliability and methodological quality using the PEDro criteria. The PRISMA guidelines were followed and the registration on the PROSPERO database was done.

Results

A total of 17 articles were reviewed of a total sample of 303 patients (age: 57.87±10.45 years and duration of stroke: 40.49±25.63 months) who were treated with ESWT. Recent data confirm both a subjective (spasticity, pain, and functioning) and objective (range of motion, postural control, muscular endurance, muscle tone, and muscle elasticity) improvements for post-stroke spasticity. The mean difference showing clinical improvement was: ∆=34.45% of grade for fESWT and ∆=34.97% for rESWT that gives a slightly better effect of rESWT (∆=0.52%) for spasticity (p<0.05), and ∆=38.83% of angular degrees for fESWT and ∆=32.26% for rESWT that determines the more beneficial effect of fESWT (∆=6.57%) for range of motion (p<0.05), and ∆=18.32% for fESWT and ∆=22.27% for rESWT that gives a slightly better effect of rESWT (∆=3.95%) for alpha motor neuron excitability (p<0.05). The mean PEDro score was 4.70±2.5 points for fESWT and 5.71±2.21 points for rESWT, thus an overall quality of evidence grade of moderate (“fair” for fESWT and “good” for rESWT). Three studies in fESWT and four in rESWT obtained Sackett’s grading system’s highest Level 1 of evidence.

Conclusion

The studies affirm the effectiveness of ESWT in reducing muscle spasticity and improving motor recovery after stroke.