Extracorporeal shock-wave therapy for tendonitis of the rotator cuff

Extracorporeal Shockwave Therapy for the Treatment of Noncalcific Rotator Cuff Tendinopathy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the systematically review the short-, intermediate-, and long-term effects of extracorporeal shockwave therapy on pain intensity and shoulder function in individuals with noncalcific rotator cuff tendinopathy.

DESIGN

The MEDLINE, CINAHL, SPORTDiscus, and Embase were searched from inception up to June 2023. We included randomized controlled trials that investigated the effects of extracorporeal shockwave therapy on pain intensity and shoulder function.

RESULTS

Nine studies were included with a total sample of 543 individuals. Extracorporeal shockwave therapy was superior to sham extracorporeal shockwave therapy in improving pain intensity at short-term follow-up (standardized mean difference = -0.28; 95% confidence interval, -0.55 to -0.01). Extracorporeal shockwave therapy was not superior to sham extracorporeal shockwave therapy in improving pain intensity at intermediate- and long-term follow-ups ( P > 0.05). Extracorporeal shockwave therapy was not superior to other treatments in improving pain intensity at short- and intermediate-term follow-ups ( P > 0.05). Extracorporeal shockwave therapy was not superior to sham extracorporeal shockwave therapy and other treatments in improving shoulder function at short-, intermediate-, and long-term follow-ups ( P > 0.05).

CONCLUSIONS

Moderate-certainty evidence indicated that extracorporeal shockwave therapy showed small improvement in shoulder pain over sham extracorporeal shockwave therapy at short-term follow-up. In addition, extracorporeal shockwave therapy was not superior to sham extracorporeal shockwave therapy in improving function, and it was not superior to other treatments in improving shoulder pain and function.

Effect of extracorporeal shock wave therapy for rotator cuff injury: Protocol for a systematic review and meta-analysis

BACKGROUND

Rotator cuff injury (RCI) is a common musculoskeletal ailment and a major cause of shoulder pain and limited functionality. The ensuing pain and restricted movement significantly impact overall quality of life. This study aims to systematically review the effects of extracorporeal shock wave therapy (ESWT) on RCI.

METHODS

This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. A literature search, spanning inception to November 1, 2023, will include databases such as PubMed, Web of Science, the Cochrane Library, Scopus, MEDLINE, EMBASE, EBSCO, and China National Knowledge Infrastructure (CNKI) to identify ESWT studies for RCI treatment. Excluding retrospectives, bias risk will be assessed with the Cochrane tool. Two researchers will independently screen, extract data, and evaluate bias risk. Revman 5.3 software will be used for data analysis.

RESULTS

This study aims to objectively and comprehensively evaluate the effectiveness and safety of randomized controlled trials of ESWT in the treatment of RCI, and analyze in detail the effect of ESWT in the treatment of RCI. Results will be analyzed using the Pain Visual Analogue Scale (VAS), Constant-Murley score, University of California Los Angeles score (UCLA), and American Shoulder and Elbow Surgeons form (ASES). If applicable, subgroup analysis will also be performed to divide patients into groups according to the energy level of ESWT, the time of intervention, and the degree of tearing of RCI. Finally, the results are submitted for publication in a peer-reviewed journal.

DISCUSSION AND CONCLUSION

There is existing evidence suggesting that ESWT may contribute to the amelioration of pain and functional limitations associated with Rotator Cuff Injury (RCI). This systematic review aims to update, consolidate, and critically evaluate relevant evidence on the effects of ESWT for RCI. The anticipated outcomes may serve as a valuable reference for clinical ESWT practices, covering treatment methods, timing, and intensity. Moreover, this review aspires to provide high-quality evidence addressing the impact of ESWT on RCI-related pain. Simultaneously, the findings of this systematic review are poised to offer guidance to clinicians and rehabilitation therapists. This guidance is intended to enhance the management of pain and functional impairments experienced by individuals with RCI, ultimately leading to improvements in their physical well-being.

TRIAL REGISTRATION

Protocol registration number CRD42023441407. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441407.

Focused Ultrasound Mechanical Disruption of Ex Vivo Rat Tendon

Around 30 million tendon injuries occur annually in the U.S. costing $ 114 billion. Conservative therapies, like dry needling, promote healing in chronically injured tendons by inducing microdamage but have mixed success rates. Focused ultrasound (fUS) therapy can noninvasively fractionate tissues through the creation, oscillation, and collapse of bubbles in a process termed histotripsy; however, highly collagenous tissues, like tendon, have shown resistance to mechanical fractionation. This study histologically evaluates whether fUS mechanical disruption is achievable in tendons. Ex vivo rat tendons (45 Achilles and 44 supraspinatus) were exposed to 1.5-MHz fUS operating with 0.1-10 ms pulses repeated at 1-100 Hz for 15-60 s with peak positive pressures <89 MPa and peak negative pressures <26 MPa; other tendons were exposed to dry needling or sham. Immediately after treatment, tendons were flash-frozen and stained with hematoxylin and eosin (H&E) or alpha-nicotinamide adenine dinucleotide diaphorase ( α -NADH-d) and evaluated by two reviewers blinded to the exposure conditions. Results showed successful creation of bubbles for all fUS-treated samples; however, not all samples showed histological injury. When the injury was detected, parameter sets with shorter pulses (0.1-1 ms), lower acoustic pressures, or reduced treatment times showed mechanical disruption in the form of fiber separation and fraying with little to no thermal injury. Longer pulses or treatment times showed a combination of mechanical and thermal injury. These findings suggest that mechanical disruption is achievable in tendons within a small window of acoustic parameters, supporting the potential of fUS therapy in tendon treatment.

Effectiveness of conservative therapy in tendinopathy-related shoulder pain: A systematic review of randomized controlled trials

OBJECTIVE

Systematic review investigated efficacy of conservative therapy on pain and function in people with tendinopathy-related shoulder pain.

METHODS

Searches were conducted on six databases. All randomized controlled trials investigating efficacy of any conservative therapy on pain and function in people with tendinopathy-related shoulder pain were included. Estimates for each specific conservative therapy were presented as weighted mean differences (WMDs) or mean differences (MDs), with 95% confidence intervals (CIs). Quality of the evidence was assessed using GRADE.

RESULTS

Five randomized controlled trials were included. Extracorporeal shock-wave therapy (ESWT) was effective on pain at short-term (i.e., ≤3 months) when compared with control (WMD = -1.7 out of 101 points, -3.1 to -0.3; n = 158). Individual trials also suggested effects of non-steroidal anti-inflammatory drugs (NSAIDs) (-13.7 to -2.3; n = 365) and extracorporeal radial pressure pulse therapy (rESWT) (-40.0 to -27.0; n = 79). Laser therapy and ESWT were not effective on pain and function at short-term, respectively. No trials investigated medium- or long-term effects, and quality of the evidence ranged from low to very low quality.

CONCLUSIONS

Conservative therapies currently available for the rotator cuff management and biceps tendinopathy are not supported by low to very-low quality evidence.

Shock wave therapy for rotator cuff disease with or without calcification

BACKGROUND

Shock wave therapy has seen widespread use since the 1990s to treat various musculoskeletal disorders including rotator cuff disease, but evidence of its efficacy remains equivocal.

OBJECTIVES

To determine the benefits and harms of shock wave therapy for rotator cuff disease, with or without calcification, and to establish its usefulness in the context of other available treatment options.

SEARCH METHODS

We searched Ovid MEDLINE, Ovid Embase, CENTRAL, ClinicalTrials.gov and the WHO ICTRP up to November 2019, with no restrictions on language. We reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that used quasi-randomised methods to allocate participants, investigating participants with rotator cuff disease with or without calcific deposits. We included trials of comparisons of extracorporeal or radial shock wave therapy versus any other intervention. Major outcomes were pain relief greater than 30%, mean pain score, function, patient-reported global assessment of treatment success, quality of life, number of participants experiencing adverse events and number of withdrawals due to adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed the certainty of evidence using GRADE. The primary comparison was shock wave therapy compared to placebo.

MAIN RESULTS

Thirty-two trials (2281 participants) met our inclusion criteria. Most trials (25) included participants with rotator cuff disease and calcific deposits, five trials included participants with rotator cuff disease and no calcific deposits, and two trials included a mixed population of participants with and without calcific deposits. Twelve trials compared shock wave therapy to placebo, 11 trials compared high-dose shock wave therapy (0.2 mJ/mm² to 0.4 mJ/mm² and above) to low-dose shock wave therapy. Single trials compared shock wave therapy to ultrasound-guided glucocorticoid needling, ultrasound-guided hyaluronic acid injection, transcutaneous electric nerve stimulation (TENS), no treatment or exercise; dual session shock wave therapy to single session therapy; and different delivery methods of shock wave therapy. Our main comparison was shock wave therapy versus placebo and results are reported for the 3 month follow up. All trials were susceptible to bias; including selection (74%), performance (62%), detection (62%), and selective reporting (45%) biases. No trial measured participant-reported pain relief of 30%. However, in one trial (74 participants), at 3 months follow up, 14/34 participants reported pain relief of 50% or greater with shock wave therapy compared with 15/40 with placebo (risk ratio (RR) 1.10, 95% confidence interval (CI) 0.62 to 1.94); low-quality evidence (downgraded for bias and imprecision). Mean pain (0 to 10 scale, higher scores indicate more pain) was 3.02 points in the placebo group and 0.78 points better (0.17 better to 1.4 better; clinically important change was 1.5 points) with shock wave therapy (9 trials, 608 participants), moderate-quality evidence (downgraded for bias). Mean function (scale 0 to 100, higher scores indicate better function) was 66 points with placebo and 7.9 points better (1.6 better to 14 better, clinically important difference 10 points) with shock wave therapy (9 trials, 612 participants), moderate-quality evidence (downgraded for bias). Participant-reported success was reported by 58/150 people in shock wave therapy group compared with 35/137 people in placebo group (RR 1.59, 95% CI 0.87 to 2.91; 6 trials, 287 participants), low-quality evidence (downgraded for bias and imprecision). None of the trials measured quality of life. Withdrawal rate or adverse event rates may not differ between extracorporeal shock wave therapy and placebo, but we are uncertain due to the small number of events. There were 11/34 withdrawals in the extracorporeal shock wave therapy group compared with 13/40 withdrawals in the placebo group (RR 0.75, 95% CI 0.43 to 1.31; 7 trials, 581 participants) low-quality evidence (downgraded for bias and imprecision); and 41/156 adverse events with extracorporeal shock wave therapy compared with 10/139 adverse events in the placebo group (RR 3.61, 95% CI 2.00 to 6.52; 5 trials, 295 participants) low-quality evidence (downgraded for bias and imprecision). Subgroup analyses indicated that there were no between-group differences in pain and function outcomes in participants who did or did not have calcific deposits in the rotator cuff.

AUTHORS' CONCLUSIONS

Based upon the currently available low- to moderate-certainty evidence, there were very few clinically important benefits of shock wave therapy, and uncertainty regarding its safety. Wide clinical diversity and varying treatment protocols means that we do not know whether or not some trials tested subtherapeutic doses, possibly underestimating any potential benefits. Further trials of extracorporeal shock wave therapy for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review. A standard dose and treatment protocol should be decided upon before further research is conducted. Development of a core set of outcomes for trials of rotator cuff disease and other shoulder disorders would also facilitate our ability to synthesise the evidence.

Effect of extracorporeal shock-wave therapy for treating patients with chronic rotator cuff tendonitis

BACKGROUND

This study aimed to determine the efficacy and safety of extracorporeal shock-wave therapy (ESWT) for treating patients with chronic rotator cuff tendonitis (CRCT).

METHODS

In this study, 84 patients with CRCT were randomly divided into intervention and control groups in a ratio of 1:1. Patients in the intervention group received ESWT, whereas those in the control group received placebo. The primary outcome was measured by Numeric Rating Scale (NRS). The secondary outcomes were measured by the Constant-Murley score (CMS), simple shoulder test (SST) score, and adverse events.

RESULTS

Compared with placebo, ESWT showed greater efficacy in shoulder pain relief with regard to NRS score and shoulder function as measured by using CMS and SST score at 4 weeks (P < .05) and 8 weeks (P < .01) after treatment. However, no adverse events occurred in both groups.

CONCLUSION

ESWT was efficacious and safe for treating patients with CRCT.

A Review of Systematic Reviews of the Effectiveness of Conservative Interventions for Rotator Cuff Tendinopathy

Background

Rotator cuff tendinopathy is common and a wide range of conservative interventions are currently used to treat this problem. The purpose of this review is to systematically review the systematic reviews that evaluate the effectiveness of conservative interventions for rotator cuff tendinopathy.

Methods

An electronic search of PEDro, MEDLINE and the Cochrane Library was undertaken and supplemented by hand and citation searching. The AMSTAR checklist was adopted for quality appraisal and a narrative synthesis was undertaken.

Results

Twenty-six systematic reviews were retrieved. Methodological quality was variable. Exercise and multimodal physiotherapy appear to confer superior outcomes over no treatment or placebo, although the clinical significance of these results remains unclear. Surgery does not confer an additional benefit over exercise alone or multimodal physiotherapy. Combining manual therapy with exercise is not currently supported, neither is the use of corticosteroid injections or acupuncture. Other commonly prescribed interventions lack evidence of effectiveness.

Conclusions

Exercise and multimodal physiotherapy might be effective interventions for rotator cuff tendinopathy, although the clinical significance of this effect is unclear. This interpretation is drawn from systematic reviews comprising mainly small randomized controlled trials that frequently measure outcome in a heterogeneous manner, limiting the strength of any conclusions.

Effectiveness of passive physical modalities for shoulder pain: systematic review by the Ontario protocol for traffic injury management collaboration

BACKGROUND

Shoulder pain is a common musculoskeletal condition in the general population. Passive physical modalities are commonly used to treat shoulder pain. However, previous systematic reviews reported conflicting results.

PURPOSE

The aim of this study was to evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the shoulder.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched from January 1, 1990, to April 18, 2013.

STUDY SELECTION

Randomized controlled trials (RCTs) and cohort and case-control studies were eligible. Random pairs of independent reviewers screened 1,470 of 1,760 retrieved articles after removing 290 duplicates. Twenty-two articles were eligible for critical appraisal. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Of those, 11 studies had a low risk of bias.

DATA EXTRACTION

The lead author extracted data from low risk of bias studies and built evidence tables. A second reviewer independently checked the extracted data.

DATA SYNTHESIS

The findings of studies with a low risk of bias were synthesized according to principles of best evidence synthesis. Pretensioned tape, ultrasound, and interferential current were found to be noneffective for managing shoulder pain. However, diathermy and corticosteroid injections led to similar outcomes. Low-level laser therapy provided short-term pain reduction for subacromial impingement syndrome. Extracorporeal shock-wave therapy was not effective for subacromial impingement syndrome but provided benefits for persistent shoulder calcific tendinitis.

LIMITATIONS

Non-English studies were excluded.

CONCLUSIONS

Most passive physical modalities do not benefit patients with subacromial impingement syndrome. However, low-level laser therapy is more effective than placebo or ultrasound for subacromial impingement syndrome. Similarly, shock-wave therapy is more effective than sham therapy for persistent shoulder calcific tendinitis.

Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff tendinitis

The aim of this study was to determine the effect of radial extracorporeal shock-wave therapy (rESWT) on patients with chronic tendinitis of the rotator cuff. This was a randomised controlled trial in which 82 patients (mean age 47 years (24 to 67)) with chronic tendinitis diagnosed clinically were randomly allocated to a treatment group who received low-dose rESWT (three sessions at an interval 10 to 14 days, 2000 pulses, 0.11 mJ/mm2, 8 Hz) or to a placebo group, with a follow-up of six months. The patients and the treating orthopaedic surgeon, who were both blinded to the treatment, evaluated the results. A total of 44 patients were allocated to the rESWT group and 38 patients to the placebo group. A visual analogue scale (VAS) score for pain, a Constant–Murley (CMS) score and a simple shoulder test (SST) score significantly improved in both groups at three and six months compared with baseline (all p ≤ 0.012). The mean VAS was similar in both groups at three (p = 0.43) and six months (p = 0.262). Also, the mean CMS and SST scores were similar in both groups at six months (p = 0.815 and p = 0.834, respectively).

It would thus seem that low-dose rESWT does not reduce pain or improve function in patients chronic rotator cuff tendinitis compared with placebo treatment.

Cite this article: Bone Joint J 2013;95-B:1521–6.

Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-year results of a single-blind randomized controlled trial

BACKGROUND

Evidence from a recent randomized controlled trial indicated that supervised exercises (SE) were more effective than radial extracorporeal shock-wave therapy (rESWT) for the treatment of subacromial shoulder pain in the short to medium term. Little knowledge exists about the long-term results of rESWT for subacromial pain.

OBJECTIVE

The aim of this study was to evaluate the results of rESWT and SE provided to patients with subacromial shoulder pain after 1 year.

DESIGN

This was a single-blind randomized controlled trial.

SETTING

The study was conducted in the outpatient clinic of the Physical Medicine and Rehabilitation Department at Oslo University Hospital, Ullevaal, Norway.

PATIENTS

One hundred four patients with subacromial shoulder pain lasting at least 3 months participated. Patients were randomly assigned to either an rESWT group (n=52) or an SE group (n=52).

INTERVENTION

The rESWT intervention consisted of one session weekly for 4 to 6 weeks. The SE intervention consisted of two 45-minute sessions per week for up to 12 weeks.

MEASUREMENTS

The primary outcome measure was the Shoulder Pain and Disability Index. Secondary outcome measures were questions regarding pain and function and work status.

RESULTS

After 1 year, an intention-to-treat analysis showed no significant differences between the 2 groups for the primary outcome measure (-7.6 points, 95% confidence interval=-16.6 to 0.5) and pain, function, and medication use. Twenty-nine participants (60%) in the SE group versus 24 participants (52%) in the rESWT group were categorized as clinically improved. Thirty-eight participants in the SE group were at work compared with 30 participants in the rESWT group (odds ratio=1.1, 95% confidence interval=1.0 to 1.2). Fewer patients in the SE group had received additional treatments between 18 weeks and 1 year.

LIMITATIONS

The lack of a placebo control group, the lack of a cost-benefit analysis, and the small sample size were limitations of the study.

CONCLUSION

No significant difference was found between the SE and rESWT groups at the 1-year follow-up. More participants in the SE group had returned to work.

Biomechanical basis for tendinopathy

Tendinopathy affects millions of people in athletic and occupational settings and is a nemesis for patients and physicians. Mechanical loading is a major causative factor for tendinopathy; however, the exact mechanical loading conditions (magnitude, frequency, duration, loading history, or some combinations) that cause tendinopathy are poorly defined. Exercise animal model studies indicate that repetitive mechanical loading induces inflammatory and degenerative changes in tendons, but the cellular and molecular mechanisms responsible for such changes are not known. Injection animal model studies show that collagenase and inflammatory agents (inflammatory cytokines and prostaglandin E1 and E2) may be involved in tendon inflammation and degeneration; however, whether these molecules are involved in the development of tendinopathy because of mechanical loading remains to be verified. Finally, despite improved treatment modalities, the clinical outcome of treatment of tendinopathy is unpredictable, as it is not clear whether a specific modality treats the symptoms or the causes. Research is required to better understand the mechanisms of tendinopathy at the tissue, cellular, and molecular levels and to develop new scientifically based modalities to treat tendinopathy more effectively.