Radial Type Low-Intensity Extracorporeal Shockwave Therapy Enhances Penile Microvascular Perfusion in an Aging Rat Model: A Novel Interventional Strategy to Treat Erectile Dysfunction

PURPOSE

Physiological aging is associated with microvascular dysfunction, including in the penis, and this may contribute to age-related erectile dysfunction (ED). Low-intensity extracorporeal shockwave therapy (Li-ESWT) is a non-invasive intervention for ED, but its effect on penile microvascular function, remains unclear. Our objectives are to (i) evaluate the effect of Li-ESWT (specifically radial type ESWT [rESWT]) on penile microvascular perfusion (PMP) in aging rats, (ii) elucidate a possible mechanism, and (iii) evaluate its impact on angiogenic and smooth muscle biomarkers in cavernosal tissue.

MATERIALS AND METHODS

Male rats (n=9; 15-18 months) were anesthetized and subjected to rESWT while monitoring PMP. The nitric oxide (NO) pathway involvement was assessed by measuring the effect of rESWT on PMP following an intracavernosal injection of N(G)-nitroarginine methyl ester (L-NAME) (NO synthase inhibitor). To elucidate the cellular mechanism, another group of rats received repeated rESWT (n=4) or no treatment (n=4) three times/week for two weeks. Rats were euthanized at the end of the study and penile tissues were analyzed for angiogenic markers (vascular endothelial growth factor-A [VEGF-A], endothelial nitric oxide synthase [eNOS]) and smooth muscle content (α-actin) using immunostaining, Western blot, and quantitative polymerase chain reaction (qPCR).

RESULTS

rESWT resulted in more than a 2-fold increase in PMP (from 68.5 arbitrary units; 163.7 AU). L-NAME injection produced a <40%-50% decrease (185.3 to 101.0 AU) in rESWT-induced PMP response. Immunostaining revealed increased α-actin, eNOS, and VEGF-A in the cavernosum and these findings were confirmed by qPCR and Western blot results.

CONCLUSIONS

rESWT improved PMP, which may be mediated via increased VEGF expression, which stimulates the NO/cyclic guanosine monophosphate pathway, resulting in sustained PMP. rESWT devices could offer a safe, non-invasive treatment for age-related ED.

Extracorporeal Shock Wave Therapy (eSWT) in Spinal Cord Injury-A Narrative Review

BACKGROUND

Injury of the spinal cord causes motor and sensory dysfunction as well as pathological reflexes, leading to paraplegia or tetraplegia. The sequelae of traumatic spinal cord injury (SCI) are a significant burden and impact on healthcare systems. Despite constant progress in medicine, traumatic SCI still remains irreversible. To date, no satisfying treatment that can enable neuronal regeneration and recovery of function at the damaged level has been found. Hundreds of experiments have been conducted on various possibilities of influencing spinal regeneration; some of them have yielded promising results, but unfortunately, the successes obtained in experimental animals have not translated into humans.

METHODS

This narrative review article presents the application of extracorporeal shock wave therapy (eSWT) in patients with SCI. The article has been divided into parts: 1) use of extracorporeal shock wave therapy for regeneration of the spinal cord after traumatic spinal cord injury; 2) application of extracorporeal shock wave therapy in spasticity after spinal cord injury. In both cases, the hypotheses of possible mechanisms of action will be described.

RESULTS AND CONCLUSIONS

A small number of clinical trials have demonstrated the potential of eSWT to influence the regeneration of the spine, as an innovative, safe, and cost-effective treatment option for patients with SCI. Some reports have shown that eSWT can improve spasticity, walking ability, urological function, quality of life, and independence in daily life.

Use of Rehabilitation Therapy in Palliative Care Patients

Palliative care is a unique area of veterinary medicine, where primary goals include maintaining quality of life, as opposed to treating with a curative intent. Using the disablement model and client partnership allows for the development of a function-targeted treatment plan individualized to patient and family needs. Rehabilitation modalities, especially when combined with adaptive pain management, are well-suited to palliative care because they can greatly enhance a patient's ability to achieve improved function and quality of life. These areas join in a concept called palliative rehabilitation which combines the unique needs of these patients and the tools accessible to the rehabilitation practitioner.

Low-intensity shockwave treatment (LISWT) improves penile rigidity in eugonadal subjects with erectile dysfunction: a pilot study

BACKGROUND

Since low-intensity shockwave treatment (LISWT) has putative effects on penile hemodynamics remodeling, the aim of this study was to evaluate any improvement of penile vascular flows after LISWT treatment in patients with erectile dysfunction (ED) and poor response to PDE5i.

METHODS

Twenty-one eugonadal patients with different ED severity underwent 6 weekly LISWT sessions (1500-4000 pulses) after 2 weeks withdrawal from PDE5i assumption. Once daily Tadalafil (2.5 mg daily) was reintroduced 4 weeks apart from LISWT termination and patients were evaluated at 1, 2 and 6 months follow-up (T1, T2, T6) by the International Index of Erectile Function-15 items questionnaire (IIEF-15) erectile function (EF) domain, Erection Hardness Score (EHS) and Global Assessment Questionnaires (GAQ). Basal Penile Color-Doppler Ultrasound parameters in the flaccid state (B-PCDU) were evaluated before, during and after interventional protocol.

RESULTS

Mean EHS score improved in 35% of patients at T1, and in up to 50% of patients at T2 and T6 follow-up visits (P<0.05). We found 25% improvement of EF scores at T1 session, 43.75% at T2 and 62.5% at T6, respectively (P<0.05). No statistically significant differences in flow parameters, EF-domain and testosterone levels were found when baseline and last observation carried forward (LOCF) parameters were compared. The GAQ questionnaire scored higher satisfaction rates either at the end of the treatment (100%), or at LOCF (92.5%).

CONCLUSIONS

Despite the study limitations with respect to B-PCDU in this setting, our results confirm a trend toward improvement of erectile questionnaire scores after LISWT with higher overall satisfaction rates among patients with ED. We conclude that LISWT may be an effective option in some difficult-to-treat patients with ED by improving the erectile response to PDE5i.

Systematic Review of Complementary and Alternative Veterinary Medicine in Sport and Companion Animals: Extracorporeal Shockwave Therapy

BACKGROUND

Extracorporeal shockwave therapy (ECSWT) is increasingly used to treat different types of musculoskeletal conditions in sport and companion animals. To explore the scientific basis for the treatment, we conducted a systematic review of the literature on ECSWT used in horses, dogs, and cats.

METHODS

Relevant articles published in 1980-2020 were identified from three major databases. Each article was assessed for risk of bias.

RESULTS

The review identified 27 relevant articles on the effects of ECSWT in horses, nine in dogs, but none in cats. Typically, ECSWT involved one to three treatment sessions at 1- to 3-week intervals. We identified studies on bone mass and bone healing, wound healing, navicular disease, ligament injury, desmitis, sesamoiditis, tendon injury, osteoarthritis, and short-term analgesic effects. Common to all indications was that the scientific evidence was very limited. For each separate indication, there were relatively few studies, many of which had methodological flaws. Where favorable results were reported, they were usually not replicated in independent studies. A few encouraging results were found.

CONCLUSIONS

In sport and companion animals, the scientific evidence for clinical effects of ECSWT in horses, dogs, and cats is limited. For some applications, notably short-term pain relief, ligament ailments, and osteoarthritis, the results seem promising and warrant further exploration in high-quality studies.

Combined ultrasound guided peritendinous hyaluronic acid (500-730 Kda) injection with extracorporeal shock waves therapy vs. extracorporeal shock waves therapy-only in the treatment of shoulder pain due to rotator cuff tendinopathy. A randomized clinical trial

BACKGROUND

Rotator cuff tendinopathy (RCTe) is the most common cause of pain and shoulder dysfunction. Numerous clinical studies have demonstrated the therapeutic capacity of exogenous peritendinous hyaluronic acid (HA), and the effectiveness of extracorporeal shockwaves therapy (ESWT) in reducing pain. The aim of this study was to evaluate the added effects of HA treatment plus ESWT (E-g) or ESWT alone (SC-g), focusing on reduction of self-reported pain and disability of patients with RCTe.

METHODS

Monocentric, randomized open-label clinical trial. Patients' selection, enrollment and interventions were conducted at the Chiparo Physical Medicine and Rehabilitation outpatient facility (Lecce, Italy). Patients with a diagnosis of RCTe, were randomly allocated to the E-g or to the SC-g. Participants were assessed for self-perceived pain, and for disability, at baseline, after 30 and 60 days.

RESULTS

Forty adults (mean age 50.8±6.3; 23 woman, 17 men) were enrolled in the study, twenty for each group. During the study, both groups improved their perceived level of disability of the arm (-25.01±2.79; P<0.001), and for pain (-3.13±0.50; P<0.001). A multiplicative effect was demonstrated in the time × treatment interaction for disability (beta±SE beta: 7.40±1.77; P<0.001), and pain (beta±SE beta: 0.95±0.32; P<0.001). Moreover, more patients in the E-g reached the MCID in the outcomes-score compared to SC-g. Lastly, number needed to treat were calculated, for disability: NNT=2 (95% CI: 1-3), and for pain-score: NNT=1 (95% CI: 1-2).

CONCLUSIONS

This study provides preliminary evidence that, compared to ESWT alone, the combining ESWT and peritendinous HA-injections, revert disability and reduces shoulder pain faster in patients with RCTe.

Rehabilitation of the Canine Forelimb

The goal of rehabilitation is to restore function and mobility and reduce pain associated with chronic disease. In human medicine, physical therapy is standard of care for acute and chronic injuries and an integral component of postoperative recovery. Although there is a dearth of evidence-based veterinary medical studies in rehabilitation therapy and modalities for forelimb injuries in dogs, some extrapolation from human medicine can be made and applied. When developing a rehabilitation and therapeutic plan, the biomechanics of the affected limb and timeline of tissue healing of the target tissue and/or joint are important to consider.

Extracorporeal Shock Wave Therapy Enhances the In Vitro Metabolic Activity and Differentiation of Equine Umbilical Cord Blood Mesenchymal Stromal Cells

Extracorporeal shock wave therapy (ESWT) has been shown to induce different biological effects on a variety of cells, including regulation and stimulation of their function and metabolism. ESWT can promote different biological responses such as proliferation, migration, and regenerations of cells. Recent studies have shown that mesenchymal stromal cells (MSCs) secrete factors that enhance the regeneration of tissues, stimulate proliferation and differentiation of cells, and decrease inflammatory and immune reactions. Clinically, the combination of these two therapies has been used as a treatment for tendon and ligament lesions in horses; however, there is no scientific evidence supporting this combination of therapies in vivo. Therefore, the objectives of the study were to evaluate the effects of ESWT on equine umbilical cord blood mesenchymal stromal cells (CB-MSCs) proliferative, metabolic, migrative, differentiation, and immunomodulatory properties in vitro. Three equine CB-MSC cultures from independent donors were treated using an electrohydraulic shock wave generator attached to a water bath. All experiments were performed as triplicates. Proliferation, viability, migration and immunomodulatory properties of the cells were evaluated. Equine CB-MSCs were induced to evaluate their trilineage differentiation potential. ESWT treated cells had increased metabolic activity, showed positive adipogenic, osteogenic, and chondrogenic differentiation, and showed higher potential for differentiation toward the adipogenic and osteogenic cell fates. ESWT treated cells showed similar immunomodulatory properties to none-ESWT treated cells. Equine CB-MSCs are responsive to ESWT treatment and showed increased metabolic, adipogenic and osteogenic activity, but unaltered immunosuppressive properties. In vivo studies are warranted to determine if synergistic effects occur in the treatment of musculoskeletal injuries if ESWT and equine CB-MSC therapies are combined.

[Prospective clinical study on extracorporeal shock wave therapy combined with platelet-rich plasma injection for knee osteoarthritis]

OBJECTIVE

To investigate the effectiveness of extracorporeal shock wave therapy combined with platelet-rich plasma (PRP) injection in treatment of knee osteoarthritis (KOA) by prospective clinical study.

METHODS

Between June 2015 and June 2018, 180 patients with KOA met the inclusion criteria were included in study and randomly allocated to group A (n=60), group B (n=60), and group C (n=60). The patients were treated with autologous PRP intra-articular injection in group A, extracorporeal shock wave therapy in group B, and extracorporeal shock wave therapy combined with autologous PRP intra-articular injection in group C, once a week and 5 times a duration of treatment. There was no significant difference in age, gender, disease duration, side of KOA, and Kellgren-Lawrence grading between groups (P>0.05). The pain and function of knee joint were assessed by visual analogue scale (VAS) score, Lequesne Index score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and knee joint activity before treatment and at 1, 3, and 5 weeks after the first treatment.

RESULTS

There were significant differences in VAS score, Lequesne Index score, WOMAC score, and knee joint activity between pre- and post-treatment in all groups (P<0.05). VAS score, Lequesne Index score, and WOMAC score gradually decreased with the prolongation of treatment time (P<0.05); but there was no significant difference in knee joint activity between different time points (P>0.05). There was no significant difference in VAS score, Lequesne Index score, WOMAC score, and knee joint activity between groups before treatment (P>0.05); the scores of group C were superior to groups A and B (P< 0.05) at different time points after treatment; while the knee joint activities of 3 groups were similar (P>0.05).

CONCLUSION

The extracorporeal shock wave therapy combined with PRP injection can relieve the pain synergistically for KOA.

Exposure of zebra mussels to extracorporeal shock waves demonstrates formation of new mineralized tissue inside and outside the focus zone

The success rate of extracorporeal shock wave therapy (ESWT) for fracture nonunions in human medicine (i.e. radiographic union at 6 months after ESWT) is only approximately 75%. Detailed knowledge regarding the underlying mechanisms that induce bio-calcification after ESWT is limited. We analyzed the biological response within mineralized tissue of a new invertebrate model organism, the zebra mussel Dreissena polymorpha, after exposure with extracorporeal shock waves (ESWs). Mussels were exposed to ESWs with positive energy density of 0.4 mJ/mm² (A) or were sham exposed (B). Detection of newly calcified tissue was performed by exposing the mussels to fluorescent markers. Two weeks later, the A-mussels showed a higher mean fluorescence signal intensity within the shell zone than the B-mussels (P<0.05). Acoustic measurements revealed that the increased mean fluorescence signal intensity within the shell of the A-mussels was independent of the size and position of the focal point of the ESWs. These data demonstrate that induction of bio-calcification after ESWT may not be restricted to the region of direct energy transfer of ESWs into calcified tissue. The results of the present study are of relevance for better understanding of the molecular and cellular mechanisms that induce formation of new mineralized tissue after ESWT.

Extracorporeal Shockwave Therapy Increases Growth Factor Release from Equine Platelet-Rich Plasma In Vitro

Introduction

Extracorporeal shockwave therapy (ESWT) and platelet-rich plasma (PRP) are common treatments for soft tissue injuries in horses. Shockwave triggers cell specific responses to promote healing. Growth factors released from PRP also promote healing. It has been hypothesized that greater growth factor release would amplify the healing process. The combination of ESWT and PRP could promote healing in injured tendons and ligaments in the horse. The objective of this study was to determine if application of shockwaves to PRP samples increases the concentration of transforming growth factor-β₁ (TGF-β₁) and platelet-derived growth factor ββ (PDGF-ββ) released from the platelets in vitro.

Materials and methods

PRP was produced from blood drawn from six horses. The PRP from each horse was exposed to the following treatments: (1) positive control (freeze-thaw cycle), (2) untreated negative control, or shockwaves with either (3) a "standard probe" (ESWT-S) with a 2 cm focal width and medium energy density or (4) a "power probe" (ESWT-P) with a 1 cm focal width and high energy density. After each treatment, the samples were centrifuged, and the supernatant was harvested. The supernatant was then used for growth factor quantification via commercially available ELISA kits for TGF-β₁ and PDGF-ββ.

Results

Concentrations of TGF-β₁ and PDGF-ββ in PRP that underwent a freeze-thaw cycle were significantly increased compared with all other treatments. Both ESWT-S and ESWT-P resulted in significantly increased TGF-β₁ concentrations, 46 and 33%, respectively, when compared with the negative control. Both ESWT-S and ESWT-P resulted in significantly increased PDGF-ββ concentrations, 219 and 190%, respectively, when compared with the negative control.

Discussion

These data indicate that the application of ESWT to PRP increases the expression of growth factors in vitro. This suggests that the combination therapy of local PRP injection followed by ESWT may stimulate release of growth factors from platelets after they have been injected into the area of injury.

Conclusion

The combination of PRP and ESWT might result in synergism of two modalities previously utilized individually for tendon and ligament injuries in horses.