Instrumented assisted soft tissue mobilization vs extracorporeal shock wave therapy in treatment of myofascial pain syndrome

BACKGROUND Active myofascial trigger points(TrPs)often occur in the upper region of the upper trapezius(UT)muscle.These TrPs can be a significant source of neck,shoulder,and upper back pain and headaches.These TrPs and their related pain and disability can adversely affect an individual’s everyday routine functioning,work-related productivity,and general quality of life.AIM To investigate the effects of instrument assisted soft tissue mobilization(IASTM)vs extracorporeal shock wave therapy(ESWT)on the TrPs of the UT muscle.METHODS A randomized,single-blind,comparative clinical study was conducted at the Medical Center of the Egyptian Railway Station in Cairo.Forty patients(28 females and 12 males),aged between 20-years-old and 40-years-old,with active myofascial TrPs in the UT muscle were randomly assigned to two equal groups(A and B).Group A received IASTM,while group B received ESWT.Each group was treated twice weekly for 2 weeks.Both groups received muscle energy technique for the UT muscle.Patients were evaluated twice(pre-and posttreatment)for pain intensity using the visual analogue scale and for pain pressure threshold(PPT)using a pressure algometer.RESULTS Comparing the pre-and post-treatment mean values for all variables for group A,there were significant differences in pain intensity for TrP1 and TrP2(P=0.0001)and PPT for TrP1(P=0.0002)and TrP2(P=0.0001).Also,for group B,there were significant differences between the pre-and post-treatment pain intensity for TrP1 and TrP2 and PPT for TrP1 and TrP2(P=0.0001).There were no significant differences between the two groups in the post-treatment mean values of pain intensity for TrP1(P=0.9)and TrP2(P=0.76)and PPT for TrP1(P=0.09)and for TrP2(P=0.91).CONCLUSION IASTM and ESWT are effective methods for improving pain and PPT in patients with UT muscle TrPs.There is no significant difference between either treatment method.

Low-intensity extracorporeal shock wave therapy for midshaft clavicular delayed union: A case report and review of literature

BACKGROUND One of the most common complications following surgery for midshaft clavicle fracture is nonunion/delayed union.Extracorporeal shock wave therapy(ESWT)is an alternative to promote new bone formation without surgical complications.To date,no literature has reported low-intensity ESWT(LI-ESWT)in delayed union of midshaft clavicle fracture.CASE SUMMARY We reported a 66-year-old Chinese amateur cyclist with clavicle delayed union treated with 10 sessions of LI-ESWT(radial,0.057 mJ/mm^(2),3 Hz,3000 shocks).No anesthetics were applied,and no side effects occurred.At the 4 mo and 7 mo follow-ups,the patient achieved clinical and radiographical recovery,respectively.CONCLUSION In conclusion,our findings indicated that LI-ESWT could be a good option for treating midshaft clavicular delayed union.

Extracorporeal shock wave therapy treatment of painful hematoma in the calf:A case report

BACKGROUND Extracorporeal shock wave therapy (ESWT) can be applied to variousmusculoskeletal conditions including calcific tendinitis. Muscle injuries can leadto hematomas, and unabsorbed hematomas sometimes cause pain. We report acase of painful hematoma successfully treated with ESWT. To our knowledge, thisis the first reported case of painful intramuscular hematoma treated with ESWT.CASE SUMMARY A 65-year-old man visited the outpatient department for left calf pain withswelling that had persisted since he slipped two weeks prior. The calf pain hadpersisted and was rated visual analog scale 7. On physical examination, there wasa localized, stiff, ovoid mass on his left upper posterior calf. The pain wasaggravated by dorsiflexion of the left ankle or weight-bearing on the left foot.Initial diagnostic ultrasonography showed a hematoma in the left gastrocnemiusmuscle;its texture was firm with low heterogeneity. We applied ESWT to thehematoma. His pain decreased immediately to a visual analog scale 3, and themass was softened. The texture of the hematoma became more heterogeneous onultrasonography. Due to planned overseas travel, he returned three months afterthe initial visit to report that the pain and swelling were dramatically relievedafter ESWT.CONCLUSION We propose that painful hematomas could be a new indication for ESWT. Furtherinvestigation on the effects of ESWT for hematomas is needed.

Radial shock wave therapy in the treatment of chronic constriction injury model in rats： a preliminary study

Background Pain physicians pay close attention to neuropathic pain （NP）,since there is currently no ideal treatment.Radial shock wave therapy （RSWT） is a noninvasive treatment to chronic pain of soft tissue disorders.So far,there is no information on the use of RSWT for the treatment of NP.Therefore we observe the effects of RSWT on a NP model induced by chronic constriction injury （CCI） in rats.Methods Four different energy densities （1.0,1.5,2.0 and 2.5 bar） RSWT administered as a single session or repeated sessions in rats with NP induced by CCI of the sciatic nerve.The analgesic effect was assessed by measuring mechanical withdrawal threshold （MWT） and thermal withdrawal latency （TWL）.The safety was assessed through calculating sciatic functional index （SFI）.Results MWT and TWL increased after a single session of RSWT from day 1 to day 5 but retumed to baseline levels by day 10.Following repeated sessions of RSWT,both the MWT and TWL were significantly higher than NP group （P ＜ 0.01）for at least 4 weeks.In addition,no significant changes of SFI were observed in any groups after repeated sessions of RSWT and no increased pain or other side effects in any animals.Conclusions A single session of RSWT is rapidly effective in the treatment of CCI,but the efficacy maintained in a short period.However,repeated sessions of RSWT have prolonged efficacy.

Usefulness of radial extracorporeal shock wave therapy for the spasticity of the subscapularis in patients with stroke： a pilot study

Background There are not many studies about treatment of shoulder spasticity. Although botulinum toxin injection has been reported to be effective for shoulder spasticity, the effectiveness was judged by pain and limited motion change, but not the spasticity itself. Shoulder spasticity is considered to play an important role in hemiplegic frozen shoulder. However, the subscapularis muscle, unlike the pectoralis major muscle, is located deep beneath scapula, where conventional injection is difficult to perform. As extracorporeal shock wave therapy （ESWT） has been reported to be effective for spasticity relief, and we thought spasticity of subscapularis muscle located deep beneath the scapula would be a good candidate for ESWT treatment. This study was to evaluate the beneficial effects of radial ESWT （rESWT） on spastic subscapularis muscle in stroke patients. Methods This is an uncontrolled, prospective, unicenter, clinical pilot study. Stroke patients （n=57; mean age 55.4 years） with spastic shoulders were recruited between June 2011 and February 2012 at the University Rehabilitation Hospital. rESWT was administered to each patient every two or three days for two weeks （five total treatments）. Evaluation consisted of 11 measurements for each patient; at the start of each of the five treatments and once per week during the following six weeks. Spasticity was measured at external rotator muscles of the shoulder using the modified Ashworth scale （MAS）, and passive range of motion （ROM） of the shoulder in external rotation was recorded. Pain was measured using a visual analogue scale （VAS） during passive ROM of the shoulder in external rotation, and was additionally recorded for patients who preserved cognitive and communicative ability （Pain group）. Results Reduction in MAS and VAS and improvement of ROM during and after rESWT treatments were prominent compared to baseline. The reduction in MAS and VAS and improvement of ROM continued four weeks after the last treatment and the effects of the treatment decreased afterward. Conclusion rESWT will be able to provide stroke patients with an effective and safe procedure for the reduction of spasticity and pain as well as for the improvement of ROM of spastic shoulders.

Extracorporeal shock wave for plantar flexor spasticity in spinal cord injury:A case report and review of literature

BACKGROUND Approximately 65%-78%of patients with a spinal cord injury(SCI)develop any symptom of spasticity.The aim of this study was to investigate the tolerability and short-term effects of radial extracorporeal shock wave therapy(r ESWT)on plantar flexor spasticity in a patient with incomplete SCI.CASE SUMMARY An 18-year-old man with an incomplete SCI completed five sessions of r ESWT.The primary outcomes were the changes in ankle-passive range of motion(APROM)and passive resistive force to ankle dorsiflexion.The outcomes were assessed at baseline(T0),immediately after treatment(T1)and 1 wk after the end of treatment(T2).The A-PROM increased by 15 degrees at T1 and 25 degrees at T2 compared with T0.The passive resistive force to ankle dorsiflexion at low velocity decreased by 33%at T1 and 55%at T2 in the gastrocnemius muscle and by 41%at T1 and 39%at T2 in the soleus muscle compared with T0.At high velocity,it also decreased by 44%at T1 and 30%at T2 in the gastrocnemius muscle compared with T0.However,in the soleus muscle,the change was minor,with a decrease of 12%at T1 and increased by 39%at T2 compared with T0.CONCLUSION In this patient,the findings showed that r ESWT combined with conventional therapy was well-tolerated and could be effective in improving A-PROM and passive resistive force to ankle dorsiflexion in the short-term.Further randomized controlled clinical trials with longer period of follow-up are necessary to confirm the results obtained in patients with SCI.

Low-intensity extracorporeal shock wave therapy for Peyronie’s disease:a single-center experience

The aim of this article is to assess the outcomes of a low-intensity extracorporeal shock wave therapy(LiESWT)protocol for the treatment of Peyronie’s disease(PD).Patients treated for PD were prospectively recorded,and data were retrospectively reviewed.Age,characteristics of fibrous plaques,concomitant treatments,International Index of Erectile Function(IIEF-5),Lue score,and pain score on Likert scale were collected.Patients in acute phase of PD and an angulation of<40°were included.The protocol consisted of 6 weekly sessions of 4000 pulses each,applied from different directions,with a maximal power of 20 W and 8 Hz frequency.We included 39 patients(median age:56.8 years,interquartile range[IQR]:35.8–62.2 years).The median number of sessions received per patient was 7.2.After treatment,the median Lue score decreased from 6.8 initially to 3.3(P=0.003),the median Likert pain score dropped from 1.8 to 0.7(P=0.004),the median plaque size was reduced from 2 cm to 1.2 cm(P=0.08),and the median penile curvature diminished from 31°to 17°(P=0.07).On univariate and multivariate analysis,the only predictors of success were younger age(odds ratio[OR]=0.95,P=0.03 and OR=0.91,P=0.04,respectively)and concomitant use of phosphodiesterase-5 inhibitors(PDE5i;OR=0.92,P=0.02 and OR=0.93,P=0.01,respectively).LiESWT had a favorable impact on Lue score and notably penile pain,curvature,plaque size,and erectile function in patients treated for PD during the early inflammatory phase,with no side effects.Younger age and concomitant use of PDE5i were the only success predictors.

Low-intensity extracorporeal shock wave therapy promotes recovery of sciatic nerve injury and the role of mechanical sensitive YAP/TAZ signaling pathway for nerve regeneration

Background:Histological and functional recovery after peripheral nerve injury(PNI)is of significant clinical value as delayed surgical repair and longer distances to innervate terminal organs may account for poor outcomes.Low-intensity extracorporeal shock wave therapy(LiESWT)has already been proven to be beneficial for injured tissue recovery on various pathological conditions.The objective of this study was to explore the potential effect and mechanism of LiESWT on PNI recovery.Methods:In this project,we explored LiESWT’s role using an animal model of sciatic nerve injury(SNI).Shockwave was delivered to the region of the SNI site with a special probe at 3 Hz,500 shocks each time,and 3 times a week for 3 weeks.Rat Schwann cells(SCs)and rat perineurial fibroblasts(PNFs)cells,the two main compositional cell types in peripheral nerve tissue,were cultured in vitro,and LiESWT was applied through the cultured dish to the adherent cells.Tissues and cell cultures were harvested at corresponding time points for a reverse transcription-polymerase chain reaction,Western blotting,and immunofluorescence staining.Multiple groups were compared by using one-way analysis of variance followed by the Tukey-Kramer test for post hoc comparisons.Results:LiESWT treatment promoted the functional recovery of lower extremities with SNI.More nerve fibers and myelin sheath were found after LiESWT treatment associated with local upregulation of mechanical sensitive yes-associated protein(YAP)/transcriptional co-activator with a PDZ-binding domain(TAZ)signaling pathway.In vitro results showed that SCs were more sensitive to LiESWT than PNFs.LiESWT promoted SCs activation with more expression of p75(a SCs dedifferentiation marker)and Ki67(a SCs proliferation marker).The SCs activation process was dependent on the intact YAP/TAZ signaling pathway as knockdown of TAZ by TAZ small interfering RNA significantly attenuated this process.Conclusion:The LiESWT mechanical signal perception and YAP/TAZ upregulation in SCs might be one of the underlying mechanisms for SCs activation and injured nerve axon regeneration.

Efficacy of radial extracorporeal shock wave therapy compared with botulinum toxin type A injection in treatment of lower extremity spasticity in subjects with cerebral palsy: A randomized, controlled, cross-over study

Objectives To investigate whether botulinum toxin type A (BTX-A) injection is more effective than radial extracorporeal shock wave therapy in reducing plantar flexor muscle spasticity in subjects with cerebral palsy.Methods A total of 68 subjects with cerebral palsy were randomly allocated to BTX-A injection (Group 1) or radial extracorporeal shock wave therapy (Group 2) (first experiment;E1). Outcome was evaluated using the Tardieu V1 and V3 stretches, at 3 weeks, 2 months (M2) and M3 after baseline. At M6 subjects in Group 1 received radial extracorporeal shock wave therapy and subjects in Group 2 received BTX-A injection (second experiment;E2);outcome was evaluated as in E1. Treatment success was defined as improvement in foot dorsiflexion ≥10° when performing the V3 stretch at M2 in both experiments.Results In both experiments mean V1 and V3 significantly improved over time. In E1 both treatments resulted in similar treatment success. In E2 fewer subjects treated with BTX-A injection reached the criteria of treatment success than did subjects treated with radial extracorporeal shock wave therapy, which was due to a carry-over effect from E1. No significant complications were observed.Conclusion BTX-A injection is not superior to radial extracorporeal shock wave therapy in the treatment of plantar flexor muscle spasticity in subjects with cerebral palsy.

Long-term efficacy of extracorporeal shock wave therapy on lower limb post-stroke spasticity: a systematic review and meta-analysis of randomized controlled trials

Objectives The purpose of this systematic review and meta-analysis is to evaluate the long-term efficacy of Extracorporeal Shock Wave Therapy (ESWT) on reducing lower limb post-stroke spasticity in adults.Methods A systematic electronic search of PubMed/ MEDLINE, Physiotherapy Evidence Database (PEDro), Scopus, Ovid MEDLINE(R), and search engine of Google Scholar was performed. Publications that ranged from January 2010 to August 2020, published in English, French, Spanish, Portuguese, and Italian language and available as full texts were eligible for inclusion and they were searched without any restrictions of country. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. Two authors screened the references, extracted data, and assessed the risk of bias. The primary outcome was spasticity grade mainly assessed by the Modified Ashworth Scale (MAS). Secondary outcomes were passive range of motion (PROM), pain intensity, electrophysiological parameters, gait assessment, and adverse events.Results A total of seven recent randomized controlled trials (RCTs) were included in the systematic review and meta-analysis, and a beneficial effect on spasticity was found. The high level of evidence presented in this paper showed that ESWT ameliorates spasticity considering the parameters: MAS: standardized mean difference (SMD)=0.53;95% confidence interval (95% CI): (0.07-0.99);Modified Tardieu Scale (MTS): SMD=0.56;95% CI: (0.01-1.12);Visual Analogue Scale (VAS): SMD=0.35;95% CI: (-0.21-0.91);PROM: SMD=0.69;95% CI: (0.20-1.19).Conclusions ESWT presented long-term efficacy on lower limb post-stroke spasticity, reduced pain intensity, and increased range of motion. The effect of this novel and non-invasive therapy was significant and the intervention did not present adverse events, proving a satisfactory safety profile.

Indications and contraindications for shock wave lithotripsy and how to improve outcomes

For over 35 years shock wave lithotripsy has proven to be an effective,safe and truly minimally invasive option for the treatment of nephrolithiasis.Various technical factors as well as patient selection can impact the success of the procedure.We used published work focusing on outcomes of shock wave lithotripsy,risk of complications,and strategies for improving stone fragmentation to create this review.Multiple patient and technical factors have been found to impact success of treatment.Skin to stone distance,stone density and composition,size and location of the stone within the urinary system all influence stone free rates.A slower rate with a gradual increasing voltage,precise targeting,proper coupling will improve stone fragmentation and decrease risk of complications.The selection of appropriate patients through a shared decision making process and attention to the technical factors that improve stone free rates is key to providing an effective treatment and patient satisfaction.

The current state of knowledge on the clinical and methodological aspects of extracorporeal shock waves therapy in the management of post-stroke spasticity-overview of 20 years of experiences

Background and objectives In many patients after stroke, spasticity develops over time, resulting in a decrease in the patient′s independence, pain, worsening mood, and, consequently, lower quality of life. In the last ten years, a rich arsenal of physical agents to reduce muscle tone such as extracorporeal shock therapy (ESWT) wave has come through. The aim of this narrative review article is to present the current state of knowledge on the use of ESWT as a supplement to the comprehensive rehabilitation of people after stroke suffering from spasticity.Methods The PubMed and PEDro databases were searched for papers published in English from January 2000 to December 2020, 22 of which met inclusion criteria for clinical studies related to post-stroke spasticity management with ESWT.Results A total of 22 studies including 468 post-stroke patients-11 reports with the upper limb (267 patients) and 10 reports within the lower limb (201 patients), as well as one report including both upper and lower limb. We focused our attention on clinical and methodological aspects. Therefore, we performed the assessment of enrolled studies in terms of methodological quality using the PEDro and level of evidence using the National Institute for Health and Clinical Excellence (NICE) guidelines. Furthermore, we indicated implications for clinical practice in using ESWT for post-stroke spasticity management. Moreover, we discussed a suggestion for future research directions.Conclusions In conclusion, an ESWT effectively reduces muscle tone in people with spastic limb after stroke. Further, ESWT is safe and free of undesirable side effects.The mechanism of action of ESWT on muscles affected by spasticity is still unknown.To date, no standard parameters of ESWT in post-stroke spasticity regarding intensity, frequency, location, and the number of sessions has been established. Further research, meeting the highest standards, is needed to establish uniform muscle stimulation parameters using ESWT.

Synergic use of botulinum toxin injection and radial extracorporeal shockwave therapy in Multiple Sclerosis spasticity

Background and aim In Multiple Sclerosis(MS)spasticity worsen patient′s quality of life.Botulinum NeuroToxin TypeA(BoNT-A)is extensively used in focal spasticity,frequently combined with physical therapies.Radial extracorporeal shock waves(rESW)were already used in association with BoNT-A.Considering that loss of efficacy and adverse events are determinants of BoNT-A treatment interruption,this study aimed to evaluate the possibility to prolong BoNT-A′s effect by using rESW in MS focal spasticity.Methods Sixteen MS patients with spasticity of triceps surae muscles were first subjected to BoNT-A therapy and,four months later,to 4 sections of rESWT.Patients were evaluated before,30,90 days after the end of the treatments,by using Modified Ashworth Scale(MAS),Modified Tardieu Scale(MTS)and kinematic analysis of passive and active ankle ROM.Results BoNT-A determined a significant reduction of spasticity evaluated by MAS with a reduction of positive effects after 4months(P<0.05);MTS highlighted the efficacy only 90 days after injection(P<0.05).rESWT decreased MAS values at the end and 30 days later the treatment(P<0.01);MTS values showed instead a prolonged effect(P<0.01).BoNT-A determined a gain of passive and active ankle ROM,persisting along with treatment and peaking the maximum value after rESWT(P<0.05).Conclusions rESWT can prolong BoNT-A effect inducing significant reduction of spasticity and improvement in passive and active ankle ROM in MS patients.The use of rESWT following BoNT-A injection is useful to avoid some limitations and to prolong the therapeutic effects of BoNT-A therapy.

Effects of Roughly Focused Extracorporeal Shock Waves Therapy on the Expressions of Bone Morphogenetic Protein-2 and Osteoprotegerin in Osteoporotic Fracture in Rats

Background：Roughly focused extracorporeal shock waves therapy （ESWT） is characterized by a wide focal area,a large therapy zone,easy positioning,and less pain during treatment.The purpose of this study was to investigate the effects of roughly focused ESWT on the expression of osteoprotegerin （OPG） and bone morphogenetic protein-2 （BMP-2） in osteoporotic fractures in rats.Methods：Seventy-two female Sprague-Dawley （SD） rats,3 months old,were divided into sham-operated group （n =6） and an ovariectomized （OVX） group （n =66）.Sixty OVX SD rats were used as a model of double proximal tibial osteotomy and inner fixation.The osteotomy site in the left tibia was treated with roughly focused ESWT once at an energy density of 0.26 mJ/mm^2,60 doses/min,and 2000 pact quantities.The contralateral right tibia was left untreated and served as a control.Expression of OPG and BMP-2 in the callus of the osteoporotic fracture area was assessed using immunohistochemistry,real-time polymerase chain reaction （PCR）,and Western blotting analysis.Results：Bone mineral density （BMD） at the proximal tibia,femur,and L5 spine was significantly reduced after ovariectomy.BMD of proximal tibia was 12.9% less in the OVX group than that in the sham-operated group.Meanwhile,bilateral oophorectomy resulted in a lower trabecular bone volume fraction （BV/TV） in the proximal tibia of the sham-OVX animals.Three months after bilateral oophorectomy,BV/TV was 14.29% of baseline BV/TV in OVX legs versus 45.91% in the sham-OVX legs （P 〈 0.001）.These data showed that the SD rats became a suitable model of osteoporosis,3 months after they were OVX.Immunohistochemical analysis showed higher levels of BMP-2 and OPG expression in the treatment group than those in the control group.Compared with the contralateral controls,decreased expression of OPG and BMP-2 at 3 days after roughly focused ESWT,followed by a later increase at 7 days,was indicated by real-time PCR and Western blotting analysis.The OPG messenger RNA （mRNA） expression levels peaked at 6 weeks after the shock wave treatment,paired with a much earlier （at 4 weeks） increase of BMP-2,and declined close to normal at 8 weeks.Conclusions：Roughly focused ESWT may promote the expression of OPG and BMP-2 in the osteoporotic fracture area in rats.BMP-2 and OPG may act synergistically and may lead to a significant enhancement of bone formation and remodeling.

Treatment for subtrochanteric fracture and subsequent nonunion in an adult patient with osteopetrosis:A case report and review of the literature

BACKGROUND As a congenital metabolic bone disease caused by defective osteoclastic resorption of immature bone,osteopetrosis is characterized by diffused sclerosis of bones,brittle bones,easy fracturing,narrow medullary canals,and a weak fracture healing ability.At present,clear standards and principles for the treatment of fractures in patients with osteopetrosis are lacking.Non-operative treatment can prevent fracture hematoma and preserve the blood supply to the bone fragments,while being associated with frequent failures and higher mortality rates.Meanwhile,closed reduction and internal fixation with intramedullary nail(CRIF+IMN)approaches can also protect blood supply to the fracture site.However,IMN cannot be used for the vast majority of patients with osteopetrosis due to the narrowing of medullary canals.Thus,open reduction and internal fixation with plate remains the most appropriate surgical method for treating fractures in patients with osteopetrosis,but this approach is complicated by the lack of intramedullary hematopoiesis in such patients.Fracture healing primarily depends on the blood supply to the external periosteum.Open reduction can also easily destroy the periosteum and cause delayed fracture healing or even nonunion;however,CRIF may be the most practical approach.As a result,it would be prudent to solve the difficulty of drilling during the operation and the problem of postoperative nonunion.CASE SUMMARY In 2018,we treated an adult patient with osteopetrosis presenting with a subtrochanteric fracture.The fracture was fixed using a femoral locking compression plate.Because of delayed consolidation,at 12 mo postoperatively the patient was further treated with platelet-rich plasma(PRP)combined with radial extracorporeal shock wave therapy(rESWT).Antero-posterior and lateral radiographs obtained at the latest follow-up(10 mo)showed that the callus had grown at the original fracture site,and the medial fracture line almost disappeared.CONCLUSION Osteosynthesis remains the first choice of treatment approach for fractures in patients with osteopetrosis,especially peritrochanteric fractures.Preoperative preparation is necessary to avoid risks such as drill bit breakage and iatrogenic fracture during the operation.Moreover,fractures in a patient with osteopetrosis present with a high risk of delayed union and nonunion,which can be potentially cured with PRP+rESWT.