Monday, December 23, 2013

A collection of articles in support of Acoustic ShockWave Therapy

A collection of research articles in support of Acoustic ShockWave Therapy

Source:  http://shockwavetherapy.org/index.php/ismst-congress-history-abstracts/2013-salzburg-austria

Piezoelectric Shockwave Therapy for the Treatment of Calcifying Tendinopathy of the Shoulder
Paulo Roberto Rockett
Institution: Ortosom, Brazil
Device and Producing Company: Piezoson 100 plus
Introduction:
The aim of this study is to evaluate the efficiency of piezoelectric shockwave therapy on the course of a Calcifying Tendinopathy of the Shoulder.
Methods:
Fifty eight patients (65 shoulders) were enrolled in this retrospective study, ages ranging from 32 to 87 years (an average age of 55 years). The treatment was delivered with a piezoelectric SWT generator. The protocol consisted of at least three and a maximum of nine sessions at weekly intervals. In each session 2500 impulses were delivered at a 0, 22 and 0, 32 mJ/mm² energy flux density. The symptoms were classified using the analog visual scale and the clinical evaluation according to the Roles and Maudsley score at 45, 90 and 180 days after the end of the treatment.
Results:
One hundred and eighty days after the treatment, the results were evaluated as excellent in 32,3%; good in 33,9%, acceptable in 15,4% and poor in 18,4% of the patients. Side effects were rare and associated with pain during, or some days after, the applications, but no cases of worsening of previously reported complaints have been observed during follow-up.
Discussion:
The results have been evaluated in a consecutive series of patients who did not achieve satisfactory results after conservative treatment for three months, or with complaints for more than six months. Procedures were performed in the doctor´s office without anesthesia.
Conclusion:
Shockwave therapy should be considered as an optional treatment for Calcifying Tendinitis of the Shoulder in cases when the conservative treatment failed. It is a safe alternative, non-invasive, without significant complications, thus reducing risks and costs of a surgical procedure.


P8
High Energy Extracorporeal Shockwave Therapy versus Radial Shockwave Therapy in Lumbar Facet Joint Pain – Searching for Optimal Treatment Protocol

Tomas Nedelka (1), Jiri Nedelka (2), Jakub Schlenker
Institution: (1) Charles University Prague, (2) Center for Rehabilitation and Pain Treatment, Prague, (3) Czech Technical University, Kladno, Czech Republic
Device and producing company: Storz DUOLITH ESWT; BTL SWT5000 rSWT
Introduction:
The facet joints are common sources of chronic low back pain with high prevalence in mid-age population. According to literature, more than 30 percent of patients with chronic non-radicular low back pain suffer from facet syndrome, which is characterized by localized axial pain, elicited by hyperextension in lumbar area, with referred pain to the buttocks and posterior thigh. Therapeutic approaches include pharmacological treatment such as 3rd generation anticonvulsant pregabaline and NSAID or opioids. Semi-invasive approaches to facet joints include diagnostic medial branch blocks, corticosteroids or radiofrequency treatment. In our previous pilot study, we have proved efficacy of radial shockwave therapy in treatment of lumbar facet joint pain, with results better than ultrasound guided corticosteroid injections and practically equal to radiofrequency treatment with favorable treatment effect duration. The aim of this study was to find optimal shockwave therapy procedure and to compare high-energy focused extracorporeal shockwave therapy (ESWT) against rSWT.
Methods:
A prospective study comparing effectiveness of high energy ESWT and rSWT was done in 64 patients fulfilling diagnostic criteria for chronic lumbar facet syndrome and responding to medial branch anesthetic nerve blocks. In all 64 patients (33 women, 31 men), we have provided MRI examination of lumbar spine, those with lumbar stenosis and moderate to severe degeneration lumbar disc disease were not included in our study. In 28 of patients, 99mTc bone scintigraphy was performed, all the results were positive with appropriate radionuclide accumulation within the facet joints. ESWT was performed in 32 patients (Group A) in 5 weekly sessions. Energy flux density was set to 0.35 mJ/mm2, 1000 shocks per session were applied under US guidance, covering 2 segments. rSWT group (Group B) involved 30 patients in 5 weekly sessions and energy flux density was set to 0.12 mJ/mm2 (compressor pressure of 3.8 bar), with 3000 shocks per session in 2 segments.
Results:
The data from 62 patients were collected and statistically evaluated, using paired t-test and ANOVA. Pre-treatment average visual analogue scale (VAS) was 5.2 cm in group A and 5.0 cm in group B. Severity of low back pain was measured using the Oswestry low back pain validated score with no changes between groups. Follow-up was set to 2 and 6 months. At 2 months follow up, we registered significant decrease in average VAS against the baseline value in both ESWT and rSWT groups (p=0.01 in group A, p=0.03 in group B). After 6 months, ESWT (group A, p=0.02) and rSWT (group B, p=0.04) shown significant changes in average VAS against the baseline. Mean VAS decrease (in p=50%) was higher in ESWT group (2.9 mm) than in rSWT group (2.0 mm) in 6 months follow-up. In patients with BMI>30 (6 patients in Group A, 5 in Group B, respectively), has shown significant VAS decrease in ESWT group only after 2 and 6 months.
Discussion:
In our previous study (Nedelka et al., 2012), we have found that rSWT could be the considerable therapeutic option with similar or higher efficacy, compared to ultrasound guided steroid injection. Advantages of rSWT were safety, absence of damage to facet joints and absence of local side effects – inflammatory reaction or medial branch denervations. Important pitfall of rSWT was depth of application, which restricted the usage of radial SWT to patients with BMI lower than 28. Energy administration in focused ESWT seems to be more suitable for use in facet joints. According to our recent results, ESWT confirmed increased efficacy in comparison to radial procedure almost with no limitations.
Conclusion:
Both ESWT and rSWT were effective in treatment of chronic lumbar facet joint pain. However, ESWT has shown its added value in superior pain relief with equal tolerability compared to rSWT. We have proved efficacy of ESWT also in obese patients, where rSWT usually fails due to insufficient depth of penetration.


P9
 First High Definition 3 Tesla MRI-Imaging Pictures Before and After Piezoelectric Focused ESWT with Low Energy Level of a Myofascial Trigger Point
Hannes Müller-Ehrenberg (1), Birgit Ertl-Wagner (2), (3) Florian Heinen
Institution: (1) Orthopeadic Private Office, Münster; (2) Ludwig Maximilians University, Munich; (3) Dr. von Hauner’schen Children's Hospital, Munich; Germany
Device and producing company: Piezowave (Richard Wolf, Germany)
Introduction:
Myofascial Trigger Points (MTrP) are considered to be an important reason for musculo-skeletal pain. Focused ESWT have shown to be a good method to treat MTrP successfully. The exact mechanisms are yet unclear.
Methods:
A MTrP in a patient suffering from neck pain and headache has been identified by clinical examination and 3 Tesla MRI scan in the trapezius muscle. After identification a direct focused ESWT with low energy level has been applied on the MTrP. About 40 min after ESWT 3 Tesla MRI scan has been repeated.
Results:
On the second MRI-Scan significant changes of the MTrP have been shown.
Discussion:
With low energy levels of focused ESWT no kind of tissue damage has ever been reported. The changes that have been found seem to be the result of activation of specific ESWT induced biological activity.
Conclusion:
The imaging pictures of 3 Tesla MRI can show MTrP and effects of piezoelectric focused ESWT on MTrP.


 The effects of Shockwave Application Frequency on Pain in Normal Subjects
Carlos Leal, Diana Lemus, Maria Camila Gallo
Institution: Fenway Medical, Bogota, Colombia
Device and producing company: BTL5000 POWER
Introduction:
For over ten years we have applied Radial SWT for chronic tendinopathies. We have found subjectively that using a progressive protocol starting with high number of repetitions per second and low energy, the patient feels less pain. This way, and using a two session treatment, we have been able to avoid the use of anesthetics, get the results we desire and match the data published in the literature. However, there are no reports of these findings, probably because pain control is a very difficult issue to analyze, and there is a great variability in evaluating this particular emotional sensation. We designed a simple case control study in normal subjects to determine the differences in pain generated by the application of Radial Pressure Waves on their hands, comparing a progressive protocol with a continuous protocol.
Methods:
We performed a case control study on 104 volunteer subjects with no medical records. They were divided in two groups of 52. They all signed an informed consent. We chose the hypothenar region of the right hand, because it is easily available, and a well-innervated area, with submuscular bone and no major nerves or vessels in the nearby region. In all cases we used a Radial SWT generator (BTL 5000 Power – BTL Industries Checz Rep). All subjects were tested and evaluated by the ISMST & ONLAT Certified authors. In the Cases Group we applied a progressive protocol using 200 shocks on 15 Hz, 200 shocks on 10 Hz and 200 shocks on 5 Hz. In the Control Group we used a constant of 600 shocks on 10 Hz. The Pressure was constant in both groups, using 2.0 BAR. In order to determine any differences between subjects, both Cases and Control Groups volunteers were asked to try the opposite protocol on the opposite hand. We also recorded these data, as we wanted to determine if there were any differences within the subjects and avoid or find any placebo effect. We used numerical Visual Analogue Scale n/10, blinded for the patient. All data was recorded and analyzed using a One-Way ANOVA, and the P value was based in <0.01. We also analyzed intergroup differences, gender and age, and a Normalized analysis of differences at the beginning and end of the trials. We had 76 males and 28 females with an average age of 31.5 y/o (17-46 y/o). Al adverse effects were recorded.
Results:
The progressive protocol group experienced 29% less pain as compared with the continuous protocol group at the beginning of the test, with a VAS of 7,9 and 5,1 respectively. At the end of the test the differences were of 57% with VAS scores of 7,25 and 1,54 respectively. There was an average of in 43% in total pain reduction (P<0.01). The normalized analysis comparing the differences in VAS scores at the beginning and end of each test on each group also showed a pain reduction of 34,6% in the progressive group as compared with a 7,2% in the continuous group, with a statistically significant difference of 27.4%. There were no significant differences in the data collected from the contralateral hands as compared with the primary tested hands. There were no differences in gender or age related data. There were no adverse effects in any subject.
Discussion:
The use of high repetitions with low energy seemed to favor pain control in normal subjects, as compared with a continuous protocol with the same energy and number of shockwaves delivered. The progression from high repetitions to low repetitions showed the best pain control in our series. Even though these results match our subjective clinical findings in tendinopathy patients, it calls our attention the lower progressive pain control in the continuous protocols. We have the feeling that there is also a good pain reduction in continuous protocols in our patients. We did not find a placebo effect in our study, and the results in primary or secondary tested hands were similar. We did not find any adverse effects. There was a clear and obvious apprehension in our subjects, being this pain study. All patients revealed they felt a discomfort sensation more than pain, but evaluated this sensation in very high VAS numbers. Our main limitation is having the tests done in normal subjects and not in tendinopathy patients. However, this solid data does show an effect with people that have the same pain baseline: none, something very difficult to standardize in symptomatic patients.
Conclusion:
Based on these results, we do recommend a progressive shockwave protocol in the treatment of tendinopathies, delivering a minimum dose of therapeutic impulses preceded by a progressive number of analgesic shockwaves. Further studies in clinical cases must be performed to determine these doses.

 Extracorporeal Radial Shockwave Therapy for the Treatment of Achilles Tendinopathies
Edson Antonio Serrano
Institution: NEOMEDICA, Lima, Peru
Device and producing company: BTL 5000, BTL 6000
Introduction:
Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, Achilles tendinopathy and plantar fascia. This prospective study shows the efficacy of extracorporeal radial shockwave therapy in the treatment insertional and not insertional Achilles tendinopathy.
Methods:
We performed a prospective intervention study, with thirty-two patients with Achilles tendinopathy were enrolled; 26 not insertional and 8 insertional. for treatment this group received three to five applications (every week) of 6000 impulses of radial shock waves with progressive protocol, this protocol has 2000 shockwaves neurostimulation, 2000 shockwave treatment and 2000 of neurostimulation at the end of the session. Follow-up examinations were performed at a month, then every month up to 6 months using visual analog scale (VAS) of pain (0 to 10) in morning and activity pain.
Results:
Twenty four patients (75%) were very satisfied, 6 (18.76%) were satisfied, 1 (3.1%) were improved the condition, and 1 (3.1%) said it did not affect the preview condition. Ninety-three percent of patients said they would choose as first choice treatment of radial shock waves. After 6 months of follow-up the mean of VAS for morning pain decreased from 7.2 to 2.1 and activity pain decreased from 8.3 to 3.
Discussion:
This is a preliminary study demonstrates the effectiveness of radial shock waves not only in insertional tendinopathy, also no insertional tendinopathy with intra tendinous calcifications, using progressive protocol, however requires higher studies.
Conclusion:
Extracorporeal radial shockwave therapy has been shown to be effective in the treatment of patients with lateral Achilles tendinopathy.


P13
ESWT as the Treatment of Choice for Plantar Fasciitis - 12 Years’ Experience

Kandiah Raveendran
Institution: Fatimah Hospital, Ipoh, Malaysia
Device and producing company: Evotron
Introduction:
Plantar Fasciitis is a common cause of painful heel in the Malaysian population. This paper describes a 12 years’ experience to assess the efficacy and acceptability of this modality of treatment in a country where the use of ESWT is still in its infancy.
Methods:
This paper describes two studies. The first being a prospective study on the use of ESWT on 148 heels conducted from 2003 to 2004.
The second study was a retrospective study on 83 heels. The paper compares the two timeframes to see whether there has been any change in the methods and results including the popularity of the treatment with the patients. It also assessed the need for more than one treatment using the Evotron.
Results:
The first study showed that 74% had no or minimal pain without any complications noted. 18 heels had to have a second treatment.
The second study of 83 heels treated showed a 71% improvement after the first treatment but 25 heels had a second treatment and 5 heels a third treatment and the final result was 84% with no or minimal pain again with no complications.
Discussion:
The Malaysian patients have gradually accepted ESWT as the first choice of treatment in our institution. We have also been more confident to recommend second and third treatments for the recalcitrant painful heel with a consequent improvement in results and probably a reduced recurrence rate.
Conclusion:
ESWT has been the most effective treatment modality for the treatment of plantar fasciitis in the Malaysian population. It has become acceptable in spite of it being a painful procedure. We offer it very soon after the failure of conservative therapy. In the last 12 years the number of patients undergoing surgery has dropped drastically.

 Plantar Fasciitis Treatment - Physical Therapy with Ultrasound versus Extracorporeal Shock Wave Therapy. A Long-Term Follow-Up
Sara Messina (1), Paolo Buselli (2)
Institution: (1) School of Specialties in Physical Medicine and Rehabilitation, University of Pavia, (2) Istituti Ospitalieri di Cremona, Italy
Device and producing company: Ossatron OSA 140
Introduction:
In 2009 we presented a work on ESWT versus other therapies, particularly versus Ultra Sound (US) physical therapy. With respect to this, we are now presenting the results of a long-term follow-up related to the same patients.
Methods:
After having performed a systematic analysis of the patients affected by plantar fasciitis coming to our practice for totally 3 years (2006-2009), we made a second evaluation per telephone about the health of such patients after 1 and 3 years.
We checked three patient groups treated respectively with ESWT only (Group 1), US therapy with good results (Group 2A) and with ESWT after an US treatment without good clinical results (Group 2B). Afterwards we evaluated the long-term efficacy of the treatment performed with ESWT (Group 1 and Group 2B), compared to that of the treatment with physical therapies (Group 2A).
Results:
Significant clinical improvement was obtained both in Group 1 and in Group 2B. We observed no statistical significance on the results of ESWT versus US. The analysis of the self-control group showed good clinical and functional results of ESWT after US therapy. The analysis of the long-term data has confirmed the better results achieved in the ESWT group, both in the follow-up after one year and in the one after 3 years, despite the drop-out number, being, however, equally distributed within the three patient groups.
Discussion:
Despite the difficulties in contacting patients after some time, the data presented show a better long-term result in the patient group treated with ESWT compared to the one treated with other physical therapies (Group 2A).
Conclusion:
ESWT shows a long-term efficacy in the treatment of plantar fasciitis. The long-term results confirm that ESWT represents the first choice treatment for chronic plantar fasciitis.



P16
Evaluation of Factors Possibly Influencing the Outcome of Focused Extracorporeal Shockwave Treatment (ESWT) of Recalcitrant Plantar Fasciitis with Calcaneal Spur

Raphael Scheuer(1), Martin Friedrich(1), Julia Hahne (2), Matthias Pallamar(1)

Institution: (1) Orthopaedic Hospital Speising; (2) CEOPS - Centre of excellence for Orthopaedic Pain Management Speising, Vienna, Austria
Device and producing company: Storz Duolith SD1 Tower
Introduction:
There are several trials suggesting that radial as well as focused shockwave therapies show satisfying results as treatment options of plantar fasciitis. This study was performed to examine whether there are further patient or treatment related factors influencing the outcome of focused ESWT as treatment option for plantar fasciitis enabling physicians to estimate the possible benefit and to eventually improve efficacy.
Methods:
284 patients (363 feet with plantar fasciitis) received focused ESWT for plantar fasciitis and answered a questionnaire inquiring epidemiologic and anamnestic treatment data immediately before as well as 19 to 77 weeks after the first application.
Results:
74 percent of patients are satisfied, 72 percent received treatment with focused ESWT only once. The individual result was independent of the energy applied, the physician applying ESWT as well as epidemiologic data assessed, but there was a negative correlation with the number of past injections with corticosteroids.
Discussion:
We observed treatment benefits like satisfying results with no complications and no immobilization. These results were reproducible and were achieved with in most cases with one, in some cases with up to three treatment sessions. In contrast to other authors who stated that ESWT should rather be regarded as an end stage treatment we would recommend ESWT in even earlier stages to prevent chronification because of its better results compared to many other conservative treatment options.
Conclusion:
Focused ESWT is a safe and feasible treatment option for plantar fasciitis, its efficacy is consistent over different physicians. Hence, ESWT can be recommended even as early treatment option for plantar fasciitis.


ESWT: An Extraordinary Tool for Tissue Regeneration and Remodeling
Maria Cristina D’Agostino, Elisabetta Tibalt, Elena Abati, Stefano Respizzi
Institution: Shock Wave Therapy & Research Unit, Rehabilitation Department - IRCCS Istituto Clinico Humanitas, Milano, Italy
Device and Producing Company: Modulith SLK and Duolith, Storz Medical; Orthogold, MTS; Dermapace, Sanuwave
Introduction:
Regenerative Medicine nowadays represents the new frontiers of ESWT. The authors propose some interesting case reports supporting this argument, by showing some unexpected therapeutical results that suggest new perspectives and insights about this topic.
Methods:
Case A and B: two patients, with tibial fracture delayed healing, both presenting also skin ulcers, distally to the fracture site.
Case C: a sportsman, with painful swelling of the distal calf (muscular and cutaneous fibrosis, due to a deep wound).
Case D: A young woman with hip osteonecrosis.
Case E: A woman with delay of femoral fracture healing and extensive skin fibrosis of the lower limb (crash trauma --> skin graft).
All patients were treated with different ESWT protocols, according to each disease.
Results:
The use of ESWT resulted in these outcomes:
Case A and B: bone healing, and surprisingly, a faster repair of the ulcers, away from the fracture site and therefore not directly treated;
Case C: resolution of pain and swelling, as well as reduction of muscular fibrosis.
Case D: arrest of necrotic evolution and bone remodeling appearance (with a trophic effect) at medium-long term follow up (> 5 y).
Case E: besides bone healing, unexpected hair regrowth and reactivation of sweating, reduction of skin fibrosis and tactile hypersensitivity.
All results were documented by clinical and instrumental data (including photos).
Discussion:
These case reports would suggest some positive changes after ESWT:
Real stem cell mobilization “in vivo”, with effects at a distance.
A regenerative effect also on intact tissues (remodeling action).
The authors will discuss in detail the regenerative potential of ESWT that seems to be even more extraordinary than believed and proven. It is effective also on already healed or ”intact” tissues (remodeling effect).
Conclusion:
We expect that the use of ESWT will be further encouraged as a safe and versatile therapy, both alone and associated to other treatment tools in the field of Regenerative Medicine. New studies will be able to widen the list of therapeutical indications, especially in the field of post - traumatic and complicated clinical cases.

 Focal ESWT in Greater Trochanteric Pain Syndrome
Osvaldo Patiño, Daniel Moya
Institution: Centro Argentino De Ondas De Choque, Buenos Aires, Argentina
Device and producing company: Orthima-Direx
Introduction:
Trochanteric pain syndrome (TPS) is a common and frustrating condition encountered by orthopedic surgeons and rheumatologists in patients older than 50 years. Patients feel pain on the greater trochanter during activities and at rest, with functional impairment. Many conventional treatments have been used to treat these patients with controversial results. Focal Extracorporeal Shock Wave Therapy (FESWT) has been successfully used since 1980 to treat different tendon pathologies. Our objective with this presentation is to describe the results using FESWT in patients with greater TPS who did not response to conventional therapy.
Methods:
We studied 37 patients, 7 males and 30 females (average age 65.4 years), with a history of lateral hip pain over the greater trochanter for more than 14 months with unsuccessful conventional treatment. We used an Orthima FESWT device (Direx inc.), with a 2000 shockwaves, 0,20mJ/cm² protocol, in 3 sessions once every 15 days. Evaluation was performed using Visual Analogue Scale (VAS) for pain, and Lower Extremity Functional Scale (LEFS), being 80 points the best, and 0 points the worse. For statistical analysis we used a T-test for paired data and a Wilcoxon Sign-Rank.
Results:
After treatment and from baseline values, VAS score significantly decreased 2.99 points (2.74-3.25; p<0.001) and LEFS score improved 30.24 points (27.47-33.02; p<0.001).
Discussion:
We found statistical and clinical significant improvement in pain and function in patients with greater TPS treated with a short protocol of FESWT.
Conclusion:
We suggest the use of FESWT in patients with greater TPS that show poor improvements with conventional treatments. Our results are promising and this therapy should be evaluated in the future through randomized trials.

 Radial Extracorporeal Pressure Pulse Therapy for the Primary Long Bicipital Tenosynovitis: A Prospective Randomized Controlled Study
Gen Yan Xing
Institution: General Hospital of Chinese Peoples’ Armed Police Force, Beijing, China
Device and producing company: Swiss DolorClast, EMS
Introduction:
Long bicipital tenosynovitis is regarded as one of the common causes of shoulder pain and dysfunction. The traditional therapeutic approach includes a variety of conservative treatments, but they are not substantiated, owing to the lack of proven clinical efficacy. Radial extracorporeal shock wave therapy (RESWT) uses a pneumatically generated and radially propagating low-energy pressure pulse and has been clinically shown to be a new alternative form of treating refractory soft tissue inflammation.
Methods:
Seventy-nine adults with long bicipital tenosynovitis were randomized to receive either active (1500 pulses, 8 Hz, 3 bars) or sham treatment through four sessions that were held once a week. All of these adults were assessed before treatment and at time intervals of 1, 3 and 12 months since the completion of the treatment. The outcomes were measured through the visual analogue scale (VAS) and L’Insalata shoulder questionnaire.
Results:
Mean VAS in the RESWT group showed significant and sustained reduction from 5.67 ± 1.32 at baseline to 2.58 ± 1.49 at one month, 1.83 ± 1.25 at three months and 1.43 ± 0.94 at 12 months. The sham group’s mean VAS was 6.04 ± 0.97 before treatment and stabilized at 5.57 ± 0.84 at 12 months. Similar trends were found for the function scores. Mean scores were increased after RESWT from 60.57 ± 6.91 at baseline to 79.85 ± 6.59 at 1 month and 83.44 ± 5.21 at 12 months from baseline. Both pain and function scores showed significant differences between the two groups (p 0.001).
Discussion:
When primary pathogenesis like impingement syndrome was excluded, radial shock wave therapy for the primary long bicipital tenosynovitis of the shoulder produced a high rate of success in achieving the relief from pain and functional restoration. Negligible complications were associated, regardless of whether the patients received conservative treatment previously or not.
Conclusion:
RESWT should be considered as the preferred method for treating long bicipital tenosynovitis.



Extracorporeal Shockwave Therapy (ESWT) in Impingement Syndrome of the Shoulder
Ayman Elwely Balabel, Faisal Ramadan Al-Kandary, Amani Ahmed Yacoub, Sahar Sobhi Othman
Institution: Ahmadi Hospital, Kuwait Oil Company, Kuwait
Device and producing company: Piezoson 300, Richard Wolf
Introduction:
The rotator cuff muscle tendons pass through a narrow space between the acromion process of the scapula and the head of the humerus. Narrowing of this space can result in impingement syndrome. Thickening or calcification of the coracoacromial ligament and inflammation of the subacromial bursa can also cause impingement that will reduce the space between rotator cuff and the acromion (subacromial impingement). The cause of the formation of calcium in the rotator cuff is idiopathic. It is common in people between the ages of 30-60 years of age.
Methods:
We performed a retrospective study including 20 patients with impingement syndrome, ages 35-57 years old, with a pain VAS rating of 7-9, with pain in all overhead activities and at rest, as well as a marked limitation of shoulder ROM. X-rays were done in all cases in order to exclude other pathology. Inclusion criteria were: shoulder pain present for a minimum of 5 months, rotator cuff calcification on the plain x-rays, or unsuccessful conservative treatment for at least six months. The exclusion criteria were: generalized osteoarthritis, pregnancy, infectious or tumorous diseases, and any neurological abnormalities. We performed the treatment as an outpatient procedure without anesthesia in 3 Focused ESWT sessions every two weeks, with a 3000 pulses, energy level of 0,11 – 0,14 mJ/mm² protocol. All patients had been advised to start ROM and strengthening (RTC) exercises within 4-6 weeks after treatment. Eccentric exercises were encouraged to be started gradually and progressively to core muscle stability for 3 months, seeking cuff recovery. Patients were advised to continue exercises for 12 weeks.
Results:
We followed out patients for six months, and found that 85% of the cases showed significant clinical improvement. Pain had been reduced to VAS 2-3 and range of motion had significantly improved. 10 % of our patients were slightly better for pain and ROM. 5 % had poor results. Mean pain score before treatment was 8.95 ± 0.76 and after we recorded 4.20 ± 1.40. ROM changed from 29.50 ± 8.26 to 76.25 ± 10.11 with a highly significant P-value > 0.001.
Discussion:
Focused Shock wave therapy produces significant relief of pain, improves ROM in Impingement Syndrome of the Shoulder, and has effects in changing the absorptions of calcium deposits at RCT calcified tendon.
Conclusion:
FESWT in calcific tendinitis of the shoulder is a very effective, noninvasive, and safe procedure with no complications or any side effects, especially as compared to arthroscopic surgery. Shock Waves treatments can be recommended as a valuable treatment for impingement shoulder syndrome, in addition to core muscle stability exercises program.


Extracorporeal Radial Shockwave Therapy for Lateral Epicondylitis
Edson Antonio Serrano
Institution: Neomedica, Lima, Peru
Device and Producing Company: BTL 5000, BTL 6000
Introduction:
Extracorporeal radial shockwave therapy has shown to be effective in the treatment of chronic tendinopathies of the elbow, shoulder and plantar fascia. This prospective case series study evaluates the efficacy of extracorporeal radial shockwave therapy in the treatment of chronic lateral epicondylitis.
Methods:
We conducted a prospective study in forty-two patients with lateral epicondylitis. Our patients were treated with three to five weekly applications of 6000 impulses of radial shock waves with a progressive protocol. This protocol includes 2000 initial analgesic shockwaves followed by 2000 therapeutic shockwaves, and ending with 2000 of neurostimulation impulses. Analgesic or neurostimulation impulses are done with high frequencies of 12 – 18 pressure waves per second at a very low constant energy of 1.5 Bar. Therapeutic levels are considered above 2 Bar, and the frequency is managed from 12 to 6 impulses per second in a decreasing manner. Follow-up examinations were performed after one month, then every month up to 6 months using a pain visual analog scale from 0 to 10.
Results:
After 6 months of follow up, twenty-seven elbows (64.2%) were free of complaints, 10 (23.8%) were significantly better, 2 (4.7%) were slightly better, and 2 (4.7%) were unchanged. The only minor complication observed in the series was petechiae in 5 (11. 9%) patients.
Discussion:
This case series showed the benefits of radial shock waves using a progressive protocol that includes analgesic shockwaves before and after the therapeutic session, in the treatment of lateral epicondylitis.
Conclusion:
Our protocols showed to be effective and safe in the treatment of lateral epicondylitis of the elbow with radial extracorporeal shockwaves. Case control studies are required to follow our results.


 Piezoelectric Shockwave Therapy in the Treatment of Chronic Lateral Epicondylitis
Paulo Roberto Rockett
Institution: Ortosom, Brazil
Device and Producing Company: Piezoson 100 plus
Introduction:
The aim of the study is to evaluate the efficiency of piezoelectric shockwave therapy in the treatment of chronic lateral epicondylitis.
Methods:
Sixty nine patients (73 elbows), with ages ranging from 32 to 70 years old (average 52 y/o) were included in this retrospective study. Treatment was delivered with a piezoelectric shockwave generator (Piezoson 100 plus). The protocol consisted of at least three and a maximum of nine sessions at weekly intervals. Two thousand impulses with energy between 0,22 and 0,32 mJ/mm² were administered in each session. The symptoms were classified using the Visual Analogue Scale, and the clinical evaluation followed the Roles and Maudsley score, at intervals of 45, 90 and 180 days after the treatment was considered finished.
Results:
One hundred and eighty days after treatment the results were classified as excellent in 39,7%; good in 23,3% fair in 13,7% and poor in 23,3% of the patients. Side effects were rare and were associated with pain during or immediately after the applications, but no cases of worsening of the previously reported complaints were observed during follow-up.
Discussion:
The results were evaluated in a consecutive series of patients who did not achieve satisfactory results after the three months of conservative treatment, or in patients symptomatic for more than six months. Procedures were performed in the doctor´s office, without anesthesia.
Conclusion:
Shockwave Therapy should be considered as an optional treatment for Chronic Lateral Epicondylitis in cases the conservative treatment failed. It is a non-invasive safe method without significant complications, thus reducing risks and costs of surgical procedures.


P38
Epicondylitis: A Problem with a Difficult Solution

Maria Cristina Ottone (1), Francesca Maria Roldi (2), Emanuela Maria Roldi (3)
Institution: (1) ASL AL, Tortona, (2) LIST SpA, Milano, (3) no inst., Italy
Device and producing company: Piezoson 300 – Wolf
Introduction:
Chronic epicondylitis is a problem without an easy solution. It may frequently appear in a symptomatic acute mode. The purpose of this study is to verify our results of ESWT in this medical condition with the passing of time.
Methods:
In this retrospective study we checked a homogeneous group of patients including ordinary workers, as well as in amateur sports men and women. We treated 120 patients from January 2010 to September 2011. There was no predominance of the dominant side. The treatment was carried out using a Wolf Piezoson 300 device. The protocol of treatment included 4 sessions of 2000 pulses at 0,08mJ/mm².
Results:
The follow-up was after a short period of three months, but for this paper we wanted to verify the results at longer time: 18-24 months. We had excellent or good results in 85% of patients; only in 10 patients (8,5%) we had poor results.
Discussion:
In our series of patients were symptomatic for 6 to 12 months, and the patients had poor or no results with other conservative treatments. We didn't use anesthesiology and there were no complications.
Conclusion:
ESWT is not the answer to all problems of orthopedic pathology, but it is a very good solution for elbow epicondylitis according to the good results and the absence of associated problems reported in the literature and our own series.


 High-Energetic Focused Extracorporeal Shockwave (ESWT) Reduces Pain Levels in the Nodular State of Dupuytren’s Disease (DupuyShock) – A Randomized Study
Marie Kühn (1), Heiko Sorg (1), Peter M. Vogt (1), Karsten Knobloch (2)
Institution: (1) Hannover Medical School; (2) SportPraxis, Hannover, Germany
Device and producing company: Storz Duolith SD1
Introduction:
Given the effect of high-energetic focused shockwave therapy (ESWT) in the resolution of kidney stones we hypothesized whether high-energetic focused ESWT is able to improve quality of life and reduce pain in the nodular state of Dupuytren’s disease.
Methods:
In this prospective, randomized, blinded, placebo-controlled single center trial we included 58 patients (mean age: 58.2±9.2, 35 males, 23 females) with nodular Dupuytren’s disease Tubiana N. They were randomly assigned to receive either
• 3 treatments with high-energetic focused ESWT (2000 shots, 3Hz, mean: 49mJ/mm2/hand, Storz Duolith SD1, n=27, 15 males, mean age 57.6±8.1)
• or placebo (2000 shots, 3 Hz, 0.01mJ/mm2/hand, n=25, 17 male, mean age 58.9±10.9) in a weekly interval
Outcome was assessed by three validated quality of life instruments
• DASH score (0=perfect, 100= maximal impairment)
• MHQ score (0=maximal impairment, =perfect)
• URAM scale (0=perfect, 45=maximal impairment)
In addition, pain on a visual analogue scale and grip strength (JAMAR) were assessed before and after three months.
Results:
Treatment with ESWT reduced pain from 3.6±1.8 to 1.90±1.2 (53% reduction, p=0.0096) in intervention group, whereas in placebo group pain even increased from 2,24±1,36 to 3,53±1,70 (58% increase) (p=0.0096). Quality of life score tented to improve in the intervention group (MHQ: 77±19 to 83±15, DASH: 12±18 to 9±12, URAM: 3±4 to 2±4) while it deteriorated in the placebo group as Dupuytren’s disease was progressing (MHQ: 80±15 to 77±16, DASH: 6±10 to 8±10, URAM: 1±2 to 2±3. The strength of the affected hand and fingers did not change significantly in either of the groups (JAMAR Intervention: 37±12kg to 37±13kg, Placebo: 39±14kg to 40±14kg). No adverse events were reported beside a moderate pain during treatment.
Discussion:
It appears that high-energetic focused ESWT is able to reduce pain and improve quality of pain in nodular Dupuytren's disease.
Conclusion:
Treatment with extracorporeal focused shockwaves reduces pain in patients with nodules in Dupuytren’s disease.

 Molecular Changes after Extracorporeal Shockwave Therapy in Osteoarthritic Knee in Rats
Ching-Jen Wang
Institution: Kaohsiung Chang Gung Memorial Hospital, Taiwan
Device and producing company: DermaPACE; Sanuwave, USA
Introduction:
Extracorporeal shockwave therapy (ESWT) was shown to have chondroprotective effects in the initiation and progression of osteoarthritis (OA) of the knee in rats. However, the mechanism of ESWT in OA knee is unknown. This study investigated the molecular changes of DKK-1, MMP13, Wnt-5a and β-catenin after ESWT in anterior cruciate ligament transected (ACLT) osteoarthritic knee in rats.
Methods:
Twenty-seven male Sprague-Dawley rats were divided into 3 groups. Group I was the control and received sham knee arthrotomy but no ACLT or ESWT. Group II underwent ACLT but received no ESWT. Group III underwent ACLT and received ESWT one week after surgery. Radiographs of the knee were obtained at 0 and 12 weeks. The animals were sacrificed at 12 weeks, and the articular cartilage and subchondral bone of the knee were subjected to histopathological examination and immunohistochemical analysis.
Results:
Radiographs of the knee showed no discernible difference among 3 groups at 0 week. At 12 weeks, group II showed more arthritic changes including the formation of osteochondral fragments, whereas very subtle arthritis was noted in groups I and III. In histopathological examination group II showed significant increases of Mankin score and decreases of subchondral trabecular bone as compared to groups I and III. Group III showed significant decreases of Mankin score and increases of subchondral trabecular bone with the data comparable to group I. In immunohistochemical analysis group II showed significant increases of DKK-1 and MMP13 and decreases of Wnt-5a and β-catenin in articular cartilage and subchondral bone as compared to groups I and III. Group III showed significant decreases of DKK-1 and MMP13 and increases of Wnt-5a and β-catenin with the comparable data as compared to group I.
Discussion:
Prior studies showed ESWT has chondroprotective effect in OA knees of the rats. The results of this study supported the hypothesis that ESWT improves the subchondral bone remodeling that result in chondroprotective effects in OA knee. In clinical practice, the concept for the management of OA knee may change with the initial focus from articular cartilage to subchondral bone.
Conclusion:
ESWT produces molecular changes associated with improvement in subchondral bone remodeling and chondroprotective effect in ACLT OA knees in rats.


P47
Extracorporeal Shock Wave Treatment for Osteonecrosis of the Femoral Head - Case Report

Ana Claudia Souza
Institution: ORTHOTRAUMA, Rio de Janeiro, Brazil
Device and producing company: Orthogold 120 - SwiTech Medical AG
Introduction:
The objective of this study is to demonstrate the result obtained using ESWT for bilateral Osteonecrosis of the femoral head.
Methods:
A 49 years old male patient presenting bilateral Osteonecrosis of the femoral head stage II FICAT was treated with one single application by an electro-hydraulic device and under sedation. After treatment the patient was instructed to walk on crutches with partial weight bearing for four weeks. Follow up examinations were at one, two, three, six and twelve months. Clinical assessments included to determine pain scores and Harris Hip Score (HHS). Radiographs were performed before and after treatment (0, 1, 2, 3 and 6 months) and Magnetic Resonance Image (MRI) with three and six months after the treatment.
Results:
After three months the patient had recovered clinically, improved in HHS with remission of painful symptoms and also a total remission of the lesion in the MRI.
Discussion:
The principle of treatment of Osteonecrosis is to preserve the femoral head in the early stages. Decompression with or without bone graft is considered the gold standard. However the results of decompression are irregular and inconsistent evolving for total hip arthroplasty (THA). Recently the use of ESWT has been shown to be effective at the beginning of osteonecrosis. Studies have shown that treatment by SW induces neovascularization and osteogenesis. It is reasonable to believe that neovascularization may play a role in improving the blood supply to the femoral head which in turn promotes bone remodeling and regeneration.
Conclusion:
The result found in this case is encouraging, based on clinical and MRI examination. However it is necessary to confirm the efficacy of this new treatment for osteonecrosis through randomized clinical trials and long-term results for a best scientific evidence of the method.

 The Effectiveness of Extracorporeal Shockwave Therapy in the Treatment of Surgical Hand Scars
R. Saggini (1), N. Scuderi (3), I. Dodaj (4), G. Soda (5), M. Maruccia (3), RG Bellomo (2)
Institution: (1) Dept. Neuroscience and Imaging, “G. D’Annunzio” University, Chieti, Italy; (2) Dept. Medicine and Science of Aging, “G. D’Annunzio” University, Chieti, Italy; (3) Department of Plastic and Reconstructive Surgery, Sapienza University, Viale del Policlinico, 155, 00161 Rome, Italy; (4) School of Specialties in Physical Medicine and Rehabilitation, “G. d’Annunzio” University, Chieti, Italy; (5) Department of Molecular Medicine, ‘Sapienza’ University, Viale del Policlinico, 155, 00161 Rome, Italy.
Device and producing company: DermaGold, MTS, Konstanz, Germany
Introduction:
Cutaneous scarring can cause patients symptoms ranging from psychological to physical pain. Although the process of normal scarring is well described the ultimate cause of pathological scarring remains unknown. The retracting scars on the hands may cause significant functional deficits. For this reason clinical studies for preventative or curative scarring treatments are crucial.
Previous studies showed that shockwaves are effective in stimulating several endogenous growth factors such as EGF, IGF1, VEGF and nitric oxide production inducing angiogenesis and promoting the healing of fractures, ulcers and complex lesions. In 2009 Kuo et al. also showed that ESWT is able to: 1) reduce the inflammatory response with subsequent reduction in the number of circulating leukocytes and of oxygen free radicals; 2) promote the production of fibroblasts and the vascularization of the compromised skin, thus reducing the number of apoptotic cells. The aim of our study was to evaluate the efficacy of the treatment of hand scars with unfocused shockwaves and to judge the improvement of the function of the hand.
Methods:
We studied a group of 60 patients, aged between 20 and 65 years, with painful scars over one month after surgery. The patients were randomly divided in 5 groups: group A with surgical scars did not receive treatment with ESWT (control group), group B with surgical scars received treatment only with unfocused ESWT, group C with surgical scars with  regional pain complex syndrome received treatment only with unfocused ESWT, group D with surgical scars received treatment with unfocused ESWT associated with manual rehabilitation , group E with surgical scars received treatment with unfocused ESWT associated with manual rehabilitation and local treatment with I-COONE system.
The patients were treated with a frequency of 2 sessions every 7 days for 5 weeks with Dermagold system using 500 impulses at 0,11 mJ/mm².
Their evolution was monitored by histological and clinical examination, scar scales and photography.
For histological examination, biopsy specimens were performed on patient’s scars before and 5 weeks after shockwave therapy and subsequently stained with hematoxylin-eosin, picrosirius red and immunohistochemical stains for FXIII, CD34 to evaluate collagen and stain for CD34 to assess vascular response to therapy. Biopsies were also taken from patients who did not undergo shockwave therapy.
Scar scales have been devised to quantify scar appearance in response to treatment. We used 3 scar scales for the evaluation that were originally designed to assess subjective parameters in an objective way. The Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), Visual Analogic Scale (VAS). These observer-dependent scales consider factors such as scar height or thickness, surface area, texture, pigmentation and vascularity.
Results:
In the groups B, C, D, E a significant improvement of vascularity, color, height, thickness, pigmentation, and a significant reduction of scars hypersensibility and a remission of pain has been observed evaluated with Visual Analogic Scale. Reduction of hand disability and return to the daily activity was very important for shock wave treated patients. Conversely the control group not receiving shockwave therapy did benefit on the reduction of hand disability and pain and did not show a significant improvement of vascularity, color, height, thickness, and pigmentation.
We observed in all patients of B, C, D and E group a more ordered disposition of collagen bundles, increased amount of fibroblasts and vascular proliferation in histological examination compared to the control group A.
Conclusion:
Unfocused shockwave therapy seems to have a positive influence on scar formation on scars of the hand after surgery.


Poster 1
ESWT for Patellar Spur (Case Study)

Ayman Elwely Balabel, Faisal Ramadan Al-Kandary, Shafeek Abubacker
Institution: Ahmadi Hospital, Kuwait Oil Company, Kuwait
Device and producing company: EMS Swiss Dolorclast®
Introduction:
Patella bone spurs are abnormal bone growth that develops along the joint margins of the patella, Bone spurs are also known as osteophytes. They can affect any part of the body, including the shoulders, hips, and the spine. They develop in the joint areas where the bones meet other bones, or where the bones connect to the ligaments and tendons. In majority of the cases, there are no significant symptoms and the condition can remain undetected for years. However, in some cases when it causes severe pain and loss of motion of the joints, it needs to be treated immediately. Treatment options vary from non–surgical (conservative treatment) to surgical excision of spur to remove bony projection.
Methods:
A case of a 51 y old very active man is described. He used to play cricket and did gymnastic exercise regularly. He presented himself in our clinic with an anterior knee pain over the patella for the last 5 months, mainly as a suprapatellar pain. He was limping and unable to do squatting, upstairs and downstairs walking. Pain was VAS 8-9 and he was unable to do full flexion of the knee, showed weakness of the knee extensor muscle and had tried multiple conservative treatments for last few months. X-ray had been taken and showed a patellar spur. R-ESWT treatment has been advised for 3 sessions at weekly intervals. Each treatment consisted of 3000 pluses at a frequency of 9-11 Hz and a pressure of 1.9–2.7 bar. The patient was advised to stop any activities or sport during and after treatment program for a minimum of 4-6 weeks. Treatment was performed as an outpatient procedure without anaesthesia.
Results:
Follow up at 3 months showed a significant improvement for pain (VAS 2-3), ROM and a full flexion. Patient was advised to start eccentric exercise program and graduated muscle power exercises close chain exercises as well as home program exercised. Follow up at 6 months showed an excellent improvement for pain & ROM. Muscle power has been improved back to its normal activities with walking and exercising. X-ray showed that the spur was reduced in size.
Discussion:
Radial Shock Wave Therapy showed a significant clinical improvement for both pain and ROM in people with patellar spur.
Conclusion:
The authors considered that SWT is as first line to treat patellar spur, provided no contraindication related for the patient since the treatment is non–invasive, effective and shows absence of side effect.

 Piezoelectric Shockwave Therapy for the Treatment of Chronic Tendinopathy of the Rotator Cuff
Paulo Roberto Rockett
Institution: Ortosom, Brazil
Device and producing company: Piezoson 100 plus
Introduction:
The aim of the study was to evaluate the efficiency of piezoelectric shockwave therapy on the course of a Chronic Tendinopathy of the Rotator Cuff.
Methods:
One hundred and thirty one patients (142 shoulders) were enrolled in this retrospective study, ages ranging from 14 to 79 years old (an average age of 53 years). SWT was delivered with a piezoelectric shockwave generator. The protocol consisted of at least three and a maximum of nine sessions at weekly intervals. In each session 2000 impulses at an EFD of 0,22 mJ/mm² and 0,32 mJ/mm² were delivered. The symptoms were classified using the Visual Analogue Scale (VAS) and the clinical evaluation according to the Roles and Maudsley score at 45, 90 and 180 days after the end of the treatment.
Results:
One hundred and eighty days after the treatment the results were evaluated as excellent in 23,3%, good in 40,2%, acceptable in 12% and poor in 24,6% of the patients. Side effects were rare and associated with pain during, and immediately after, the application, but no cases of worsening of the complaints previously reported were observed during follow-up.
Discussion:
The results were evaluated in a consecutive series of patients who did not achieve satisfactory results after conservative treatment for three months, or with complaints for more than six months. Procedures were performed in the doctor´s office without anesthesia.
Conclusion:
Shockwave therapy should be considered as an optional treatment to Chronic Tendinopathy of the Rotator Cuff in cases when the conservative treatment failed. It is a safe, non-invasive alternative without significant complications, thus reducing risks and costs of surgical procedures.

 The Effectiveness of ESWT in Patients with Myofascial Pain
Ummuhan Bas Aslan (1), Fatma Uguz (2)
Institution: (1) Pamukkale University School of Physical Therapy and rehabilitation, Denizli Turkey, (2) Servergazi State Hospital, Bereketli Beldesi, Denizli Turkey
Device and producing company: Masterpuls MP 100, Storz Medical
Introduction:
The purpose of the study was to investigate the effectiveness of Extracorporeal Shockwave Therapy combined home stretching exercise in patients with chronic cervical myofascial pain.
Results:
Before treatment pain pressure threshold and cervical range of motion (ROM) scores were 5,81 ±2,11 kg and 293,81±46,47º, respectively. After the SW treatment the scores of pain pressure threshold and cervical range of motion were 10.80 ±2,80 kg and 350,57±56,71º. After the treatment, differences in pain pressure threshold and cervical range of motion were significant (p<0,05).
Discussion:
Pain pressure threshold, cervical range of motion of the patients improved after the radial extracorporeal shockwave therapy.
Conclusion:
Our results suggest that the use of radial extracorporeal shockwave therapy for the management of chronic cervical myofascial pain is effective, leading to a significant increase in pain pressure threshold and improvement of the cervical range of motion after 6 weeks.






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