Extracorporeal Shockwave therapy (ESWT) provides numerous scientific vindications for its supremacy in the conservative management of subacute and chronic conditions relating to the musculoskeletal system. Shockwave therapy scientific evidence include but is not limited to:
Achilles tendinopathy; Chronic Achilles tendinopathy is considered to be the most common over use and recalcitrant (responds poorly or resistant to conventional treatment) injury in sports medicine. Achilles tendonitis, inflammation of the Achilles tendon, can present with pain, swelling and irritation at the back of the leg near the heel; and may be considered as a disability in the professional athlete. Although conclusive evidence recommending ESWT as a treatment for Achilles tendinopathy is still lacking; ESWT is recently the best conservative evidence based treatment option for plantar fasciitis as well as for calcific shoulder tendinopathy (Gerdesmeyer et al. 2015). Subjects with Achilles tendinopathy received 5 treatment sessions of ESWT. VAS (Visual Assessment Scale) pain scores consisting of pain in the morning and during active activity were measured at baseline, post-interventions and at a 6 month follow-up. The baseline scores served as the control. The ESWT subjects showed post-treatment session that 75% were very satisfied, 18.76 % were satisfied, 3.1 % were improved, and 3.1 % had no effect. At the 6 month; the mean ESWT subjects showed a significant decrease in VAS pain scores by 51 % (p < 0.05) and a decrease in active activity pain by 53% (p <0.05). Although higher studies are required; ESWT may be used as an effective treatment option for Achilles tendinopathy (Serrano 2013).
Calcific tendonitis; Calcific tendonitis is the build-up of calcium (calcific deposits) in the rotator cuff (supraspinatus). The calcific deposits build up pressure in the tendon and lead to extreme intense shoulder pain (the second worst considered shoulder pain after frozen shoulder), as well as can result in shoulder impingement syndrome. The cause is not entirely known; calcium build-up in injured tendons may be the result of micro-tears or other trauma. Although calcific tendonitis eventually disappears spontaneously; it can take up to 10 years to resolve by itself. The efficacy of ESWT was compared to conventional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, corticosteroid injections, physiotherapy and rehabilitation (control group) in subjects with confirmed calcific tendonitis. The interventions were applied at baseline and at 3 months; the VAS pain, pain-free grip strength test, and Constant and Murley Scale (indicate the shoulder functioning) scores were measured at baseline and post-interventions. The calcifications disappeared completely in 84.3 % of the ESWT subject (p <0.05), whereas calcifications disappeared partially in 15.6 % of the control subjects. ESWT is an established completely efficient and safe conservative treatment tool in the treatment of degenerative and inflammatory pathology of the shoulder with tendinous lesions idiopathic calcific disease (Dima et al. 2008). Calcific tendonitis commonly progress to functional disability and may lead to pharmacological overuse when conventional treatment fails. A single ESWT session with cryotherapy (the application of ice) and medical exercises was administered in subjects with confirmed calcific tendonitis of the shoulder. Range of motion and voluntary isometric contraction muscle strength of the shoulder were measures as well as VAS pain scores at baseline, immediately post-intervention and at 6 months. X-rays were also taken 6 months post-intervention for assessment of calcific deposits. The baseline scores served as the control. The mean ESWT subjects showed significant (p < 0.05) improvement in range of motion, rotator cuff strength and a decrease in VAS pain scores. The x-rays confirmed a decrease in the size of the rotator cuff calcifications. ESWT significantly improves the functioning and muscle strength of the shoulder in the treatment of calcific tendonitis (Avancini-Dobrovic et al. 2011).
Greater trochanteric pain syndrome; Chronic greater trochanteric pain syndrome or known as trochanteric/ hip bursitis is in the majority a clinical manifestation of gluteal tendinopathy; ESWT have been shown to be effective in the treatment of various tendinopathies. Hip bursa(s) serve as a cushioning between the bones and soft tissue of the hip; irritation of the bursa can lead to inflammation of the bursa known as hip bursitis, and can present as hip pain particularly when sleeping on the affected hip or during active activates. The efficacy of ESWT was compared to additional forms of conservative conventional therapy (control group) in subjects with chronic greater trochanteric pain. The interventions were applied at baseline, 1, 3 and 12 months; mean VAS pain and Harris hip (indicate functioning of hip) scores were taken at baseline and post-interventions. The ESWT showed a significant difference (p < 0.01) in both VAS pain and Harrison hip scores at 1, 3 and 12 months, compared to the control. ESWT can be used as an effective treatment option for chronic greater trochanteric pain (Furia et al. 2009).
Hamstring tendinopathy; Chronic proximal hamstring tendinopathy is a common overuse injury and predominantly progress to surgical intervention in the professional athlete; ESWT has been shown to be an effective conservative treatment option for the treatment of various tendinopathies. Chronic hamstring tendinopathies may increase the predisposition of hamstring muscle tears and may be career ending in the professional athlete. The efficacy of ESWT was compared to the conventional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, physiotherapy and rehabilitation (control group) in professional athletes with chronic proximal hamstring tendinopathy. The interventions were applied at baseline, week 1, 3, 6 and 12; the VAS pain scores and Nirschl phase rating scale (assessment of sporting injury) at baseline and pre- and post-interventions were measured. The primary follow-up occurred at 3 months. The ESWT showed a significant difference in the VAS pain scores (p< 0.01) post-interventions at 3 months compared to the control; and a significant difference in the Nirschl phase rating scale scores (p < 0.001) post-interventions at 3 months compared to the control. In addition, at 3 months post-interventions; 85 % of the ESWT subjects and 10 % of the control subjects achieved a pain reduction of a minimum of 50 % (p < 0.01). ESWT can be used as an effective non-operative treatment option for chronic proximal hamstring tendinopathy (Cacchio et al. 2010).
Lateral epicondylitis; Lateral epicondylitis or known as tennis elbow is a very common recalcitrant overuse injury, and is predominantly encountered in tennis, violinists, surgeons, dentists, and the individual who types a lot such as a receptionist/ secretary; predominantly between the age of 40 and 50 and in amateur tennis players. Lateral epicondylitis is inflammation (progress to degeneration) of the common wrist extensor origin mass (extensor carpi radialis brevis), and can present as pain or burning sensation on the outer part of the elbow and weak grip strength. The treatment of tennis elbow is very complex and diversified, and reoccurrence is significantly high even after 3 months of conventional treatment. ESWT was applied twice a week for a duration of 5 weeks in subjects with chronic lateral epicondylitis between the ages of 40 and 50 and who experienced no positive results in conventional therapy beforehand. VAS pain scores entailed the intensity of pain on palpation, during the performance of daily activities, and immediately pre- and post-ESWT interventions; and were measured at baseline and post-treatment session. The baseline scores served as the control. The ESWT showed a significant (p < 0.05) decrease in VAS pain scores as well as the complete disappearance of pain in some subjects after 5 weeks of treatment, compared to the control. ESWT produced positive results in subjects with chronic lateral epicondylitis who experienced no improvement with conventional therapy; and thereby ESWT may help where conventional therapy fails (Daniel-Lucian and Tatiana 2014). A 5 treatment session over 5 weeks (one treatment session per week) was administered to subjects with chronic lateral epicondylitis. VAS pain scores were measures at baseline, month 1 to 6 post-interventions. The baseline served as the control. Post-six months of the ESWT treatment; 64.2 % of the subjects were completely free of pain, 23.8 % of the subjects significantly improved (p < 0.05), 4.7 % of the subjects showed no significant change (p > 0.05), and 11.9 % of the subjects experienced minor complication entailing petechiae (small haemorrhage/ bleeding of skin) at the site of treatment. ESWT can be used as an effective and safe treatment option for lateral epicondylitis as well as significantly reduce re-occurrence at 6 months (Serrano 2013).
Spinal facet joint syndrome; Lumbar facet joint syndrome/ pain contribute to one third of chronic low back pain. Facet syndrome refers to inflammation of the facet joint capsular ligament or pain arising from the facet joints in the spine, and is commonly caused by repetitive postural strain or trauma. Medial branch radiofrequency neurotomy after failure of corticosteroid injections (conventional conservative treatment) is considered to be the gold standard in the treatment of lumbar facet joint pain, although risk of possible complication arises such as infection and damage to nerve roots or medial branch structures. The efficacy of ESWT was compared to interventional treatment procedures, radiofrequency neurotomy, and corticosteroid facet joint injections; in subjects with unilateral chronic lumbar facet pain. The ESWT showed significant decrease in VAS pain scores; better long term results compared to the facet joint injections; slight inferior efficacy compared to the radiofrequency neurotomy; and no adverse effects or complications were observed. ESWT can be used as a safe and perspective treatment option without the possible complications in the treatment of facet joint pain (Nedelka et al. 2014).
Medial tibial stress syndrome; Medial tibial stress syndrome or known as shin splints is a very common over use and recalcitrant injury in sports medicine. Shin splints presents as a pain syndrome along the tibial origin of the tibialis posterior or soleus muscle (pain along the shin bone) during and after active activity particularly running; ESWT has been shown to be an effective treatment option for the treatment of various insertional pain syndromes. The efficacy of ESWT was compared to a rehabilitation program (control group) in subjects with chronic recalcitrant medial stress syndrome. The interventions were applied at baseline, 1, 4 and 15 months; the degree of recovery was measured on a VAS 6-point Likert scale (indicate complete recovery) at baseline and post-interventions. The ESWT showed a significant difference (p < 0.01) in the Likert scale at 1, 4 and 15 months, compared to the control. At 15 months; 85 % of the ESWT subjects returned to their respective sports, whereas 47 % of the control subjects returned to their respective sports. ESWT significantly return patients faster to active sport (Jan et al. 2010).
Osteoarthritis; Osteoarthritis or known as degenerative joint disease affect more than 10 % of the world’s population; 30 to 55 % of all orthopaedic patients who visit a doctor present with osteoarthritis. Repetitive trauma and overuse resulting in “wear-and-tear” over the life-span of the human being, as well as a congenital predisposition; is possibly the major causes of osteoarthritis. The conservative conventional treatment for osteoarthritis is very limiting before surgical intervention; and entails mobilization and rehabilitation of the affective joints to a certain limit of which the affected joints can tolerate without inducing more degenerative changes (“wear-and-tear”). A 3 to 6 treatment session with ESWT with an interval of 3 to 6 days between the interventions were administrated to subjects with confirmed osteoarthritis of the knee joint. VAS pain scores (represents the painful syndrome associated with arthrosis), morning stiffness rate (morning stiffness is a clinical manifestation associated with arthrosis), joint index and functional index scores (indicate functioning of the joint) were measures at baseline and post-interventions. The baseline scores served as the control. The post-treatment session with ESWT showed that the VAS pain scores reduced significantly in 85 % of the subjects (p < 0.05), the mean morning stiffness rate was reduced by 44 %, the joint index improved by 39 %, and the functional index improved by 18 %; compared to the control. ESWT can be used as an effective conservative treatment option for osteoarthritis, reduce the painful syndrome associated with arthrosis in 85 % of cases, and may improve the functioning of the affected degenerative joint (Sheveleva and Minbaeva 2014).
Patellar tendinopathy; Patellar tendinopathy or known as jumper’s knee is considered to be sport career ending, over use injury, and is very common in the professional athlete as well as post-total knee arthroplasty (TKA); ESWT has been shown to be an effective conservative treatment option for the treatment of various tendinopathies. Patellar tendinopathy is inflammation (leads to degeneration) of the patellar tendon and give rise to anterior knee pain during and after active activity, particularly activity which require active squatting (bending of the knee). A 2 weekly session of ESWT was administrated to subjects who have undergone a TKA, a Genesis II total knee transplant (all subjects received the same implant and techniques with no patellar implants), who presented with patellar tendinopathy, and experienced no significant improvements with previous conventional treatments. All subjects were actively involved in golf that played twice weekly. VAS pain and Maudsley (indicate knee functioning) scores were measured at baseline and at 1 and 3 month with x-ray and bone scan for confirmation of any possible changes or signs for loosening of surgical implants. The baseline scores served as the control. Post-baseline intervention; 46 % of the ESWT subjects showed an improvement in VAS pain scores. Post-one month intervention; the mean ESWT subjects showed a decrease in VAS pain scores by 65 %. Post-three month intervention; the mean ESWT subjects showed a decrease in VAS pain scores by 69 %, with no x-ray and bone scan confirmed damage or changes of the surgical implants or the bone-cement-prosthesis interfaces, as well as no complication were reported. All ESWT subjects showed improvement in the Maudsley scores post-interventions with a good return to golf and little or no pain during or after the sporting activity. ESWT may be an efficient and safe conservative treatment tool in the treatment of patellar tendinopathy particularly after operative-intervention with or without surgical implant, as well as show promising faster return to active sport post-operative intervention (Carlos et al. 2014).
Plantar fasciitis; Plantar fasciitis is a very common painful condition of the subcalcaneal aspect of the foot (heel and foot pain) which result from inflammation or contracture of the deep fascia of the sole of the foot with or without a heel spur (bony outgrowth at heel). The pain at the bottom of the foot is most prevalent with the first few steps after getting out of bed in the morning, after a long period of rest such as after a long car ride, and after (predominantly not during) active activity (the pain usually subsides after a few minutes of walking). Chronic recalcitrant plantar fasciitis is common, particularly in the active individual. The efficacy of 3 interventions of ESWT was compared to a placebo in subjects with chronic recalcitrant plantar fasciitis. VAS pain scores and an overall success rate score was measured (heel pain at first step in the morning, during daily activities and during standardized pressure force) at baseline, 12 weeks and at 12 months. The ESWT showed a significant difference (p < 0.05) in the VAS pain and success rate scores compared to the placebo at both 12 weeks and 12 months. At 12 weeks; the mean ESWT subjects showed a decrease in VAS pain scores by 72.1 % and an overall success rate of 61 %, whereas the mean placebo subjects showed a decrease in the VAS pain scores by 44.7 % and an overall success rate of 42.2 %. ESWT significantly improves pain, function and quality of life in patients with recalcitrant plantar fasciitis (Gerdesmeyer et al. 2008). Despite conventional conservative treatment which consist of rest, physiotherapy, heel cushion, nonsteroidal anti-inflammatory drugs, corticosteroid injections, taping, orthotics and shoe modification, night splinting and casts; recalcitrant plantar fasciitis is still common. The efficacy of ESWT was compared to a placebo intervention in subjects with chronic plantar fasciitis recalcitrant to conservative conventional therapies for a minimum of 6 months. The interventions were applied at baseline, week 1, 2, 3 and 4; VAS pain scores was measure at baseline, 4 weeks, 8 weeks and 3 months post-interventions. The ESWT showed a significant difference (p < 0.01) at 3 months in VAS pain scores compared to the placebo. At 3 months; 48.3 % of the ESWT subjects showed a decrease in mean VAS pain scores by more than 60 %, whereas only 23% of the placebo subjects met the same criteria. ESWT can be used as an effective treatment option for recalcitrant plantar fasciitis (Husseiny and Mansour).
Spasticity; There has been several reports of the use of ESWT for the management of spasticity in patients with cerebral palsy. A 4 treatment session of ESWT over 2 weeks were applied to the mainly affects muscles in children with cerebral palsy. Active range of motion, modified Ashworth scale (indicate severity of spasticity) and the subjects quality of life on VAS scores where measured at baseline and post the 4 treatment session. A significant (p < 0.05) improvement of the mean modified Ashworth scale scores was found post the 4 weeks treatment session of ESWT, without affecting the quality of life. An improvement of the global functioning of the upper and lower limbs was observed. ESWT may be an efficient and safe conservative treatment tool in the treatment of spasticity without affecting the quality of life as with anti-spastic procedures (Illieva et al. 2011).
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