16. září 2021

Neckař P*, Kadrmasová Z, Klementová R, Centrum sportovní ortopedie a medicína, U Radnice 736/4, 41501 Teplice, Česká republika

Záměr: Běžné ortopedické diagnózy jsou považovány za příčinu bolesti u velkého počtu pacientů. Mezi současné možnosti léčby bolesti patří medikace, injekce nebo operace. V poslední době získává na popularitě fokusovaná rázová vlna, Focused Shockwave Therapy (FSWT), díky své klinické účinnosti a neinvazivní aplikaci.

Cíle: Cílem této studie bylo zhodnocení krátkodobé účinnosti FSWT v léčbě bolesti u pacientů s epikondylitidou, syndromem rotátorové manžety, plantární fasciitidou, patellární tendinopatií a zánětem Achillovy šlachy.

Metody: Pacienti podstoupili průměrně 3,5 ± 0,4 ošetření v závislosti na jejich zdravotním stavu. Všichni pacienti byli ošetřováni přístrojem BTL-6000 FSWT a jejich vnímání bolesti bylo hodnoceno před začátkem terapie (baseline) a po posledním ošetření pomocí vizuální analogové škály (VAS).

Výsledky: Významný rozdíl (p<0.01) byl zaznamenán mezi počáteční hodnotou VAS a hodnotami po posledním ošetření, a to u všech diagnóz. Nejvýznamnější redukce bolesti byla zaznamenána u skupiny pacientů se zánětem Achillovy šlachy (60,9 %), následně u skupiny s patellární tendinopatií (57,8 %).

Závěr: FSWT byla shledána účinnou metodou v okamžité redukci bolesti u pacientů s epikondylitidou, syndromem rotátorové manžety, plantární fasciitidou, patellární tendinopatií a zánětem Achillovy šlachy.

FSWT uses the technology of extracorporeal shockwave which was introduced in 1980, when high-energy extracorporeal shockwaves served as a means of treating kidney stones. Gradually, the principle of regenerative effects was discovered and shockwave therapy was introduced in the field of orthopedics. Since then, ESWT has become the preferred choice in the treatment of many orthopedic disorders including plantar fasciitis of the heel, epicondylitis of the elbow, or tendinitis of the shoulder. This therapy has also proven to be useful in the treatment of nonunion of long bone fractures. Prospective studies using ESWT on patellar and Achilles’ tendinopathies indicate good results as well. Rare studies done by Asian authors also show positive results in the treatment of avascular necrosis of the femoral head.

A shockwave is defined as an acoustic wave that produces a short (microsecond duration) three-dimensional pressure pulse. There are two modalities for shockwave therapy: focused (convergence) and radial (divergence). In FSWT, the source of energy is either electrohydraulic, electromagnetic, or piezoelectric and shockwaves are concentrated into small focal areas at selected depths in the body tissues to ensure the optimal therapeutic effect. On the other hand, in Radial Shock Wave Therapy (RSWT), the focal point is not centered on the target zone, as in the case of FSWT. Instead, shockwave is generated through the acceleration of a projectile inside the handpiece of the treatment device and thus the focal point is on the tip of the applicator. The pressure wave then penetrates the body radially and can not be focused in the deeper layers, the area of treatment is more superficial.

Therapeutic effects are considered to be dependent on the energy delivered to a focal area (the energy flux density), the focal zone size, and on tissue penetration. Although the subject is still under study, it is known that ESWT stimulates the local biological response and is able to relieve pain, as well as positively regulate inflammation. Moreover, shockwaves improve tissue regeneration and healing by neoangiogenesis and stem cells activities. ESWT can be presented as an alternative to chirurgic therapy in some chronic tendinopathies and healing disorders. Its advantages are safety and non-invasivity. In the time of the Covid pandemic, the use of ESWT is coming to the fore even more.

RESULTS

A total of 149 patients received up to 6 treatments (3,5 ± 0,4 on average), depending on their diagnosis and state of health. Results will be presented for each diagnosis separately. A significant (p<0,01) difference was found between VAS baseline and VAS after the last treatment in all diagnoses.

Epicondylitis
For the patients diagnosed with epicondylitis, the VAS baseline results were 6.6 ± 1.3. From the baseline, VAS decreased to 4.5 ± 1.8. The difference of 2.1 ± 1.7 represents 31.9% reduction in pain. For 30 patients, data including the final intensity of 29.5 ± 7.1 were available.

Rotator cuff syndrome
In patients with rotator cuff syndrome, the perception of pain reduced from 6.4 ± 1.3 to 3.8 ± 1.6. The decrease corresponds with 41.5% (2.7 ± 1.6). The final intensity data of 38.0 ± 5.7 were obtained for 36 patients.

Plantar fasciitis
The VAS baseline for the group of patients with plantar fasciitis was 6.7 ± 1.7 and after the last therapy, the obtained VAS results were 3.7 ± 1.7. The difference between both VAS values is 44.8% (3.0 ± 1.8). For 39 patients of this group, there were available data about the final intensity of 34.6 ± 6.4.

Patellar tendinopathy
In the patellar tendinopathy group, VAS baseline results were 7.3 ± 1.0. A difference of 57.8% (4.2 ± 2.0) was found between VAS baseline and VAS after the last treatment. From baseline, VAS was reduced to 3.1 ± 1.5. The final intensity data were taken for 3 patients (38.7 ± 10.1).

Tendinosis of Achilles tendon
In patients diagnosed with Achilles’ tendinosis, the pain evaluation decreased from 5.8 ± 1.8 to 2.3 ± 1.6. The difference between VAS results represents 60.9% (3.5 ± 1.7) reduction in pain perception. For 10 patients, the final intensity data of 35.9 ± 6.7 were included.

CONCLUSION

FSWT is an effective modality in the treatment of patients diagnosed with epicondylitis, rotator cuff syndrome, plantar fasciitis, patellar tendinopathy and Achilles’ tendinosis based on its analgesic properties. The results of the present study proving short-term effects on pain reduction are encouraging but other studies with larger samples or comparisons with other conservative interventions should be implemented, to better understand the effects of FSWT and to unify optimal treatment parameters. For these reasons, continued research in this area is therefore of great importance.

Read the entire study here: Analgesic Effects of FSWT in Common Orthopedic Diagnoses.