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Repetitive shock wave therapy for lateral elbow tendinopathy (tennis elbow): a systematic and qualitative analysis.
No full textOBJECTIVE:
Pooled meta-analyses of statistically and clinically heterogeneous data of randomised-controlled studies are difficult to interpret. Therefore, a qualitative study-by-study assessment was thought to be of greater relevance, to physicians confronted with a therapy-resistant tennis elbow patient, to determine the effectiveness of shock wave therapy (SWT) for lateral elbow tendinopathy.
SETTING:
Orthopaedic clinic.
METHODS:
Randomized trials were identified from a current search of The Cochrane Bone, Joint and Muscle Trauma Group specialized register of trials, the Cochrane Central Register of Controlled Trials, MEDLINE and reference lists of articles and dissertations. We included 10 trials that randomized 948 participants to SWT or placebo or treatment control. For each trial, two independent reviewers assessed the methodological quality and extracted data. Methodological quality criteria included appropriate randomization, allocation concealment, blinding, number lost to follow-up and intention-to-treat analysis.
RESULTS:
Conflicting results of the 10 studies were found. There was considerable heterogeneity in terms of methodological quality; treatment regimen; patient selection and follow-up period, precluding pooled analyses. Instead, individual trial results were described in the text. Only six trials had a high-quality methodology. Two independent high-quality randomized placebo-controlled trials (196 participants) reported significant success of SWT over placebo (65 versus 28%; 61 versus 29%). Design of both trials included enrolment of chronic recalcitrant patients only; 1500-2000 shocks of low-energy flux density (0.1 mJ/mm(2)) applied to the site of maximal discomfort (clinical focusing) in weekly intervals; no use of local anaesthesia and main follow-up at least 3 months after the last application. Three other independent high-quality trials (406 participants) did not find any benefit of SWT over placebo (32 versus 33%; 35 versus 34%; 39 versus 31%). In these three trials, study designs deviated from the design described earlier, enrolling acute patients or applying SWT under local anaesthesia or expanding the application intervals to 4 weeks, while reducing the main follow-up to 4 weeks.
CONCLUSIONS:
With current studies heterogeneous in terms of the duration of the disorder; type, frequency and total dose of SWT; period of time between SWT; type of management and control group; timing of follow-up and outcomes assessed, a pooled meta-analysis of SWT for lateral elbow tendinopathy was considered inappropriate. In a qualitative systematic per-study analysis identifying common and diverging details of 10 randomized-controlled trials, evidence was found for effectiveness of shock wave treatment for tennis elbow under well-defined, restrictive conditions only
US-guided percutaneous treatment of shoulder calcific tendonitis: some clarifications are needed.
No full textWe read with great interest the article (1) by Dr Serafini and colleagues on ultrasonography (US)-guided percutaneous treatment of calcific tendinosis, which appeared in the July 2009 issue of Radiology. However, we have some concerns about their article:
Because calcific tendonitis is a self-limited condition, the assessment of outcomes in the treated population without an adequate control group could introduce a bias in the determination of response to therapy. In addition, a more objective imaging evaluation with radiography (2) or US (3) is required to determine the outcome of treatment and compare it with others. Without an adequate control, it is not obvious whether the reported success is due to spontaneous improvement, the local anesthetic, the two-needle treatment, the applied steroid, or a combination of factors.
The study group is not well characterized. The classification of calcific tendinosis (eg, as done by Gärtner and Simons [2]) has not been reported. Type III calcifications in the Gärtner and Simons classification system showed a high probability of spontaneous resolution (4), and patients with them have been excluded in a number of clinical trials (5–7). We are surprised at the complete absence of calcified supraspinatus tendons in this series of patients.
There are limited clinical follow-up data. Although this is a case control study, the 1-month, 3-month, and 1-year results may have clinical relevance. We are also concerned with the comparison of results at 5 years to those at 10 years since so many patients were lost to follow-up. Moreover, the reason for these losses is not explained.
We hope the authors can clarify their rationale for the study design limitations we have noted and clarify their approach to follow-up
Mid-portion Achilles tendinopathy--current options for treatment.
No full textPURPOSE:
To report on the present option for management of tendinopathy of the main body of the Achilles tendon.
BACKGROUND:
Tendinopathy of the main body of tendo Achillis affects athletic and sedentary patients. Mechanical loading is thought to be a major causative factor. However, the exact mechanical loading conditions which cause tendinopathy are poorly defined. Repetitive mechanical loading induces a non-inflammatory pathology, and repetitive microtrauma ultimately exceeds the healing response. The management of Achilles tendinopathy is primarily conservative. Although many non-operative options are available, few have been tested under controlled conditions. This review article specifically focuses on eccentric training, and on shock wave therapy. Surgical intervention can be successful in refractory cases. However, surgery does not usually completely eliminate symptoms and complications are not rare.
CONCLUSIONS:
Further studies are needed to discern the optimal non-operative and surgical management of midsubstance Achilles tendinopathy
Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome.
No full textBACKGROUND:
Greater trochanteric pain syndrome is often a manifestation of underlying gluteal tendinopathy. Extracorporeal shock wave therapy is effective in numerous types of tendinopathies.
HYPOTHESIS:
Shock wave therapy is an effective treatment for chronic greater trochanteric pain syndrome.
STUDY DESIGN:
Case control study; Level of evidence, 3.
METHODS:
Thirty-three patients with chronic greater trochanteric pain syndrome received low-energy shock wave therapy (2000 shocks; 4 bars of pressure, equal to 0.18 mJ/mm(2); total energy flux density, 360 mJ/mm(2)). Thirty-three patients with chronic greater trochanteric pain syndrome were not treated with shock wave therapy but received additional forms of nonoperative therapy (control). All shock wave therapy procedures were performed without anesthesia. Evaluation was by change in visual analog score, Harris hip score, and Roles and Maudsley score.
RESULTS:
Mean pretreatment visual analog scores for the control and shock wave therapy groups were 8.5 and 8.5, respectively. One, 3, and 12 months after treatment, the mean visual analog score for the control and shock wave therapy groups were 7.6 and 5.1 (P < .001), 7 and 3.7 (P < .001), and 6.3 and 2.7 (P < .001), respectively. One, 3, and 12 months after treatment, mean Harris hip scores for the control and shock wave therapy groups were 54.4 and 69.8 (P < .001), 56.9 and 74.8 (P < .001), and 57.6 and 79.9 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 10 and 0 (P < .001), 16 and 12 (P < .001), 4 and 13 (P < .001), and 3 and 8 (P < .001), respectively. Chi-square analysis showed the percentage of patients with excellent (1) or good (2) Roles and Maudsley scores (ie, successful results) 12 months after treatment was statistically greater in the shock wave therapy than in the control group (P < .001).
CONCLUSION:
Shock wave therapy is an effective treatment for greater trochanteric pain syndrome
[Shock wave treatment for tennis elbow].
No full textRandomized controlled trials were evaluated to assess the effectiveness of extracorporeal shock wave treatment in the management of tennis elbow. Five trials had a mediocre methodology and four trials had a high-quality design. Well-designed randomized control trials have provided evidence of the effectiveness of shock wave intervention for tennis elbow
Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial.
No full textBACKGROUND:
Few randomized controlled trials compare different methods of management in chronic tendinopathy of the main body of tendo Achillis.
PURPOSE:
To compare the effectiveness of 3 management strategies-group 1, eccentric loading; group 2, repetitive low-energy shock-wave therapy (SWT); and group 3, wait and see-in patients with chronic tendinopathy of the main body of tendo Achillis.
STUDY DESIGN:
Randomized controlled trial; Level of evidence, 1.
METHODS:
Seventy-five patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on intention-to-treat basis.
RESULTS:
At 4 months from baseline, the Victorian Institute of Sport Assessment (VISA)-A score increased in all groups, from 51 to 76 points in group 1 (eccentric loading), from 50 to 70 points in group 2 (repetitive low-energy SWT), and from 48 to 55 points in group 3 (wait and see). Pain rating decreased in all groups, from 7 to 4 points in group 1, from 7 to 4 points in group 2, and from 8 to 6 points in group 3. Fifteen of 25 patients in group 1 (60%), 13 of 25 patients in group 2 (52%), and 6 of 25 patients in Group 3 (24%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 did not differ significantly. For all outcome measures, groups 1 and 2 showed significantly better results than group 3.
CONCLUSION:
At 4-month follow-up, eccentric loading and low-energy SWT showed comparable results. The wait-and-see strategy was ineffective for the management of chronic recalcitrant tendinopathy of the main body of the Achilles tendon
CLINICAL APPLICATION OF SHOCK WAVE THERAPY (SWT) IN MUSCULOSKELETAL DISORDERS
No full textCurrently the application of shock wave therapy (SWT) in musculoskeletal disorders has been primarily used in the treatment of tendinopathies (proximal plantar fasciopathy, lateral elbow tendinopathy, calcific tendinopathy of the shoulder, and patellar tendinopathy, etc.) and bone defects (delayed- and non-union of bone fractures, avascular necrosis of femoral head, etc.). Although the mechanism of their therapeutic effects are still unknown, the majority of published papers have shown positive and beneficial effects of using SWT as a treatment for musculoskeletal disorders, with a success rate ranging from 65% to 91%, while the complications are low or negligible. The purpose of this paper is to inform the reader about the published data on the clinical application of SWT in the treatment of musculoskeletal disorders. In this paper, with the help of a literature review, indications and success rates for SWT in the treatment of musculoskeletal disorders are outlined, while adequate SWT parameters (e.g., rate of impulses, energy flux density, etc.) are defined according to the present state of knowledge
Shock wave therapy for chronic plantar fasciopathy.
No full textINTRODUCTION:
Relevant data of randomized-controlled studies on shock wave treatment for chronic plantar fasciopathy are statistically and clinically heterogeneous.
METHODS:
Randomized trials were identified form a current search of the Cochrane Bone, Joint and Muscle Trauma Group specialized register of trials, the Cochrane Central Register of Controlled Trials, MEDLINE and reference lists of articles and dissertations. We identified and retrieved a total of 17 articles. Methodological quality criterial included appropriate randomization, allocation concealment, blinding, number lost of follow-up and intention to treat analysis. Significant heterogeneity between studies precluded pooled analyses. Instead, individual trial results were described in the text.
RESULTS:
We identified conflicting results in the 17 studies, involving more than 2100 participants. There was considerable heterogeneity in terms of methodological quality, treatment regimen, patient selection and follow-up period.
CONCLUSIONS:
With current studies heterogenous in terms of the duration of the disorder; type, frequency and total dose of shock wave therapy (SWT); period of time between SWT; type of management and control group; timing of follow-up and outcomes assessed, a pooled meta-analysis of SWT for chronic plantar fasciopathy was considered inappropriate. Neverhteless, there was a preponderance of well-designed studies showing favourable results. It appears that one should only consider SWT for plantar fasciopathy after more common, accepted and proven non-invasive treatments have failed
Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes.
No full textBACKGROUND:
Chronic proximal hamstring tendinopathy is an overuse syndrome that is usually managed by nonoperative methods. Shockwave therapy has proved to be effective in many tendinopathies.
HYPOTHESIS:
Shockwave therapy may be more effective than other nonoperative treatments for chronic proximal hamstring tendinopathy.
STUDY DESIGN:
Randomized controlled clinical study; Level of evidence, 1.
METHODS:
Forty professional athletes with chronic proximal hamstring tendinopathy were enrolled between February 1, 2004, and September 30, 2006. Patients were randomly assigned to receive either shockwave therapy, consisting of 2500 impulses per session at a 0.18 mJ/mm2 energy flux density without anesthesia, for 4 weeks (SWT group, n = 20), or traditional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, physiotherapy, and an exercise program for hamstring muscles (TCT group, n = 20). Patients were evaluated before treatment, and 1 week and 3, 6, and 12 months after the end of treatment. The visual analog scale (VAS) score for pain and Nirschl phase rating scale (NPRS) were used as primary outcome measures.
RESULTS:
The patients were observed for a mean of 10.7 months (range, 1-12 months). Six patients were lost to follow-up because they underwent a surgical intervention: 3 (all in TCT group) were lost at 3 months; 2 (1 in each group), at 6 months; and 1 (in the TCT group), at 12 months. Primary follow-up was at 3 months after the beginning of treatment. The VAS scores in the SWT and TCT groups were 7 points before treatment (P = .84), and 2 points and 5 points, respectively, 3 months after treatment (P < .001). The NPRS scores in the SWT and TCT groups were 5 points in either group before treatment (P = .48), and 2 points and 6 points, respectively, 3 months after treatment (P < .001). At 3 months after treatment, 17 of the 20 patients (85%) in the SWT group and 2 of the 20 patients (10%) in the TCT group achieved a reduction of at least 50% in pain (P < .001). There were no serious complications in the SWT group.
CONCLUSION:
Shockwave therapy is a safe and effective treatment for patients with chronic proximal hamstring tendinopathy
Shock wave therapy as a treatment of nonunions, avascular necrosis, and delayed healing of stress fractures.
No full textShock wave therapy (SWT) stimulates angiogenesis and osteogenesis. SWT is commonly used to treat soft tissue musculoskeletal conditions such as fasciopathies and tendinopathies. Recent basic science and clinical data suggest that SWT can also be used to treat disorders of bone. Nonunions, avascular necrosis, and delayed healing of stress fractures have all been successfully treated with SWT. Success rates with SWT are equal to those with standard surgical treatment, but SWT has the advantage of decreased morbidity. The procedure is safe, well tolerated, yields few complications, and, typically, can be performed on an outpatient basis. SWT is a viable noninvasive alternative to stimulate healing of bone
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