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Shockwave therapy as a way to improve the quality of life in orthopedic diseases

Petkevich E.A., Rodionov M.M.

Republican Clinical Medical Center

Administration of the President of the Republic of Belarus

 

Shockwave therapy as a way to improve the quality of life in orthopedic diseases

Treatment and rehabilitation of patients with chronic degenerative-dystrophic diseases of the musculoskeletal system, the consequences of injuries, mechanical overloads (long-term static-dynamic loads typical for sports, ballet, professional dances) are urgent tasks of modern traumatology and orthopedics.

This can be explained both by a steady trend towards an increase in the incidence rate, a decrease in the average age of those who apply, and by the lack of a common point of view of leading specialists on the effectiveness of certain methods of conservative therapy.

Chronic pain syndrome is a difficult problem for orthopedists; often worries patients of different age groups, the most difficult to treat. Conservative and sometimes surgical treatment does not always produce the desired effect, hardware physiotherapy methods and massage are often ineffective.

Radial extracorporeal shockwave therapy (RESWT) will help to effectively solve the problems of combating chronic pain syndrome and reducing the rehabilitation period in general.

Radial extracorporeal shock wave therapy is used as monotherapy or in complex treatment for a number of pathological conditions, including diseases and consequences of injuries of the musculoskeletal system. The RSWT method is based on short-term exposure to high-energy vibration in the application area, which reduces pain syndrome, improves local blood circulation, and thus contributes to the subsequent resorption of foci of pathological compaction. With its help, it is possible to achieve both rapid relief of pain without the use of analgesics, and the subsequent improvement in the quality of life of patients with orthopedic diseases.

For the first time in medicine, shock waves were used in 1980 to crush kidney stones [1], and in 1985 - gallbladder stones [2]. The first publications describing the use of shock wave therapy in orthopedic pathology and the consequences of trauma date back to the early 1990s [3]. The use of shock waves in orthopedics using devices for lithotripsy has shown that they do not meet the requirements necessary for the treatment of pathology of the musculoskeletal system. In the last decade, special devices have been developed that use various methods of generating shock waves. All of them are aimed at creating a pressure impulse transmitted to tissues with minimal energy loss, for which various connecting media are used [4].

Since the beginning of 2010, the surgical department of the State Institution "Republican Clinical Medical Center" of the Presidential Administration of the President of the Republic of Belarus has been treating patients with orthopedic pathology using the Orthospec shock wave therapy device manufactured by Medispec (Israel) [5]. Orthospec generates an acoustic shock wave transmitted through the membrane covering the contact head of the device on the basis of an electro-hydraulic principle. This mechanism of shock wave generation provides the largest size of the shock wave focusing zone - 35–95 mm, which allows treatment without the use of additional visualization and targeting devices (ultrasound scanner or X-ray unit), provides a uniform energy distribution throughout the focal zone and does not require anesthesia. The principle of patient feedback is used to induce the shock wave, the subsequent adjustment of the position of the contact head and the level of exposure energy, which makes it possible to choose a comfortable mode of the RSWT session. The device generates a shock wave with a unique shape specially designed for orthopedic purposes.

A contact gel is used to minimize energy losses during shock wave conduction. To date, there have been numerous prospective controlled randomized trials in the field of orthopedics and traumatology, confirming the favorable results of treatment with extracorporeal shock waves [6-9]. RSWT finds application in traumatology and orthopedics, rehabilitation, rheumatology, sports medicine.

Indications for the use of shock wave therapy [10-12]:

Taking into account the similarity of the pathogenesis of degenerative-dystrophic processes of the musculoskeletal system, we have expanded the classical (in accordance with the manufacturer's recommendations) indications for RSWT and use shock waves to relieve pain in arthrosis of the knee, ankle, wrist joints, hand joints, and stenosing ligamentitis ... The main criterion for prescribing RSWT is the presence of local palpation pain in patients with diseases of the musculoskeletal system.

Contraindication to RSWT, according to the manufacturer, is the presence of a malignant neoplasm or a purulent inflammatory process in the area of ​​the intended impact; Do not use shock waves over the epiphyseal zones in children and adolescents, over the region of the ribs, vertebral bodies and bones of the skull, in the projection of the intestines and lung tissue, in case of systemic diseases of the connective tissue. Based on our experience, caution is needed when prescribing shock waves to the shoulder joint area in patients with cardiac arrhythmias and to the knee joint area in patients with deep vein thrombosis of the lower leg.

Materials and methods:

1015 RSWT procedures were performed in 314 patients (211 men, 103 women) aged 26 to 83 years (mean age 58 years), the distribution by nosology is presented in Table 1.

Table 1.

Nosology Procedures performed
Medial epicondylitis 93
Lateral epicondylitis 100
Heel spur" 298
Shoulder pathology 253
Stenosing ligamentitis 23
Knee arthrosis 118
Ankle arthrosis 22
Sacroiliac arthrosis 21
Arthrosis of the joints of the hand 40
Bursitis of the greater trochanter 47

 

Before REWT, all patients had a long pain history, repeatedly underwent classical complex treatment, including physiotherapy, massage, physiotherapy exercises, medication, etc. In all patients, at the start of treatment, points of palpation tenderness in the area of ​​the joints of the extremities were determined. The complex of the examination included X-ray in 2 projections, general clinical blood test, according to indications - computed tomography or magnetic resonance imaging, ultrasound of blood vessels. The intensity of pain was assessed using a visual analogue scale (VAS), before treatment averaged 7.3 points. The average pain scores for individual nosologies are presented in Table 2.

Table 2.

Nosology Average pain score by VAS before treatment
Medial epicondylitis 8,5
Lateral epicondylitis 7,625
Heel spur" 7,82
Shoulder pathology 6,4
Stenosing ligamentitis 7,5
Knee arthrosis 6,52
Ankle arthrosis 7,5
Osteoarthritis of the sacroiliac joint 9,0
Arthrosis of the joints of the hand 7,0
Bursitis of the greater trochanter 7,0

 

For the course of treatment, from 1 to 3 (in isolated cases - up to 5) procedures were dispensed with an interval of at least a week. During the procedure, from 2000 to 3000 impulses were supplied to the focus of pain, there are 3 frequency options (96,120 and 160 impulses per minute) and 7 levels of impulse energy.

The procedure was well tolerated, we met the only case when a patient with a heel spur had to stop treatment due to an aggravation of pain syndrome. Due to the ability to change the pulse energy (from 9.4 to 110 mJ) in accordance with the patient's perception, pain during the procedure was at the border of the tolerance threshold. Often, at the point of initial focusing of the contact head of the apparatus during the procedure, pain disappeared, which required a search for a new focus, and, in its absence, early termination of the procedure.

The criterion for the effectiveness of treatment was a decrease in the level of pain assessment according to the VAS by at least 2.5 points, high efficiency - by more than 5 points. With a decrease in the VAS score of less than 2.5 points, the treatment was considered ineffective. International studies show an average ESWT efficiency of 77% (for individual nosologies - up to 92%).

Results: the results of treatment were studied in the period from 6 to 12 months and are presented in table 3.

Table 3.

Nosology VAS Before treatment VAS After treatment VAS distant % efficiency
Medial epicondylitis 8,5 3,5 4,3 83%
Lateral epicondylitis 7,625 3,0 4,7 78%
Heel spur" 7,82 2,8 3,0 81%
Pathology of the shoulder joint 6,4 2,0 3,5 72%
Stenosing ligamentitis 7,5 3,0 4,5 72%
Knee arthrosis 6,52 3,6 4,3 56%
Ankle arthrosis 7,5 5,0 5,2 56%
Arthrosis of the sacral iliac joint 9,0 5,0 5,2 74%
Arthrosis of the joints of the hand 7,0 3,0 4,0 70%
Bursitis of the greater trochanter 7,0 4,5 4,8 60%
All nosologies 7,3 3,39 3,8 69%

 

Discussion: the closest analgesic effect of RESWT is associated with a rhythmic high-energy effect on the nerve endings in painful areas and, most likely, with the phenomena of transcendental inhibition in them. A further decrease in pain syndrome can be explained by the stimulation of microcirculation in the focus of degenerative-dystrophic processes. The effectiveness of treatment in our observations, in principle, coincided with world data. We noted the maximum analgesic effect in the near future after the end of the course of treatment, over time the pain syndrome relapsed to a certain extent, but all patients noted a significant decrease in the pain background and an improvement in the quality of life. The greatest effect of RSWT was recorded in the treatment of diseases that are classical indications for it: medial and lateral epicondylitis, heel spur. The lower efficiency of shock waves in relieving pain in arthrosis of large and small joints is apparently associated with the diffuse nature of degenerative-dystrophic changes and pain syndrome in these diseases.

Conclusions: Thus, our experience with the Orthospec apparatus allows us to assume that extracorporeal shock wave therapy will take its rightful place in the complex method of relieving pain in diseases and consequences of injuries of the musculoskeletal system.

Literature:


1. Chaussy C., Chaussy C., Brendel W., Schmiedt E. // Lancet. – 1980. – Vol. 13. – P. 1265–1268.
2. Mulagha E., Fromm H.J. // Gastroenterol. Hepatol. – 2000. – Vol. 15. – P. 239–243.
3. Valchanou V.D., Michailov P. // Intern. Orthop. – 1991. – Vol. 15. – P. 181–184.
4. Schr?bler S. Ein abtastendes Verfahren zur Darstellung und Analyse von Stosswellen in Fl?ssigkeit. – Shaker Verlag, 1999.
5. «Ортоспек: новые технологии травматологии и ортопедии», Здравоохранение,№12,2006г.
6. Haupt G., Katzmeier P. Anwendung der hochenergetischen extrakorporalen Sto?wellentherapie bei Pseudarthrosen, Calcific tendinitis der Schulter und Ansatztendinosen (Fersensporn, Epicondylitis) / Ch. Chaussy, F. Eisenberger, D. Jocham, D. Wilbert (Hrsg.) // Die Sto?welle — Forschung und Klinik. – T?bingen: Attempto Verlag, 1995. – S. 143–146.
7. Lohrer H., Sch?ll J., Alt W., Hirschmann M. // Leistungssport. –1998. – Bd 28. – S. 42–44.
8. Rompe J.D. Extrakorporale Sto?wellentherapie – Grundlagen, Indikation, Anwendung. – Chapmann & Hall GmbH, Weinheim, 1997.
9. Sch?ll J., Lohrer H. // Orthop?die Schuhtechnik. – 2001. – Bd 7–8. – S. 66–70.
10. Котенко К.В., Корчашкина Н.Б., Рубанченко А.А.   «Экстракорпоральная ударно-волновая терапия как современный метод немедикаментозной терапии при плантарном фасциите и пяточной шпоре»,  в сб. «Материалы 4го международного конгресса «Восстановительная медицина и реабилитация», Москва, 2007г., с.118
11. Березенко М.Н. , Лазарев С.В. «Комплексное лечение больных с плечелопаточным периартрозом с использованием экстракорпоральной ударно-волновой терапии на аппарате Orthospec производства Medispec,Израиль», «Вестник ФГУ Клиническая больница УД Президента Российской Федерации»,№1,2006г., с.5-6
12. Васильев А.Ю., Егорова Е.А. «Экстракорпоральная ударно-волновая терапия в лечении травм и заболеваний опорно-двигательного аппарата», М.,ОАО «Издательство Медицина»,2005,с.44-46
эпикондилит лечение, бурсит лечение, лечение бурсита ударно-волновой терапией