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Radial extracorporeal shock-wave therapy - Benefits in the treatment of tendinopathies

Radial extracorporeal shock-wave therapy - Benefits in the treatment of tendinopathies

It becomes increasingly harder to talk about adequate treatment of tendinopathies without the possibility of using shock-wave therapy (SWT). This technique, developed recently, remains relatively little-known. For a partial explanation of the therapeutic effects of this method of therapy, it is first necessary to consider several concepts relating to the presumptive mechanism of action. Below we present the results obtained during the examination of 467 patients to treat which for 4 years we used SWT.

Estimated mechanism of action

Evidence of the advantages of applying a radial waters in an experiment on animals to the use of this method in humans. The use of this method in veterinary medicine (from race horses) was started in parallel using it in humans. To date, histological data on changes occurring at the so-called extracorporeal waters are limited (8-10). Therefore, our understanding of the mechanisms of action of this method of therapy is still on the hypothetical stage. Perhaps the role of SWT is about the same as in certain "coarse" psychotherapeutic techniques, the effectiveness of which is generally recognized (deep transverse massage Cyriax, a defibrozing massage, etc.). This method combines a mechanical impact, a biochemical analgesic effect and / or local anti-inflammatory effect. With the help of Doppler echography, it was shown that the rate of shock-wave effect on the rotator cuff leads to the phenomena of local hypervascularization [9]. These phenomena lead to an increase in the activity of local metabolism. Shock waves lead to fresh microtrams, which contribute to the activation of healing processes, in contrast to chronic unpropressing and sharply painful damage (this principle is used to treat certain types of pseudoarthrosis).

Methods

For the treatment of patients who applied to the sports traumatologist, since 1999, we used the SWISS DolorClast® device. At first, we used this treatment method very carefully, and then increasingly, as a result of the rarity of side effects and the complete lack of deterioration of patients suffering from the lower limb trendinople. The unsatisfactory initial experience of the treatment of lateral epicondylitis made us stop using this method on this indication for 2 years, and then we again began to apply SWT in these cases with less aggressive parameters of the procedure.

Protocol of treatment

There are three parameters of the device: the number of shock waves, their frequency and energy level. Since we wanted to comply with the most easily reproducible protocol, our initial choice was due to preceding Swiss and German research. This approach to defining the parameters of the procedure is a definite "adventure", since it is these treatment parameters that will not necessarily lead to the best results. Some settings of the outside changed during our research, as well as depending on the results of the other studies currently.

Used device parameters

The heel tendon (tendinite Achilles tendon), plantar aponeurosis (plantar tendinite) and high enhisopathy of the tendons of the popliteal pate: 2000 shock waves, 9 Hz, 2.5 bar. Heel enntsopathy (heel spur), palator tendinitis (tendinitis of the patella region), lateral and medial epicondylitis: 200 shock waves, 15 Hz, 1.5 bar (attempt to use the frequency of 15 Hz for patellar tendon turned out to be unsatisfactory) (if the portability was good, then We gradually increased pressure up to 2 or even 2.5 bar).

Session frequency and sessions

The chosen protocol assumed the greatest frequency of sessions 1 time per week, and for professional athletes - twice a week. The total number of sessions was 6 or less. We reduced the recommended interval between sessions (which is 2 weeks), as they wanted to carry out a relatively short course, which is especially valued among athletes. Thus, the maximum duration of the course of therapy for professional athletes amounted to 18 days, and for other patients - 36 days. We did not have to observe any reactions of intolerance, which would be the result of shortening the interval between individual sessions.

Purpose

Our goal is to show that if the shock-wave therapy is an effective way to treat tendinopathies, then efficiency will continue with a smaller number of therapy sessions. Therefore, our protocol was limited to 6 sessions. The patient could refuse treatment before, if a significant significant improvement in the state felt. After treatment and the 6-week period of subsequent observation, it became clear that in cases of partial improvement, which was perceived as a patient as an insufficient result, several additional sessions could improve the result of treatment. We conducted similar experiments from many patients, although the preliminary results of treatment have always been considered unsatisfactory.

The impact force on the working part of the device

In all cases, we used the maximum patient pressure on the working head of the apparatus (reverse control based on painful sensations); The impact turned out to be on the most painful zone without exception. At first, we did not use a contact gel, and then began to apply it systematically (according to the technical demonstration conducted by physicists from EMS) and have learned some benefit from its use. On the other hand, we never used local anesthesia. In many cases, it was necessary to use a wide head of the apparatus (20 mm), since the 5-mm head could cause skin damage.

Recognizing treatment

Patients were instructed to stop all associated treatment methods, except for carrying the heel holder, which is recommended in all cases of heel tendinopathies, and wearing an inelastic bracelet on the upper part of the forearm in the case of urban tendinopathies.

Sport classes

Refusal of sports did not need. On the contrary, patients were instructed to try to continue their sports, so that during the exercise did not have pain. Be that as it may, we admitted pain and her relief. This solution is a logical consequence of the intended mechanism of SWT operation: if the emergence of microtrams occurs, the continuation of the physical activity "will send" the healing processes towards improving functionality, which will not be able to achieve at rest. This approach is a debate and may determine the moderate results of the WTW, which we received for some localizations of the pathological process. Later we will return to this issue.

Indications and contraindications

In addition to fundamental contraindications (pregnancy, children's age, local tumor diseases), we considered it important to focus on local neurological and circulatory problems, coagulation disorders and anticoagulant therapy, as well as algodistrophy. The upper boundary of the age was not. Our cases were mainly lower limbs (84%): heel tendinopathy, plantar aponeurosis (and possibly incorrectly recognized talalgia, which reduced the effectiveness of treatment), high enetopathy of the tendons of the poplined pate (all cases were confirmed by MRI), and palatlated tendinopathy . Local tendinopathy were presented not so wide (16%), as we started the study of this pathology later. The duration of the subsequent observation period remains too small for the shoulder tendinopathies, and is currently a study of this pathology in the framework of the study of rheumatological pathology. The possibility of the destruction of the calcinates of the rotator cuff, which is predicted by supporters of the DVT method on the basis of extrapolation of the destruction of the ureteral stones, is a reality, although the relevant result is removed not to achieve all patients [7]. In addition, it is impossible to ignore the anesthetic effect of the treatment method under consideration.

Assessment of results

The assessment is based on data from 467 patients, the last update of these data was made in September 2003. None of the patients were carried out by concomitant therapy. The results are presented in Table 1. OK + X = very good and good results; N + O = inadequate results and no positive results. Table 1. Results.

Показание

ОХ+Х

Н+О

The tendinite of the body of the heel tendon (node or spine-shaped). n = 205. 74,6% 25,4%
Average session 4 4,5
Tendinitis attachment of heel tendon. n=35 68,6% 31,4%
Average session 4,1 5,1
Fallen tendinit. n=73 67,1% 32,9%
Average session 4 4,5
High enhesopathy of the tendons of the patellied pate. n=25 76% 24%
Average session 4,4 4,5
Tendinitis of the area of the patella. n=51 52,9% 47,1%
Average session 3,3 3,9
Radie epicondylitis of the shoulder bone. n=50 58% 42%
Average session 4,3 5,3
Elbow epicondylitis of shoulder bone. n=12 61,5% 38,5%
Average session 4,7 5,1

 

Discussion

The results obtained must be compared with the data published earlier [3-6]. 24 patients (5%) that could not be contacted during the subsequent observation period were considered lost for observation. All estimates were carried out at least 6 weeks after the final session of therapy. This period is the necessary time for healing by microtrams caused by the impact of shock waves. RSWT was well tolerated by all patients included in the study. Only several patients with lateral epicondylitis occurred pronounced pain when using a small 5-millimeter working part of the device, which was then replaced with a large one. None of the patients with the lower extremities have no deterioration in the state after the RSWT using the described parameters of the procedure. It must be emphasized that satisfactory results managed to achieve with a limited number of sessions. The average number of sessions was 4-5, which corresponds to the duration of the course of therapy at 22 -29 weeks, if the sessions were carried out with an interval of one week. This is to a lesser extent limits the patient in terms of terms and cost of treatment. Therapy sessions were undoubtedly accompanied by painful sensations, which is not an obstacle to treatment. We did not observe direct side effects (wounds, bruises) when applying a large head and the described parameters of the procedure. Deferred side effects (hyperalgia, edema, ekkimosis) were insignificant and detected at about 10% of cases. Their results clearly follows that not all tendons are equally responding to the effects of shock waves, although, perhaps, these results may vary when using different treatment protocols. The table shows the results of the treatment of heel entaopathy and pathology of the patellular tendon after changing the strength and frequency of the shock waves. The source results were much worse. Other authors received the results that differ in the best way using other parameters of the procedure [1]. Many other German publications are reported on very good results. We tried to determine the predictive factors capable of affecting the result of treatment of 120 patients with heel entaopathy [6]. Neither the age of the patient nor the duration of symptoms nor the type of tendinopathy or the intensity of sports has not affected the result of treatment. The results were better in women than in men, although the female population was significantly less. Currently, it is impossible to adequately evaluate some disease groups due to a small sample size. It is necessary to make some comments to our decision to allow to continue the patients to continue sports, despite the expected originality of pain. For example, for a runner for long-term distances it is easy to stop running, as soon as pain will appear. When exercising sports, involving the "explosive" nature of activity, it is possible to make it often only theoretically. In the first situation, the patient does not cause the tendons of additional harm, on the contrary, we believe that such loads help shock-wave therapy, whereas in the second situation (for example, in the event of a football or tennis), an athlete can significantly exceed the tendon resistance threshold, committing a certain Movement, and thereby contribute to further damage to the tendon, which will negatively affect the treatment. Currently, we change our approach and begin to limit the "explosive" physical exertion.

Conclusion

Being a new achievement in the treatment of tendinopathies, radial extracorporeal shock-wave therapy is a non-invasive method of therapy and shows quite essential results. The effectiveness of a short course of therapy and the ability to continue dosage and controlled physical activity are significant arguments in favor of using this method in athletes, although it is not the only area of ​​Refów. We investigated the use of this method of therapy. It is possible that with the sharing of traditional methods of therapy, the results may be even better.

Literature

  1. Brunet-Guedj E, Brunet B, Girardier J, Renaud E: Traitement des tendinopathies chroniques par ondes de choc radiales J Traumatol Sport, 2002, 19, 239-243 2. Gremion G, Augros R, Gobelet Ch, Leyvraz PF : Efficacit? de la th?rapie par ondes de choc extra-corporelle dans les tendinopathies rebelles. J Traumatol Sport, 1999, 16, 117-121 3. Labareyre H (de), Saillant G : Evaluation de l’efficacit? des traitements par ondes de choc radiales sur les tendinopathies du membre inf?rieur chez le sportif. Le sp?cialiste de M?decine du Sport, 2000, 28, 34-40 4. Labareyre H (de), Saillant G : Tendinopathies calcan?ennes ; formes cliniques et ?valuation de l’efficacit? des ondes de choc radiales. J Traumatol Sport, 2001, 18, 59-69 5. Labareyre H (de), Saillant G : Tendinopathies du membre inf?rieur chez le sportif; int?r?t du traitement par ondes de choc radiales. Reflexions Rhumatologiques, 2002, 47, 40-42 6. Labareyre H (de), Saillant G : A propos du traitement des ondes de choc radiales; actualisation des r?sultats. J Traumatol Sport, 2002, 19, 244-246 7. Noel E : Prise en charge des calcifications de la coiffe des rotateurs. 4?me Symposium de Rhumatologie, « T?te, Cou, Epaule », Paris, May 2002 8. Orhan Z, Alper M, Akman Y et al: an experimental study of extracorporeal shock waves in treatment of tendon injuries; preliminary report. J Orthop Sci, 2001, 6, 566-570 9. Peers K, Brys P, Lysens R: Power Doppler sonography measurement of tendon vascularity after ESWT. Muskuloskeletale Stosswellentherapie, Mainz, March 2001 10. Wang CJ, Ko JY, Chen HS: Shock wave-enhanced neovascularization at the tendonbone junction; an experiment in dogs. J Foot Ankle Surg, 2002, 41, 16-22 11. Wang CJ, Wang FS, Yang KD, Weng LH, Hsu CC, Huang CS, Yang LC: Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits. J Orthop Res, 2003, 21, 984-989

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