w w w . r b o . o r g . b r
Update
article
Shockwave
treatment
for
musculoskeletal
diseases
and
bone
consolidation:
qualitative
analysis
of
the
literature
夽
Paulo
Kertzman
a,∗,
Mario
Lenza
b,
André
Pedrinelli
c,
Benno
Ejnisman
daDepartamentodeOrtopedia,SantaCasadeSãoPaulo,SãoPaulo,SP,Brazil
bServic¸odeOrtopediaeTraumatologia,HospitalIsraelitaAlbertEinstein,UniversidadeFederaldeSãoPaulo(Unifesp),SãoPaulo,SP,
Brazil
cInstitutodeOrtopedia,HospitaldasClínicas,FaculdadedeMedicina,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
dEscolaPaulistadeMedicina,UniversidadeFederaldeSãoPaulo(Unifesp),SãoPaulo,SP,Brazil
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Articlehistory:
Received13February2014 Accepted18February2014 Availableonline22January2015
Keywords:
High-energyshockwaves Musculoskeletaldiseases Evaluationstudiesassubject Peerreview
Tendinopathy Pseudarthrosis
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Shockwavetreatmentisanoptionwithinorthopedics.Theexactmechanismthroughwhich shockwavesfunctionfortreatingmusculoskeletaldiseasesisunknown.Theaimofthis studywastomakeaqualitativeanalysisontheeffectivenessofshockwavetreatmentamong patientswithmusculoskeletalpathologicalconditionsandpseudarthrosis.Searcheswere conductedintheCochraneLibrary,MedlineandLilacsdatabases.Thirty-ninestudiesthat reportedusingshockwavetreatmentformusculoskeletaldiseaseswerefound.Theirresults variedgreatly,asdidthetypesofprotocolused.Thestudiesthatevaluatedtheeffectiveness ofshockwavetreatmentforlateralepicondylitis,shouldertendinopathy,knee osteoarthro-sis,femoralheadosteonecrosisandtrochantericbursitisreportedinconsistentresultsfor mostoftheirpatients.Thosethatevaluatedpatientswithcalcifyingtendinopathy,plantar fasciitis,Achillestendinopathy,patellartendinopathyandpseudarthrosisshowedbenefits. Shockwavetreatmentisasafeandnon-invasivemethodforchroniccasesinwhich conven-tionaltechniqueshavebeenunsatisfactoryandshouldbeusedinassociationwithother treatmentmethodsfortendinopathy.Furtherqualitystudiesareneeded.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Tratamento
por
ondas
de
choque
nas
doenc¸as
musculoesqueléticas
e
consolidac¸ão
óssea
–
Análise
qualitativa
da
literatura
Palavras-chave:
Ondasdechoquedealtaenergia Doenc¸asmusculoesqueléticas
r
e
s
u
m
o
Otratamentoporondasdechoqueéumaopc¸ãonaortopedia.Omecanismoexatopeloqual funcionamasondasdechoqueparatratardoenc¸asmusculoesqueléticasnãoéconhecido.O objetivodestetrabalhoéfazeraanálisequalitativadaefetividadedotratamentoporondas
夽
WorkdevelopedasastudycommissionedbytheBrazilianSocietyofOrthopedicsandTraumatology,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](P.Kertzman).
http://dx.doi.org/10.1016/j.rboe.2015.01.003
Estudosdeavaliac¸ãocomo assunto
Revisãoporpares Tendinopatias Pseudoartrose
dechoqueempacientescompatologiasmusculoesqueléticasepseudoartroses.Apesquisa foifeitanasbasesdedadosCochraneLibrary,MedlineeLilacs.Encontrou39estudosque relatamotratamentoporondasdechoquededoenc¸asmusculoesqueléticas.Osresultados sãomuitovariados,assimcomoostiposdeprotocolo.Osestudosqueavaliarama efetivi-dadedotratamentoporondasdechoqueparaepicondilitelateral,tendinopatiasdoombro, osteoartrosedojoelho,osteonecrosedacabec¸adofêmurebursitetrocanterianarelataram resultadosinconsistentesparaamelhoriadospacientes.Osqueavaliarampacientescom tendinopatiacalcária,fasciteplantar,tendinopatiadotendãocalcâneoepatelare pseu-doartrosemostrarambenefício.Otratamentoporondasdechoqueéummétodoseguroe nãoinvasivoparaoscasoscrônicosemqueosconvencionaisnãotenhamsidosatisfatórios edeveserassociadoaosoutrosmétodosdetratamentodastendinopatias.Novosestudos dequalidadesãonecessários.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Theobjective ofthis studywastoqualitativelyanalyzethe literatureregardingtheeffectivenessofshockwavetreatment formusculoskeletaldiseasesandboneconsolidation.
Shockwavesappliedtothemusculoskeletalsystemstarted tobeusedinBrazilin1998,withthearrivalofthefirst uro-logicallithotripsymachines,whichwereadaptedforuseon orthopediclesions.Thisadaptationconsistedofintroducing newtechnologythatmadeitpossibletogradethedepthto whichandthestrengthwithwhichshockwavespenetratethe humanbody.1
IntheUnitedStates,thistreatmentwasfirstapprovedby theFoodandDrugAdministration(FDA)in2001.InBrazil,all theequipmentisregisteredandauthorizedbytheNational AgencyforSanitarySurveillance(ANVISA).1
Studieshavebeendevelopedwiththeaimof understand-ing the action of shockwaves on various human tissues, includingtheintensity,intervalbetweenapplications,depth needed,sideeffectsandefficacy.2
Theactionofshockwavesisdeterminedthroughtheir pen-etrationinto tissues without skin, vessel or nerve lesions. Whentheyreachtheinjuredarea,theypromotemechanical stimulationthatinducesaseriesofbiologicaleffects,suchas: increasedproductionofprostaglandinsrelatingtothetissue repairprocess;increasedcongestionandlocalblood microcir-culation;andincreasedlocalconcentrationofnitricacid,with painrelief.3
Shockwave treatment for tendinopathy is indicated for patientswithchronicpainforatleastthreemonths,whohave alreadyreceivedmedications,physiotherapy,infiltrationsand orthoseswithoutachievinganyimprovementandforwhoma surgicalproceduremightbeindicated.Shockwavetherapyis notindicatedfortreatingacutepathologicalconditions.4
Thereisstillsomecontroversyregardingthedifferenttypes ofequipment,whichproducedifferenttypesofwaves.Some devicesproducefocalwaves(moreintenseanddeeper pene-tration),whileothersemitradialwaves(lessintenseandmore superficial).Thetreatmentprotocolsmayrangefromasingle application,whenmorepowerfulfocal wavegeneratorsare used,tothreeorfour sessionsatone-weekintervalswhen
lesspowerfulgeneratorsareused.Theresultsfrom compar-ativestudieshavenotshownanydifferencesbetweenthese twotypesofprotocol.5
Methods
Systematicreviewsandcontrolledclinicaltrialsevaluatingthe useofshockwavetreatmentformusculoskeletaldiseasesand boneconsolidationwereincluded.
ThedatabasesusedweretheCochraneCentralRegisterof ClinicalTrials(Central;CochraneLibrary2013,volume2), Med-lineviaPubMed(from1966untilFebruary2013)andLilacsvia Bireme(from1982untilFebruary2013).Therewereno restric-tionsbasedonlanguageorpublicationstatus.
Thestrategyhadtheobjectiveoffindingrandomized clini-caltrialsandsystematicreviewsofrandomizedclinicaltrials.
Results
Thesearchinitiallyfound525references.Becauseofthelarge numberofstudieswithlevelIevidence,onlythefindingsfrom thesystematicreviewsweredescribedhere.Randomized clin-icaltrialswereevaluatedintheabsenceofthesestudies.
Theresultsweredivided accordingtothemaindiseases thancanbetreatedusingshockwavetherapy.
Lateralepicondylitis
Dingemanseet al.8 (2013): 20 RCTs and two systematic reviewsthataddressedthistopic,withresultssimilartothose ofBuchbinder.
Rompeetal.9(2007):10RCTs.Thestudiesincludedinthis reviewconcludedthattherewasnoconsensuswithregardto differentiationbetweenlow-energy andhigh-energy shock-wavesfortreatinglateralepicondylitis.Thisreviewindicated that there was some therapeutic benefit from shockwave treatmentfortherestrictedconditionofpatientswith recal-citrantchronicepicondylitis.
Insummary,thesystematicreviewsincludedinthisstudy presentresultsthatareinconsistentwithuseofshockwaves totreat patients withlateral epicondylitis. Onlyone study reportedthatshockwavetreatmentwaseffectiveforpatients withrecalcitrantchronicepicondylitis.
Patellartendinopathy
Wangetal.10(2007):quasi-randomizedclinicaltrialthat evalu-ated27patients(30knees)whoweretreatedwithshockwaves, and23patients(24knees)thatweretreatedinthe conven-tionalmanner.Thisstudydemonstratedfavorablefunctional resultsforthegrouptreatmentwithshockwaves. Ultrasono-graphyexaminationsshowed thattherewasareductionin thethicknessofthepatellartendoninthetreatedgroupand animprovementinbloodcirculationatthatlocation,in com-parisonwiththegroupthatwastreatedconservatively.
Zwerveretal.11(2011):62athleteswithpatellar tendinopa-thydividedinto31 whoweretreatedwithshockwavesand 31whoreceivedplacebotreatment.Theathletesmaintained theircompetitiveactivity.Theanalysesdidnotdemonstrate thattheshockwavetreatmentwaseffectiveforthepatients withpatellartendinopathy.
Thestudiesincludedinthepresent reviewthusshowed conflictingresultsregardingtheeffectivenessofshockwave treatmentforpatientswithpatellartendinopathy.
Tendinopathyoftheshoulder
Leeetal.12(2011):asystematicreviewrelatingtothe medium-term results from evaluating pain among patients who underwentshockwavetreatment.Thereviewfoundthatthere seemedtobeatendencyforthetreatmentusedtodiminish thepainofpatientstreatedusingthismethod.However,the studiesincludedpresentedseveremethodologicallimitations relatingtotheassessmentscoresanddosagesofthe proce-dureused.Itwasconcludedthattherewasaneedforfurther studieswithgreatermethodologicalefficacy.
Huisstedeet al.13 (2011): 11 studies relating to calcifica-tionandsixtotendinopathywithoutcalcification.Theauthors concludedthatonlythehighenergyofshockwaveswas effec-tiveforcalcareoustendinopathyanddidnotfindanyevidence forusingshockwavestotreatnon-calcifyingtendinopathyor tendinosis.
Rompeetal.14(2001):arandomizedclinicaltrialthat com-paredthe useofshockwaveswithconventionalsurgeryfor treatingcalcareoustendinopathyoftherotatorcuff.Afterone yearoffollow-up,the calcificationwasfoundtohavebeen eliminatedin85%ofthesurgicalgroupand47%ofthe shock-wavegroup.Bothgroupsimprovedtheirclinicalscores.
Liu et al.15 (2012): a randomized clinical trial versus placeboamongpatientswithtendinopathyofthelonghead of the biceps. Seventy-nine patients were randomized and theresultswerefavorabletowardshockwavetreatment.The authorsconcludedthatconservativetreatmentusing shock-wavesenabledgoodresults.
Kimetal.16(2012):arandomizedclinicaltrialinwhich71 patientswithrotatorcuffinjurieswerestudied.They under-wentarthroscopicrepairwiththeaimofevaluatingwhether shockwavetreatmentwouldstimulatehealing.Thestudydid notprovethatthismethodwouldstimulatetissuerepairand diminishtheincidenceofpostsurgicalrecurrenceoftheinjury. Krasnyetal.17(2005):arandomizedclinicaltrialthat com-pared dry needling accompanied by ultrasonography and shockwave treatment, among 40 patients with calcareous tendinopathyoftherotatorcuffwhopresentedindicationsfor arthroscopictreatment.Bothgroupspresentedimprovements intheconstantscore.Thecalcificationwasseentohave dis-appearedin60%ofthegroupthatunderwentneedling,versus 32.5%ofthegroupthatunderwentshockwavetherapy.
Galasso et al.18 (2012), Engebretsen et al.19 (2011) and Schofer et al.20 (2009): these studies evaluated shockwave treatment in comparison with conventional treatment for tendinopathy ofthe shoulderwithoutcalcification. Galasso etal.18(2012)concludedthatovertheshortterm,shockwave treatmentpresentedbetterresultsthanthoseoftheplacebo group.Ontheother hand,inacomparativestudywith140 patients,Engebretsenetal.19(2011)didnotfindanyevidence thatuseofshockwavespromotedbetterresultsafteroneyear offollow-up amongpatients withsubacromialimpact syn-dromeoftheshoulder.Schoferetal.20(2009)didnotfindany differencesintreatmentsusingtwodifferenttypesof shock-waves.
Hsu etal.21 (2008), Albertet al.22 (2007),Cacchio etal.23 (2006), Sabeti-Aschrafet al.24 (2005), Pleiner et al.25 (2004), Cosentinoetal.26(2003)andLoewetal.27(1999):theseauthors evaluateduseofshockwavesincomparisonwithconventional treatmentforcalcareous tendinopathyofthe shoulderand concludedthatuseofhighenergypromotedimprovementof thesymptoms.Cacchioetal.23(2006)demonstratedthatthis wasaneffectiveandsafetreatmentmethod.
In summary, studies that have evaluated the effective-nessofshockwavetreatmentforpatientswithtendinopathy ofthe shoulder havepresented conflictingevidence. Some studieshavereportedbeneficialeffectsincasesofcalcareous tendinopathy.
Plantarfasciitis
Changetal.28(2012):12studies,allrandomized.Shockwave treatment was shown to beeffective forthe symptomsof plantarfasciitis.
Rompeetal.29(2007):17papers.Thesestudieswere con-sidered heterogenous: there was a preponderance of good resultsandtheauthorsconcludedthattheshockwave treat-mentmethodshouldbeconsideredonlywhenthetraditional methodsfail.
reducingnocturnalpain,painwhilerestingandpaindueto short-termpressure.
Kearneyet al.31 (2010):11 studies.Thecurrent evidence favoredeccentric exercisesand shockwaves,althoughwith limitedevidenceforjudgingtheireffectiveness.
Ogdenetal.32(2002):eightstudies.Theresultssuggested that shockwave therapy should be considered before any surgicalprocedureandmightbepreferabletocorticoid infil-tration.
Insummary,shockwavetreatmentisanoptionforcases thatareresistanttotheusualtreatmentsforplantarfasciitis.
Kneearthrosis
Lauferetal.33(2012):sevenstudies.Theresultsregardingthe effectofshockwavetreatmentwereinconsistentin compar-isonwiththeplaceboeffect,andtheauthorssuggestedthat furtherstudiesonthissubjectwerenecessary.
Osteonecrosisofthefemoralhead
Alvesetal.34(2009): theseauthors didnotfindany double-blindstudiesontheefficacyoftreatmentsforosteonecrosis.
Tendinopathyofthecalcaneal(Achilles)tendon
Kearneyetal.31 (2010):11studieswerereviewedanditwas demonstrated that there was a consensus that functional treatmentmethods, including shockwaves,should be used before surgical methods for treating tendinopathy of the Achillesheel.
Trochantericbursitis
Del Buono et al.35 (2012): 14 studies that provided low to moderateevidenceforsupportingtheuseofshockwavesfor patientswithtrochantericbursitis.Thus,theseauthors con-cludedthattherewasaneedforbetter-conductedrandomized studies.
Boneconsolidation
Schaden et al.36 (2001) published the principles for using shockwavesfortreatingpseudarthrosis,inClinicalOrthopedics. Furia et al.37 (2010) compared the results from treating pseudarthrosisoffracturesofthebaseofthefifthmetatarsal betweenfixationusingscrews,fromwhich18consolidations wereobtainedoutof20patients,andshockwaves,fromwhich 20 consolidationswere obtainedout of23 patients, with a lowercomplicationrate(comprisingbreakageofthesynthesis materialandinfections).
Elsteretal.38(2010)reportedthat82.4%oftheirresultswere good,among172casesofpseudarthrosisofthetibia.
Discussion
Thisstudywasmotivatedbyaconsultationthatwassentto theBrazilianSocietyofOrthopedicsregardinghowshockwave treatmentworks,whatitsindicationsareand whatresults
areobtained.Acommitteeoforthopedistswasformed,which soughttomakeadetailed analysisoftheliteratureonthis typeoftreatment.
Althoughthereisstillsomecontroversyregardingaspects of shockwave generation, the data in the literature indi-catethattheycanbegeneratedthroughhydraulic,magnetic, piezoelectric and pneumatic means. Thereare divergences amongthe authorsinvestigated:Wang etal.3 and Schaden et al.36 preferred hydraulic devices, Fúria et al.37 reported goodresultsfrommagneticdevicesandGerdesmeyeretal.5 andRompeandMaffulli9usedpneumaticdevices.InBrazil, allofthesemethodsareused,butespeciallypneumaticand hydraulicmethods.2,3,5,9
Regardingthemechanismofactionontissue,allauthors agreethatthemechanicalactioninducesbiologicalactionthat alterscellpermeabilityandpromotesincreasedconcentration oftissueregenerationfactorsandvascularregeneration fac-torsatthesitethatisstimulated,asreportedbyOgdenetal.2 andWangetal.3
Noneoftheauthorsfoundanysideeffectsorimportant complications.
Inrelationtotheindicationsanalyzedaccordingto patho-logical condition, the results from tendinopathy of the shoulderwerefavorableinrelationtotreatmentof calcare-ous tendinopathy but not ofnon-calcareous tendinopathy. This is concordant with the results obtained within clin-ical practice. In the elbow, efficacy in relation to treating lateral epicondylitis wasnot proven,and therewere diver-gences between the findings of Buchbinder and Rompe. In clinical practice, these divergences are repeated. Some patientsreportimprovementsinsymptomsandareableto return to their activities without complaints around three months after the treatment, while others do not report improvements.6–9 Withregard topatellartendinopathy and bursitis of the hip, there are still no studies proving its efficacy, even though some studies have shown favorable results, suchas the study byWang.The study byZwerver wascriticizedbecausetheathletescontinuedtotakepartin competitions duringthe treatmentandtherestperiodwas notrespected,whichshouldbeforatleast30daysafterthe treatmenthasbeenapplied.IncasesofAchilles tendinopa-thy and plantar fasciitis, the studies by Furia, Ogden and Gerdesmeyerdemonstratedfavorableeffects,whichare con-firmed in clinical practice, independent of the equipment used.5,10,11,29,32
Regardingtheboneindicationsforkneearthrosisandfor osteonecrosisofthefemoralhead,therearestillno conclu-sivestudies,althoughWangreportedgoodresults.Inrelation to pseudarthrosis, Schaden, Furia and Elster demonstrated thatshockwaveswereeffectiveandtheclinicalresultswere encouraging.34,36–38
Final
remarks
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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