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British Journal of Healthcare and Medical Research - Vol. 10, No. 2
Publication Date: April 25, 2023
DOI:10.14738/jbemi.102.14473.
Fizzotti, G., Piccinini, M., Ramella, V., & Fassina, L. (2023). Shockwave Therapy: Still Little-Known Issues. British Journal of Healthcare
and Medical Research, Vol - 10(2). 426-431.
Services for Science and Education – United Kingdom
Shockwave Therapy: Still Little-Known Issues
Gabriella Fizzotti
Spinal Unit, ICS Maugeri SPA SB, Institute of Pavia,
IRCCS, Pavia, Italy
Maurizio Piccinini
Rehabilitation Unit, Cittadella Sociale Medical Centre.
Pieve del Cairo, Pavia, Italy
Vittoria Ramella
Bioengineering department. University of Pavia, Italy
Lorenzo Fassina
Mathematics Faculty. University of Pavia, Italy
ABSTRACT
Background: In the last few years the development of Extracorporeal shock wave
therapy (ESWT) was very fast. Shock waves can help reduce inflammation in
muscoloskeletal areas of the body. At the first time medical ESWT was used in
urologic discipline for lithotripsy therapy later the opportunity of transmit
mechanical energy by shock waves led to different technical and medical
applications. Aim: to evaluate the different indications for ESWT in more or less
frequent orthopedic pathologies. Material and Method: We enrolled 423 patients:
174 males and 249 females. All people presented orthopedic disease with specific
therapeutic indication to ESWT in skeletal segments. Conclusion: The therapeutic
efficacy of ESWT is still unclear for less frequent orthopedic pathologies. Further
studies needed to improve the quality of the health care preventing chronic painful
disease.
Keywords: Shockwave therapy, musculoskeletal pathologies. therapeutic indications.
INTRODUCTION
Shock waves are specific acoustic waves that accompany our daily lives without being noticed
(1). The therapeutic indication for extracorporeal shock wave therapy (ESWT) has
progressively changed over time in relation to the technological evolution of the equipment and
scientific studies on the mechanisms of action in various tissues. Initially the ESWT was used in
the urological discipline for the treatment of lithotripsy, later the opportunity to transmit
mechanical energy through shock waves led to technical and medical applications in the
orthopedic, dermatological, vulnology and neurological disciplines (2,3,4,5) October 12 th 2016
International Society for Medical Shockwave Treatment (ISMST) published Consensus
Statement on ESWT Indications and Controindications in order to prevent improper treatments
(6).
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Fizzotti, G., Piccinini, M., Ramella, V., & Fassina, L. (2023). Shockwave Therapy: Still Little-Known Issues. British Journal of Healthcare and Medical
Research, Vol - 10(2). 426-431.
URL: http://dx.doi.org/10.14738/jbemi.102.14473.
The aim of this study was to evaluate the different indications for ESWT in more or less frequent
musculoskeletal pathologies.
MATERIALS AND METHOD
We enrolled 423 patients: 174 males and 249 females with an average age: 60.3 years in the
period: June 2019 - March 2021. (Fig. 1) (Fig.2)
SEX
%
F 249 58.87%
M 174 41.13%
Fig. 1 Patient enrolled
Fig. 2 Range of age in considered sample
All people presented orthopedic disease with specific therapeutic indication to ESWT in
skeletal segments: hip, knee, elbow, foot, hand, shoulder, wrist. The application method of each
ESWT session responded to the indications of the Guidelines (6) of the International Society for
Musculoskeletal Shockway Therapy (I.S.M.S.T) with a weekly frequency and Piezowave 1
device. Patients give their written consent to the ESWT.
1. The treatment is carried out by a medical doctor
2. The shock waves are introduced with an applicator with contrast gel throgh the skin.
The adjustment is made before and during the treatment by means of a clinical
examination and pain description of the patient, X –ray. A fixed position is important,
an interruption of the treatment e.g., with pain is at any time possible. Usually 1000-
2000 single shocks (1-5 impulses per second) are applied during a treatment, with
small wouds at least 500 impulses per treatment. The duration of treatment is about
10 min.
3. One or more treatment is necessary, depending on the disease. The treatment data
are recordered precisely.
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British Journal of Healthcare and Medical Research (BJHMR) Vol 10, Issue 2, April- 2023
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4. The changes of succes are indicated differently in the literature, a listing and exact
discussion of the same goes beyond the scope here.
A Microsoft Access database has been developed to input all personal data of the people.
RESULTS
The analysis of the results highlighted:
➢ heel spur is the pathology most frequently indicated for ESWT: 157 patients of which
107 F and 50 M.
➢ shoulder calcific tendinopathy is the second pathology in the indication for ESWT: 136
patients of which 69 F and 67 M.
➢ Rhizarthrosis and Pes Anserine Bursitis are orthopedic pathologies less frequently
indicated for ESWT
➢ 40 patients suffering from epicondylitis
➢ Average age of onset of orthopedic pathology was 57.6 years, respectively 58 years in
women and 56.8 in men. (Fig.3)
➢ The indication for shock wave therapy was prescribed by 201 general practitioners and
203 and the specialists.
Fig.3 Average age of onset of orthopedic pathology
DISCUSSION
The results showed that heel spur or calcific enthesitis is the prevalent musculoskeletal
pathology treated with ESWT. Individuals >50 years of age, spur formation is more strikingly
common in women than in men. respectively 107 F and 50M. There was a notable moderate
positive correlation between gender and plantar spurs. The term enthesitis was introduced by
La Cava in 1959 to describe a process observed in entheses following mechanical injury. Calcific
enthesitis can be an adaptive response of the plantar fascia both to the alteration of friction
forces during walking and the inflammatory reaction of the surrounding tissues. (7-10) We
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Fizzotti, G., Piccinini, M., Ramella, V., & Fassina, L. (2023). Shockwave Therapy: Still Little-Known Issues. British Journal of Healthcare and Medical
Research, Vol - 10(2). 426-431.
URL: http://dx.doi.org/10.14738/jbemi.102.14473.
suppose that 75% of the patients suffering from heel spur and enrolled in the study showed the
development of foot pain as a result of long-term use of commonly made work shoes. This
condition may be a direct result of overloading the feet due to excessive strain.
Asymptomatic heel spur is relatively common; an epidemiological American study reports that
11% of the adult population had a random radiographic finding. (11,12).
The shoulder calcific tendinopathy found in 69 F and 67 M evidenced an overlapping gender
distribution motivated by different etiopathogenetic events that can involve both sexes.
Shoulder tendinopathies are frequently due to repeated movements in elevation of the limb
that can occur in many sports: swimming, volleyball, tennis or in work activities such as
hairdressing or painting.
The repeated movements and the functional joint stress could make difficult to maintain the
correct position of the scapula. That resulting in a reduction of the subacromial space and
consequent stress on the subacromial structures due to fatigue.
In considered sample 45 patients suffering from epicondylitis: 19 F and 26 M; they carried out
work activities with physical effort and frequent use of the upper limbs: carer, turner, worker
or sedentary jobs, with use of the computer and mouse. (13)
Epicondylitis is a progressive inflammatory disease due to overuse of the elbow associated with
repetitive microtrauma to the extensor tendon attached at the lateral epicondylar region of the
humerus.
Thumb osteoarthritis or Rhizarthrosis affects the surfaces of the joint between the trapezius
and the fist metacarpal. We recluted 6 patients with Rhizarthrosis associated to chronic pain
at the base of the thumb. Only Specialist prescribed ESWT in the patients affected by
rhizarthrosis It shows that expert advice is always necessary to define the correct effectiveness
of ESWT in less frequent orthopedic disease.
The pes anserinus is the combined insertion of the three hamstring tendons which attach to the
inside of the leg, just below the knee joint. The results evidenced that 1 patient suffered from
knee osteoarthritis (14) and 2 pes anserine bursitis; Specialist evaluated these patients and
prescribed ESWT. In recent years, ESWT has been introduced in the treatment of knee
osteoarthritis and pes anserine bursitis. (15) Pes anserine tendinopathy is an overuse injury
which is often aggravated with motor activities that involve bending the knee.
We evidenced that 201 general practitioners and 203 specialists prescribed ESWT. This data
showed an equality knowledge of indications to ESWT in outpatient hospital setting and in the
community.
The average time between the diagnosed onset of orthopedic disease and the first session of
ESWT was 3263.8 days.
The core problem in delay of diagnosis and treatment seemed to be a vicious cycle of repeated
visits at the same healthcare level, resulting in nonspecific treatment and failure to access
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specialized services. The development of ESWT was very fast only in the last few years, that can
explain the long period time delaying the diagnosis and the treatment.
Increase knowledge about the effectiveness of ESWT could be usefull to improve the
prescriptions in orthopedic pathologies.
Loss of follow-up is most problem in our study. More research is needed to understand the
effectiveness of ESWT in less frequent orthopedic pathologies.
CONCLUSION
Most muscoloskeletal pathologies present an elective inditation to ESWT.
ESWT showed many beneficts to treating the patient. It requires a limited number of sessions,
minimally invasive. Pain is the only disturbing side effect for the patient. More extensive studies
are needed to confirm whether any superiority over other available modalities or not in less
frequent orthopedic muscoloskeletal disfunctions.
Funding
This research received no specific grant from any finding agency in the public, commercial or
not for profit sectors.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research authorship
and/or publication of this article.
Patient consent
Obtained.
The study was approved by the Ethics Committee of our Centre and all patients provided
written informed consent before study treatment.
Provenance and peer review
Not commissioned; externally peer reviewed.
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Fizzotti, G., Piccinini, M., Ramella, V., & Fassina, L. (2023). Shockwave Therapy: Still Little-Known Issues. British Journal of Healthcare and Medical
Research, Vol - 10(2). 426-431.
URL: http://dx.doi.org/10.14738/jbemi.102.14473.
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