D Agostino MC, Frairia R, Romeo P, Amelio E, Berta L, Bosco V, Gigliotti S, Guerra C, Messina S, Messuri L, Moretti B, Notarnicola A, Maccagnano G, Russo S, Saggini R, Vulpiani MC, Buselli P. Extracorporeal shockwaves as regenerative therapy in orthopedic traumatology: a narrative review from basic research to clinical practice. J Biol Regul Homeost Agents. 2016 Apr-Jun;30(2):323-32. PMID: 27358117.
https://pubmed.ncbi.nlm.nih.gov/27358117/
Extracorporeal Shock Wave Therapy (ESWT), after its first medical application in the urological field for lithotripsy, nowadays represents a valid therapeutical tool also for many musculoskeletal diseases, as well as for regenerative medicine applications. This is possible thanks to its mechanisms of action, which in the non-urological field are not related to mechanical disruption (as for renal stones), but rather to the capacity, by mechanotransduction, to induce neoangiogenesis, osteogenesis and to improve local tissue trophism, regeneration and remodeling, through stem cell stimulation. On the basis of these biological assumptions, it becomes clear that ESWT can represent a valid therapeutic tool also for all those pathological conditions that derive from musculoskeletal trauma, and are characterized by tissue loss and/or delayed healing and regeneration (mainly bone and skin, but not only). As a safe, repeatable and non-invasive therapy, in many cases it can represent a first-line therapeutic option, as an alternative to surgery (for example, in bone and skin healing disorders), or in combination with some other treatment options. It is hoped that with its use in daily practice also the muscle-skeletal field will grow, not only for standard indications, but also in post-traumatic sequelae, in order to improve recovery and shorten healing time, with undoubted advantages for the patients and lower health service expenses.
Heinz Lohrer and Ludger Gerdesmeyer. Shock Wave Therapy in Practice: Multidisciplinary Medical Applications. 2014
http://www.stosswellen-praxis.com/Libri-specialistici.31+B6Jkw9NA__.0.html”
From angina pectoris to wound healing: ‘Multidisciplinary Medical Applications’ by Heinz Lohrer and Ludger Gerdesmeyer offers a current overview of indications and application areas of extracorporeal shock wave therapy (ESWT).
Galasso O, Amelio E, Riccelli DA, Gasparini G. Short-term outcomes of extracorporeal shock wave therapy for the treatment of chronic non-calcific tendinopathy of the supraspinatus: a double-blind, randomized, placebo-controlled trial. BMC Musculoskelet Disord. 2012 Jun 6;13:86. doi: 10.1186/1471-2474-13-86. PMID: 22672772; PMCID: PMC3434084. https://www.ncbi.nlm.nih.gov/pubmed/22672772
There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) in calcific tendinopathy of the rotator cuff, but the best current evidence does not support its use in non-calcifying tendinopathy. We conducted a randomized placebo-controlled trial to investigate the efficacy and safety of low energy ESWT for non-calcifying tendinopathy of the rotator cuff.
Manganotti P, Amelio E, Guerra C. Shock wave over hand muscles: a neurophysiological study on peripheral conduction nerves in normal subjects. Muscles Ligaments Tendons J. 2012 Sep 10;2(2):104-7. PMID: 23738282; PMCID: PMC3666504. https://pubmed.ncbi.nlm.nih.gov/23738282/
Background and purpose – Shock waves are defined as a sequence of single sonic pulses largely used in the treatment of bone and tendon diseases and recently on muscular hypertonia in stroke patients. Our purpose is to investigate the short and long term effect of extra-corporeal shock wave therapy (ESWT) on the peripheral nerve conduction and central conductions from the treated muscles in normal human subjects in order to define safety criteria.
Amelio E, Manganotti P. Effect of shock wave stimulation on hypertonic plantar flexor muscles in patients with cerebral palsy: a placebo-controlled study. J Rehabil Med. 2010 Apr;42(4):339-43. doi: 10.2340/16501977-0522. PMID: 20358168. https://pubmed.ncbi.nlm.nih.gov/20358168/
Background: Extracorporeal shock wave therapy has been reported to be effective in reducing muscle hypertonia in adults.
Aim: To evaluate the effect of shock wave treatment of spastic muscles in children with cerebral palsy.
Methods: Twelve children with spastic equinus foot (6 boys, 6 girls; mean age 8 years (standard deviation (SD) 2.31)) were monitored. Clinical (Ashworth Scale, passive range of motion) and instrumental (pedobarography) examination were performed. This is an open study with one placebo treatment session, followed 6 weeks later by one active shock wave treatment session. Gastrocnemius muscles and soleus muscles were treated.
Results: After placebo stimulation no clinical or instrumental effect was seen. After a single active shock wave stimulation a significant decrease in the Ashworth Scale (from 3 to 2), an increase in the range of motion (from 20° to 50°), and an increase in the whole plantar surface area of the treated limb (from 40.3 to 80.2 cm2) were observed in all patients. This effect lasted for 4 weeks in all patients.
Conclusions: A single active shock wave stimulation produced a significant long-lasting reduction in hypertonia in the plantar flexors in children with cerebral palsy.
Amelio E, Manganotti P. Effect of Extracorporeal Shock Wave Therapy on Spastic Hypertonia. Proceedings of 7th International Symposium on Experimental Spinal Cord Repair and Regeneration. 2009. Brescia University School of Medicine.
Spasticity is a disabling complication of stroke. Different not invasive treatments are used in order to reduce the muscle hypertonia. Shock waves are defined as a sequence of single sonic pulses characteristics by high peak pressure (100 MPa), fast pressure rise (<10 ns) and short duration (10 µ). Shock waves are largely used in the treatment of bone and tendon diseases and on muscular contractures. Our purpose is to investigate the long term effect of extracorporeal shock wave therapy (ESWT) on the muscle hypertonia of the hand and the wrist.
Tinazzi, E., Amelio, E., Marangoni, E. et al. Effects of shock wave therapy in the skin of patients with progressive systemic sclerosis: a pilot study. Rheumatol Int 31, 651–656 (2011). https://doi.org/10.1007/s00296-009-1339-z
https://link.springer.com/article/10.1007/s00296-009-1339-z#citeas
Vasculopathy, immunological abnormalities, and excessive tissue fibrosis are key elements in the pathogenesis of progressive systemic sclerosis (SSc). Extracorporeal shock waves (ESW) have anti-inflammatory and regenerative effects on different tissues. We hypothesized that ESW can reduce endothelial cell damage and skin fibrosis in patients with SSc. We enrolled 30 patients affected by SSc, 29 females and 1 male. Rodnan Skin Score (RSS) and Visuo-Analogical Scale (VAS) for skin wellness were performed before and immediately after ESW therapy (ESWT) and at 7, 30, 60, and 90 days after the treatment. Sonographic examination of the patients’ arms was performed before and 7, 30, 60, 90 days after treatment. Blood samples were obtained before and 30 and 60 days after treatment to measure serological levels of von Willebrand factor, vascular endothelial growth factor, intracellular adhesion molecule-1, monocyte chemotactic protein-1. The number of endothelial progenitor cells (EPCs) and circulating endothelial cells (CECs) were determined at the same time points. After ESWT we observed a rapid and persistent reduction of RSS and decrease of VAS. There was no difference in skin thickness before and after ESWT; however, we observed a more regular skin structure and an improvement in skin vascularization 90 days after treatment. EPCs and CECs increased 60 and 90 days after treatment, while serological biomarkers showed no variation before and after therapy. In conclusion, ESWT resulted in an improvement of VAS, RSS, and of skin vascular score, and in an increase of CECs and EPCs.
Tinazzi, E., Amelio, E., Marangoni, E. et al. Effects of shock wave therapy in the skin of patients with progressive systemic sclerosis: a pilot study. Rheumatol Int 31, 651–656 (2011). https://doi.org/10.1007/s00296-009-1339-z
https://pubmed.ncbi.nlm.nih.gov/21767905/
Kienböck’s disease is a rare, painful disorder of the wrist that can seriously restrict the quality of life of patients who have the disease. Although a century has passed since the pathology was identified, its etiology is still uncertain, with mechanical, traumatic, vascular, and systemic factors all being advocated. Likewise, there is no consensus regarding treatment, and no approach-either conservative or surgical-has been demonstrated to yield significantly better outcomes. Extracorporeal shock wave treatment (ESWT) has been effective in stimulating fracture healing, and it has been adopted as a therapy to restore vascular supply in those bone conditions characterized by vascular impairment. We report our experience in treating 22 patients with Kienböck’s disease at various stages with high-energy shock waves. Our results indicate that ESWT has a positive effect on pain and functional impairment of the wrist, and may delay surgical treatment. Further studies are necessary to understand the full potential of this therapeutic tool.
Trompetto C, Avanzino L, Bove M, Marinelli L, Molfetta L, Trentini R, Abbruzzese G. External shock waves therapy in dystonia: preliminary results. Eur J Neurol. 2009 Apr;16(4):517-21. doi: 10.1111/j.1468-1331.2008.02525.x. PMID: 19187259.
https://pubmed.ncbi.nlm.nih.gov/19187259/
Background and purpose: Extracorporeal shock wave therapy (ESWT) has been shown to reduce hypertonia in patients with upper motor neuron syndrome without any side effect. The aim of the present study is to investigate whether ESWT could be useful also in patients with dystonia. Methods: We evaluated three patients with secondary dystonia and three patients with idiopathic writer’s cramp. Placebo treatment was performed in each patient. ESWT was administered during four sessions (once weekly) to the target muscles of hand and forearm using an electromagnetic lithotripter (Modulith SLK – Storz Medical). Clinical evaluation was performed using the Unified Dystonia Rating Scale in patients with secondary dystonia and the Arm Dystonia Disability Scale in patients with writer’s cramp. Results: After treatment, the three patients with secondary dystonia showed a marked improvement which lasted at least until 1 month after the last session. In the patients with writer’s cramp, the improvement after ESWT was less consistent being effective only in two subjects. There were no associated adverse effects.\nConclusions: Extracorporeal shock wave therapy is probably an effective and safe treatment for upper limb dystonia, particularly for the secondary forms. Larger randomized studies are needed to confirm these preliminary results.
Khattab AA, Brodersen B, Schuermann-Kuchenbrandt D, Beurich H, Tölg R, Geist V, Schäfer T, Richardt G. Extracorporeal cardiac shock wave therapy: first experience in the everyday practice for treatment of chronic refractory angina pectoris. Int J Cardiol. 2007 Sep 14;121(1):84-5. doi: 10.1016/j.ijcard.2006.08.030. Epub 2006 Nov 9. PMID: 17097167. https://pubmed.ncbi.nlm.nih.gov/17097167/
Several alternative therapies have emerged for treating patients with chronic refractory angina pectoris, yet only a few have given rise to sufficiently published data regarding safety and effectiveness. It is imperative to establish an effective and preferably non-invasive therapy for this expanding patient cohort. We report initial experience with cardiac shock wave therapy (CSWT) in the everyday practice for refractory angina.
Aicher A, Heeschen C, Sasaki K, Urbich C, Zeiher AM, Dimmeler S. Low-energy shock wave for enhancing recruitment of endothelial progenitor cells: a new modality to increase efficacy of cell therapy in chronic hind limb ischemia. Circulation. 2006 Dec 19;114(25):2823-30. doi: 10.1161/CIRCULATIONAHA.106.628623. Epub 2006 Dec 4. PMID: 17145991.
https://pubmed.ncbi.nlm.nih.gov/17145991/
Background – Stem and progenitor cell therapy is a novel approach to improve neovascularization and function of ischemic tissue. Enhanced tissue expression of chemoattractant factors such as stromal cell–derived factor 1 and vascular endothelial growth factor is crucial for the recruitment of circulating endothelial progenitor cells (EPCs) during acute ischemia. In chronic ischemia, however, expression of these chemoattractants is less pronounced, which results in insufficient EPC recruitment into the target tissue. Therefore, we investigated the effect of targeted extracorporeal shock wave (SW) application in order to facilitate EPC recruitment into nonischemic and chronic ischemic tissue.\n\nMethods and Results – Hind limb adductor muscles of nude rats were treated with 500, 1000, and 2000 impulses of focused low-energy SW (flux density level: 0.05 mJ/mm2). Twenty-four hours later, mRNA expression of the chemoattractant stromal cell-derived factor 1 was significantly increased with 1000 impulses (stromal cell-derived factor 1/GAPDH: 0.95±0.09) and 2000 impulses (stromal cell–derived factor 1/GAPDH: 1.17±0.24; both P<0.05 versus untreated). Histologically, the number of vascular endothelial growth factor-positive endothelial cells per myocyte was significantly increased with 2000 impulses (0.24±0.05 versus 0.09±0.02; P<0.01). This preconditioning effect resulted in significantly enhanced recruitment and homing of EPCs that were intravenously infused 24 hours after SW treatment (P<0.05). In a rat model of chronic hind limb ischemia, SW-facilitated EPC treatment resulted in a significant increase in relative blood flow recovery as assessed by laser Doppler imaging (P<0.05).\n\nConclusions – Preconditioning of both nonischemic and chronic ischemic tissue with low-energy SW improves recruitment of circulating EPCs via enhanced expression of chemoattractant factors. Thus, SW-facilitated cell therapy may improve the efficacy of EPC treatment in patients with chronic ischemia.
H. Lohse-Busch, M. Kraemer, U. Reime. Extracorporeal shock waves in the rehabilitation of children with cerebral palsy. Sixteenth Meeting of the European Neurological Society. Journal of Neurology (2006) 253 [Suppl 2]: II/1–II/170.
After the informed consent of children and parents the treatments were performed 5 times during 2 weeks with a modified Minilith SL lithotriptor (Storz Medical) producing diverging ESW of 0.012mJ/mm2 – 0.024 mJ/mm2 energy flux density. This is about 10% of what is considered in physical medicine as “low energy extracorporeal shock waves (ESW)”. We performed 2 different investigations.
E. Amelio, P. Manganotti. Extracorporeal shock waves in the rehabilitation of children with cerebral palsy. Sixteenth Meeting of the European Neurological Society. Journal of Neurology (2006) 253 [Suppl 2]: II/1–II/170.
Different non-invasive treatments are used to reduce muscle hypertonia. Shock wave (ESW) are defined as a sequence of single sonic pulses largely used for bone, tendon diseases and muscular contractures. In our previous study we have documented the significant decrease of spastic hypertonia in the affected hand of patients with stroke after treatment by ESWT (Stroke vol. 36, n. 9, September 2005 1967-1971). The aim of this study is to examine the effect of shock wave treatment in spastic equinus foot in a group of children with cerebral palsy.
Meirer R, Kamelger FS, Piza-Katzer H. Shock wave therapy: an innovative treatment method for partial thickness burns. Burns. 2005 Nov;31(7):921-2. doi: 10.1016/j.burns.2005.02.013. Epub 2005 Apr 14. PMID: 16199297. https://pubmed.ncbi.nlm.nih.gov/16199297
Deep partial thickness burns are characterized by the fact that they take over 21 days to heal and scarring may be severe. As differentiation from full thickness burns is often difficult the majority of cases are skin grafted with early excision beginning within less than 72 h as it is said to be beneficial especially in children and young adults less than 30 years old [1]. This report presents an innovative idea to treat deep partial thickness burns.
Manganotti P, Amelio E. Long-term effect of shock wave therapy on upper limb hypertonia in patients affected by stroke. Stroke. 2005 Sep;36(9):1967-71. doi: 10.1161/01.STR.0000177880.06663.5c. Epub 2005 Aug 18. PMID: 16109905.
https://pubmed.ncbi.nlm.nih.gov/16109905/
Background and Purpose: Spasticity is a disabling complication of stroke and different noninvasive treatments are used to reduce muscle hypertonia. Shock waves are defined as a sequence of single sonic pulses largely used in the treatment of diseases involving bone and tendon as well as muscular contractures. The effect and duration of extracorporeal shock wave therapy (ESWT) was investigated on muscle hypertonia of the hand and wrist.
Methods: A total of 20 patients affected by stroke associated with severe hypertonia in upper limbs were evaluated. Placebo stimulation was performed 1 week before active stimulation in each patient. Evaluation was performed using the National Institutes of Health and Ashworth scales and video monitoring with a digital goniometer before and immediately after placebo or active stimulation. Motor nerve conduction velocity from abductor digiti minimi were recorded. Patients were monitored at 1, 4, and 12 weeks after active treatment.
Results: After active ESWT, patients showed greater improvement in flexor tone of wrist and fingers compared with placebo stimulation. At the 1- and 4-week follow-up visits, a significant decrease of passive muscle tonicity was noted on muscles in all patients receiving active treatment. At 12 weeks after therapy, 10 of the 20 patients showed persistent reduction in muscle tone. There were no adverse events associated with ESWT.
Conclusions: ESWT reduces hypertonia of the wrist and finger muscles for ≥12 weeks after treatment. The possible mechanisms of action of ESWT are discussed.
Mariotto S, Cavalieri E, Amelio E, Ciampa AR, de Prati AC, Marlinghaus E, Russo S, Suzuki H. Extracorporeal shock waves: from lithotripsy to anti-inflammatory action by NO production. Nitric Oxide. 2005 Mar;12(2):89-96. doi: 10.1016/j.niox.2004.12.005. PMID: 15740982.
https://pubmed.ncbi.nlm.nih.gov/15740982/
At low energy density (0.03mJ/mm2), extracorporeal shock waves (ESW), originally developed for clinical lithotripsy, have successfully been used for anti-inXammatory treatment of soft tissues. Since nitric oxide plays a critical role in inXammation, we hypothesized for ESW to increase NO production in cells. Using human umbilical vein endothelial cells as a model system, we observed that ESW, at low energy density, rapidly induced an enhancement of eNOS activity. In these cells, eNOS activity is modulatedby tyrosine- and serine-phosphorylation. ESW shifted eNOS to a less-tyrosine-phosphorylated form, without aVecting its serine-phosphorylation, thus accounting for its rapid enzyme activation. LPS/IFN-gamma treatment of human umbilical vein endothelial cells induced a rapid inhibition of eNOS activity and concomitant NF-kappaB activation which were efficiently counteracted by ESW treatment. Therefore, the present results indicate that the molecular mechanism of clinically observed anti-inflammatory action of ESW should include tyrosine-dephosphorylation of eNOS, a successive increase in NO production and suppression of NF-kappaB activation.
Ciampa AR, de Prati AC, Amelio E, Cavalieri E, Persichini T, Colasanti M, Musci G, Marlinghaus E, Suzuki H, Mariotto S. Nitric oxide mediates anti-inflammatory action of extracorporeal shock waves. FEBS Lett. 2005 Dec 19;579(30):6839-45. doi: 10.1016/j.febslet.2005.11.023. Epub 2005 Nov 28. PMID: 16325181. https://pubmed.ncbi.nlm.nih.gov/16325181/
Here, we show that extracorporeal shock waves (ESW), at a low energy density value, quickly increase neuronal nitric oxide synthase (nNOS) activity and basal nitric oxide (NO) production in the rat glioma cell line C6. In addition, the treatment of C6 cells with ESW reverts the decrease of nNOS activity and NO production induced by a mixture of lipopolysaccharides (LPS), interferon-γ (IFN-γ) plus tumour necrosis factor-α (TNF-α). Finally, ESW treatment efficiently downregulates NF-κB activation and NF-κB-dependent gene expression, including inducible NOS and TNF-α. The present report suggests a possible molecular mechanism of the anti-inflammatory action of ESW treatment.
Wang CJ, Wang FS, Huang CC, Yang KD, Weng LH, Huang HY. Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting. J Bone Joint Surg Am. 2005 Nov;87(11):2380-7. doi: 10.2106/JBJS.E.00174. PMID: 16264111.
https://pubmed.ncbi.nlm.nih.gov/16264111/
Background: There is continuing controversy regarding the optimal treatment for patients with symptomatic early-stage osteonecrosis of the femoral head. We compared the results of noninvasive treatment with extracorporeal shock waves with those of core decompression and bone-grafting in similar groups of patients.\n\nMethods: Patients with stage-I, II, or III osteonecrosis were randomly assigned to be treated either with shock waves or with core decompression and nonvascularized fibular grafting. The shock-wave group consisted of twenty-three patients (twenty-nine hips), and the surgical group consisted of twenty-five patients (twenty-eight hips). The patients in the two groups had similar demographic characteristics, duration and stage of disease, and duration of follow-up. The patients in the shock-wave group received a single treatment with 6000 impulses of shock waves at 28 kV to the affected hip. The evaluation parameters included clinical assessment of pain with a visual analog pain scale, Harris hip scores, and an assessment of activities of daily living and work capacity. Radiographic assessment was performed with serial plain radiographs and magnetic resonance imaging. Results: Before treatment, the two groups had similar pain and Harris hip scores. At an average of twenty-five months after treatment, the pain and Harris hip scores in the shock-wave group were significantly improved compared with the pretreatment scores (p < 0.001). In this group, 79% of the hips were improved, 10% were unchanged, and 10% were worse. Of the hips treated with a nonvascularized fibular graft, 29% were improved, 36% were unchanged, and 36% were worse. In the shock-wave group, imaging studies showed regression of five of the thirteen lesions that had been designated as stage I or II before treatment and no regression of a stage-III lesion. Two stage-II and two stage-III lesions progressed. In the surgical group, four lesions regressed and fifteen (of the nineteen graded as stage I or II) progressed. The remaining nine lesions were unchanged.\n\nConclusions: Extracorporeal shock-wave treatment appeared to be more effective than core decompression and nonvascularized fibular grafting in patients with early-stage osteonecrosis of the femoral head. Long-term results are needed to determine whether the effect of this novel method of treatment for osteonecrosis of the femoral head endures.
Nishida, T., Shimokawa, H., Oi, K., Tatewaki, H., Uwatoku, T., Abe, K., Matsumoto, Y., Kajihara, N., Eto, M., Matsuda, T., Yasui, H., Takeshita, A., & Sunagawa, K. (2004). Extracorporeal cardiac shock wave therapy markedly ameliorates ischemia-induced myocardial dysfunction in pigs in vivo. Circulation, 110 (19), 3055-3061. doi: 10.1161/01.CIR.0000148849.51177.97
https://kyushu-u.pure.elsevier.com/en/publications/extracorporeal-cardiac-shock-wave-therapy-markedly-ameliorates-is
Background – Prognosis of ischemic cardiomyopathy still remains poor because of the lack of effective treatments. To develop a noninvasive therapy for the disorder, we examined the in vitro and vivo effects of extracorporeal shock wave (SW) that could enhance angiogenesis. Methods and Results – SW treatment applied to cultured human umbilical vein endothelial cells significantly upregulated mRNA expression of vascular endothelial growth factor and its receptor Flt-1 in vitro. A porcine model of chronic myocardial ischemia was made by placing an ameroid constrictor at the proximal segment of the left circumflex coronary artery, which gradually induced a total occlusion of the artery with sustained myocardial dysfunction but without myocardial infarction in 4 weeks. Thereafter, extracorporeal SW therapy to the ischemic myocardial region (200 shots/spot for 9 spots at 0.09 mJ/mm2) was performed (n=8), which induced a complete recovery of left ventricular ejection fraction (51±2% to 62±2%), wall thickening fraction (13±3% to 30±3%), and regional myocardial blood flow (1.0±0.2 to 1.4±0.3 mL·min-1·g-1) of the ischemic region in 4 weeks (all P<0.01). By contrast, animals that did not receive the therapy (n=8) had sustained myocardial dysfunction (left ventricular ejection fraction, 48±3% to 48±1%; wall thickening fraction, 13±2% to 9±2%) and regional myocardial blood flow (1.0±0.3 to 0.6±0.1 mL· min-1·g-1). Neither arrhythmias nor other complications were observed during or after the treatment. SW treatment of the ischemic myocardium significantly upregulated vascular endothelial growth factor expression in vivo. Conclusions – These results suggest that extracorporeal cardiac SW therapy is an effective and noninvasive therapeutic strategy for ischemic heart disease.
Amelio, Ernesto and Paolo Manganotti. Effect of Shock Wave Therapy in Patients Affected by Stroke with Upper Limb Spasticity: Neurophysiologic and Clinical Study. Proceedings of 9th Congress of the International Federation of Societies for Surgery the Hand (2004).
https://www.semanticscholar.org/paper/Effect-of-Shock-Wave-Therapy-in-Patients-Affected-Amelio-Manganotti/a375db2417c46395fcac775956b3db2a4eaf1a6c
Aim of the study is to investigate the effect and the duration of extracorporeal shock wave therapy (ESWT) on the muscle spasticity of the hand and the wrist. We studied 15 patients affected by stroke associated to severe spastic- ity in upper limb. Clinical examination, neurological scales (NIH scale and Ashworth scales) and a video were performed before and immediately after the placebo and real stimulation. The placebo stimulation was performed before the real stimulation in each stimulation. The patients were monitored after one, four, twelve weeks from the real treatment. After four weeks needle EMG was studied. After real ESWT the patients had greater improvement in flexor tone of wrist and fingers than after placebo stimulation. After 12 weeks from the therapy ten of the fifteen patients showed persistent reduction in muscle tone. No sign of muscle denervation was recorded in all patients. There were no adverse events associated with ESWT. ESWT reduce spasticity of the wrist and finger muscles lasting at least 12 weeks from the treatment.
Suzuki, H., et al., Effect of Shock Wave on the Catalytic Activity of Endothelial Nitric Oxide Synthase in Human Umbilical Vein Endothelial Cells, 6th International Congress of the International Society for Medical Shockwave Treatment (www.ismst.com), 2003, International Society for Medical Shockwave Treatment, Austria.
Recent clinical observation indicates the beneficial effect of shock wave on inflammatory region of soft tissues. Although the molecular mechanism of this effect is poorly understood, shock wave treatment seems to locally trigger immediate vasodilation and successive angiogenesis. Nitric oxide (NO) is a gas synthesised by NO synthase (NOS), which, using L-arginine as a substrate, catalyses the synthesis of NO and citrulline (1). Two types of NOS, constitutive and inducible NOS, regulate the amounts of NO in the body. Constitutively expressed NOS (neuronal and endothelial NOS) produces the low amounts of NO (nM) and its catalytic activity is continuously regulated by a number of compounds such as co-factors and modulators. NO produced by constitutive NOS exerts physiological action such as vasodilation, neurotransmission and angiogenesis. Inducible NOS (iNOS), normally absent, locally produces massive amounts of NO under inflammatory conditions, following its induction by proinflammatory cytokines, such as interferon-g, tumour necrosis factor-a and interleukin1-b, and lipopolysaccharides (LPS). Massive amounts of NO act as double-edged sword: on the one hand, they may be involved in killing invading cells such as microbes and parasites and, on the other hand, they may damage tissues. In the present work, we hypothesised that one of the molecular mechanisms of the beneficial effect of shock wave toward inflammatory tissues may be an enhanced production of NO. To envisage this hypothesis, we, using human umbilical vein endothelial cells (HUVEC) as an experimental model, analysed the effect of shock wave on the catalytic activity of endothelial NOS (eNOS).
Dymarek R, Ptaszkowski K, Ptaszkowska L, et al. Shock Waves as a Treatment Modality for Spasticity Reduction and Recovery Improvement in Post-Stroke Adults – Current Evidence and Qualitative Systematic Review [published correction appears in Clin Interv Aging. 2021 Apr 06;16:569]. Clin Interv Aging. 2020;15:9-28. Published 2020 Jan 6. doi:10.2147/CIA.S221032
The authors report an in-vivo prospective preliminary study to assess the effectiveness of shock waves in the treatment of upper limb spastic muscles in adult patients suffering from central spasticity. In all patients an increase of velocity in the angular movement of the forearm was noted. Video score, acceleration, muscle activation timing were measured. Patients have been subjected to extracoporeal shock waves by means of electromagnetic coil lithotriptor; 1500 shots for flexor carpi ulnaris, 1500 for extensor digitorum comunis, 1500 for biceps and triceps muscles each were used, the energy was 0.030 mJ/mm2. In all patients video polyEMG was recorded. Video polygraphy system for movement analysis was used (Micromed System EEG-EMG, Sampling 1024Hz). Surface EMG were recorded form flexor carpi ulnaris, extensor digitorum comunis, biceps and triceps muscles. Surface electrodes with bipolar montage were used. An accelerometer was positioned over the forearm. Video score, acceleration, muscle activation timing were measured before and after extracorporeal shock wave treatments. Follow ups were scheduled at 1, 2 and 3 months. In all patients an increase of velocity was noted in the angular movement of the forearm. Less index of co-contraction was observed from distal and proximal muscles.
Gotte G, Amelio E, Russo S, Marlinghaus E, Musci G, Suzuki H. Short-time non-enzymatic nitric oxide synthesis from L-arginine and hydrogen peroxide induced by shock waves treatment. FEBS Lett. 2002 Jun 5;520(1-3):153-5. doi: 10.1016/s0014-5793(02)02807-7. PMID: 12044888.
https://pubmed.ncbi.nlm.nih.gov/12044888/
The evidence that nitric oxide (NO) production is possible by a non-enzymatic pathway has already been shown under restrictive experimental conditions. Here we show that NO can non-enzymatically be formed with short-time kinetics (min), by ‘bombing’ with shock waves a solution containing 1 mM hydrogen peroxide and 10 mM L-arginine. This procedure is widening its medical application with surprisingly positive effects in tissue regeneration and our finding could be one of the first steps for the understanding of the biochemical responsible for these therapeutical effects.