Extracorporeal Shock Wave Therapy (ESWT): Mechanisms, Applications, and Clinical Evidence in Musculoskeletal, Joint, and Spine Disorders

Introduction

Extracorporeal Shock Wave Therapy (ESWT) is a non-invasive treatment modality that utilizes acoustic pressure waves to stimulate healing processes in various musculoskeletal conditions. Initially developed for lithotripsy, ESWT has expanded its applications into orthopedics and rehabilitation medicine, offering therapeutic benefits in tendon injuries, joint disorders, and spinal pathologies.

Mechanisms of Action

ESWT exerts its therapeutic effects through several biological mechanisms:
• Mechanotransduction: The mechanical energy from shock waves is converted into biochemical signals, promoting cellular activities that facilitate tissue repair.
• Neovascularization: ESWT stimulates the formation of new blood vessels, enhancing blood flow and nutrient delivery to the affected area, thereby accelerating healing.
• Anti-inflammatory Effects: The therapy modulates inflammatory responses by downregulating pro-inflammatory cytokines, reducing inflammation and associated pain.
• Pain Modulation: ESWT may alter pain perception by affecting nerve conduction and reducing the sensitivity of nociceptors.
• Stem Cell Activation: The treatment encourages the migration and proliferation of mesenchymal stem cells, contributing to tissue regeneration.

These mechanisms collectively contribute to the regenerative and analgesic effects observed in clinical applications of ESWT.

A set of six painful joints, medical 3D illustration

Applications in Musculoskeletal Disorders

ESWT has been effectively utilized in managing various musculoskeletal conditions:
• Tendinopathies: Including lateral epicondylitis (tennis elbow), Achilles tendinopathy, patellar tendinopathy, and rotator cuff tendinopathy.
• Enthesopathies: Such as plantar fasciitis, calcific tendinitis, and greater trochanteric pain syndrome.
• Bone Healing: ESWT has shown efficacy in promoting osteogenesis and enhancing callus formation in cases of delayed union or non-union fractures.

Clinical studies have demonstrated significant improvements in pain reduction and functional outcomes in these conditions following ESWT.

Joint Disorders

In joint-related pathologies, ESWT has been applied with promising results:
• Knee Osteoarthritis: ESWT has been shown to alleviate pain and improve joint function in patients with knee osteoarthritis.
• Shoulder Calcific Tendinitis: The therapy aids in the resorption of calcific deposits and reduces pain, enhancing shoulder mobility.
• Temporomandibular Joint (TMJ) Disorders: ESWT has been explored as a treatment option, with studies indicating improvements in joint mobility and pain reduction.

These applications underscore the versatility of ESWT in managing joint disorders.

Spine-Related Conditions

ESWT has been investigated for its efficacy in treating various spinal conditions:
• Chronic Low Back Pain (CLBP): Systematic reviews and meta-analyses have reported that ESWT can significantly reduce pain and improve lumbar function in patients with CLBP.
• Facet Joint Syndrome: ESWT may provide pain relief and improve mobility in patients with facet joint-related back pain.
• Myofascial Pain Syndrome: The therapy has been used to alleviate trigger point pain and muscle tension in the back.

These findings suggest that ESWT is a valuable tool in the non-invasive management of spine-related disorders.

Advantages and Limitations

Advantages:
• Non-invasive and safe with minimal side effects.
• Short treatment sessions and recovery time.
• Cost-effective compared to surgical interventions.

Limitations:
• Optimal treatment protocols (e.g., energy levels, number of sessions) are still under investigation.
• May be less effective in severe degenerative conditions.
• Contraindications include coagulopathy, local infection, and malignancy at the treatment site.

Conclusion

Extracorporeal Shock Wave Therapy represents a promising non-invasive treatment modality for various musculoskeletal, joint, and spine disorders. Its multifaceted mechanisms of action contribute to tissue regeneration and pain relief, making it a valuable addition to the therapeutic arsenal in orthopedics and rehabilitation medicine. Ongoing research is essential to optimize treatment protocols and expand its clinical applications.

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References
1. Simplicio, C. L., et al. (2020). Extracorporeal shockwave therapy: Mechanisms in musculoskeletal regenerative medicine. ShockwaveNet.
2. Schmitz, C., et al. (2015). Mechanisms of shock wave therapy in musculoskeletal disorders. Bone & Joint Research, 4(3), 125–132.
3. Wang, C. J. (2012). An overview of shock wave therapy in musculoskeletal disorders. Chang Gung Medical Journal, 35(3), 197–210.
4. Kang, T. W., et al. (2020). The effectiveness of extracorporeal shockwave therapy for the treatment of knee osteoarthritis: A meta-analysis of randomized controlled trials. Medicine, 99(48), e23352.
5. Seco, J., et al. (2023). Effectiveness of extracorporeal shock wave therapy for chronic low back pain: A systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research, 18(1), 198.
6. Notarnicola, A., & Moretti, B. (2012). The biological effects of extracorporeal shock wave therapy (ESWT) on tendon tissue. Muscles, Ligaments and Tendons Journal, 2(1), 33–37.

It is my privilege to welcome you to the 46th Annual Scientific Meeting of the American Academy of Neurological and Orthopaedic Surgeons. We are gathered here at the Hilton Palacio Del Rio for our annual educational program.

Our conference will provide information on a variety of Neurological, Orthopaedic and Spine related topics and I encourage you to review the information available on the meeting APP to learn all about the various speakers and their presentations. I am delighted that in this year’s program will include a number of speakers from San Antonio and the surrounding area. Joining us from UT San Antonio will be Prof. Cristian Gragnaniello, who will present Modern Management Strategies in Thoraco-Lumbar Trauma on Saturday morning. In addition, invited guest speakers, Drs. Jon-Cecil Walkes from Houston and Steven Cyr from San Antonio will contribute two fascinating lectures on Friday morning.

I am pleased that the International College of Surgeons, as our educational partner, has worked closely with our Scientific Organizing Committee to develop additional programming that is likely to be of interest to all surgical specialties. I encourage every member of the Academy to peruse the program and participate in as many sessions as possible to earn the maximum number of CME credits.

I hope you have a most enjoyable visit to the home of the Alamo during our annual meeting!

Lucia Zamorano, MD, FICS, FAANOS
Chair, American Academy of Neurological and Orthopaedic Surgeons

Welcome Letters

Michigan Brain & Spine Surgery Center is looking for Administrative and/or Clinical Assistant to join our team of highly dedicated professionals who are committed in providing top-quality patient care. The candidate should possess attributes that include excellent communication skills, time-management skills, self-motivation, and the ability to work independently and as a team to accomplish daily goals and objectives, as well as, treating all patients’ and co-workers’ in a professional, respectful manner.

Learn more about this opportunity

The Courage Awards annually recognize a person and their family who has been diagnosed with an Autism Spectrum Disorder and demonstrates great character and perseverance in living with the challenges of this disorder.

There will be two awards presented. One will recognize an individual, sponsored by Susan V. Swider and Oakland MRI. The other will acknowledge the individual and their family, sponsored by Dr. Lucia Zamorano and Michigan Brain & Spine Surgery Center. The award will be presented to the winners at the annual Ted Lindsay Foundation Celebrity Golf Outing on Monday September 12, 2022 at Detroit Golf Club, Detroit, MI.

Ted Lindsay Foundation support research and educational programs focusing on the cause and management of Autism Spectrum Disorders.

Obesity is associated with increased operating times and higher complication rates in many types of surgery. Its impact on robotic thyroidectomy however, is not well documented. The aim of this study was to investigate the relationship between body mass index (BMI) and robotic transaxillary thyroidectomy (RTAT). A retrospective review of prospectively collected data of all patients who underwent RTAT at Yonsei University Health System from October 2007 to December 2014 was performed. Patients were divided into three groups based on BMI (Group 1: BMI < 25, Group 2: BMI 25–29.99, Group 3: BMI ≥ 30), and compared. A total of 3697 patients were analyzed. No differences between the three groups were observed in clinicopathological factors, extent of surgery or length of stay. After multivariate analysis, only seroma and transient voice hoarseness were related to increasing BMI. Total operative time was significantly longer for Group 3 patients with less-than-bilateral total thyroidectomy (BTT), but was not significantly different for patients with BTT. Although obese patients undergoing RTAT have a slightly higher risk of seroma, transient voice hoarseness, and longer operative times, BMI did not influence the other important surgical outcomes of thyroidectomy. Therefore, obesity should not be a contraindication for performing RTAT.

Minimally invasive surgery (MIS) is an increasingly common technique used in most surgical practices because of advantages of smaller incisions, reduced pain, less blood loss, shorter length of hospital stay, and earlier return to work. MIS for cervical endocrine glands began in 1996 when Gagner performed the first endoscopic subtotal parathyroidectomy in a patient with primary hyperparathyroidism1. Subsequently in 1997, Huscher et al. described the first endoscopic right thyroid lobectomy2. Different endoscopic approaches have since been developed and performed worldwide for better cosmesis and avoidance of neck scars. Endoscopic techniques are however limited by rigid instruments that cannot articulate for more precise retraction and dissection of vital structures around the thyroid gland.

Our institution developed gasless, robotic transaxillary thyroidectomy (RTAT) in 20073. Since then, we have performed more than 5000 thyroidectomies using this technique, achieving results that are comparable in complication rates and oncological outcomes to standard open operation4. Some surgeons have, however, been skeptical that such good results are only possible because of favorable patient body habitus, as the Korean population is mostly within the normal BMI range, as opposed to patients from Western countries where the obesity rate is much higher. This difference was highlighted in the 2013–2014 National Health and Nutrition Examination Survey that reported a U.S. obesity rate (BMI ≥ 30 kg/m2) of 40.4% in females and 35.0% in males5. The obesity rate in South Korea as reported by the Korean National Health and Nutrition Examination Survey for the same period, was 4.3% for females and 5.3% for males6.

Despite the significantly lower obesity rate in South Korea, our department still manages a small number of obese patients. Given that few objective data are available on the relationship between obesity and surgical outcomes of patients undergoing RTAT, we, at the largest robotic thyroidectomy center in the world, investigated the impact of BMI on operative time, morbidity and long-term outcomes of RTAT at our institution.

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The Pulse platform combines neuromonitoring, surgical planning, rod bending, radiation reduction, imaging and navigation functions, with extensible capabilities to enable increased surgical efficiencies in the OR. These integrated technologies are designed to improve a surgeon’s ability to utilize minimally invasive surgery (MIS) techniques, which have been shown to reduce blood loss, hospital stays and result in less operative morbidity compared to open spine surgery.

“NuVasive’s Pulse platform provides an unmatched surgical experience due to its responsive and optimized workflow features,” said Juan Uribe, MD, chief of the division of spinal disorders at Barrow Neurological Institute in Arizona. “The benefits of the advanced navigation and imaging, coupled with neuromonitoring, allow for optimized outcomes for patients, while gaining impactful efficiencies for my OR staff and hospital system.”

NuVasive completed limited clinical release testing of the Pulse platform, providing initial validation that its structural design supports broad clinical utility throughout the entire surgery, and is useable in 100 percent of spine surgeries, from fusions to complex corrections. Its independent device access allows OR staff to simultaneously view the technologies’ imaging and insights in real time and in parallel, creating a seamless, optimized OR workflow. In addition, the open and modular architecture of the Pulse system allows for flexible technology packages, allowing surgeons to select the exact tools they need to address specific pathologies in spine surgery procedures.

“The Pulse platform is uniquely engineered to equip surgeons with a single platform of integrated technologies necessary to perform all spine surgeries, including minimally invasive approaches,” said J. Christopher Barry, chief executive officer of NuVasive. “Pulse provides an intuitive surgeon experience by anticipating user needs and fusing these technologies to create a seamless, optimized OR workflow, while addressing a broad range of clinical challenges. This is a pivotal step in our strategic vision to deliver end-to-end solutions that enable predictable clinical and economic outcomes in spine surgery.”

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The use of robotic technologies to assist surgeons was conceptually described almost thirty years ago but has only recently become feasible. In Neurosurgery, medical robots have been applied to neurosurgery for over 19 years. Nevertheless this field remains unknown to most neurosurgeons. The intrinsic characteristics of robots, such as high precision, repeatability and endurance make them ideal surgeon’s assistants. Unfortunately, limitations in the current available systems make its use limited to very few centers in the world. During the last decade, important efforts have been made between academic and industry partnerships to develop robots suitable for use in the operating room environment. Although some applications have been successful in areas of laparoscopic surgery and orthopaedics, Neurosurgery has presented a major challenge due to the eloquence of the surrounding anatomy. This review focuses on the application of medical robotics in neurosurgery. The paper begins with an overview of the development of the medical robotics, followed by the current clinical applications in neurosurgery and an analysis of current limitations. We discuss robotic applications based in our own experience in the field. Next, we discuss the technological challenges and research areas to overcome those limitations, including some of our current research approaches for future progress in the field.

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On Monday, Brown underwent a different procedure to prevent a second aneurysm from causing harm. But instead of an incision across her head, she has a tiny incision on her groin.

Brown was the first patient in the country to receive a new FDA-approved alternative surgical procedure.

Brown first discovered she had aneurysms when she started getting headaches in 2009.

Her primary care physician recommended she go see Dr. Adam Arthur at Semmes-Murphey where a scan of her brain revealed she had an aneurysm about the size of a pen hole on each side of her brain.

Determined too small to operate, Brown was seen every six months to a year to make sure there were no changes.

“Back in December of 2015, something shifted. I don’t know what, but they started growing,” Brown said.

The aneurysm on the right side of her brain grew to the size of a small fruit, and the first surgery was scheduled.

After Brown was put under anesthesia, Arthur, who is also the chief of neurosurgery at Methodist University Hospital, pinned her head to keep it still and cut an incision from behind her ear up to her hairline.

“She’s a beautiful woman and I didn’t want to do anything to her face,” he said.

He then cut a muscle near her temple and removed a piece of her skull, so he could go into her brain and insert a titanium clip to pinch the opening of the aneurysm. Arthur then put the skull back in and sewed her muscle and skin back together.

“I don’t want to criticize the work that was done on her because it’s my work and I’m proud of it, and she’s still a fully-functional person. She didn’t have a stroke, but for a patient,” Arthur said, “the difference between having that done, versus a little hole in her groin, you’re done, you go home the next day — if we can fix the aneurysm on the other side of her head without putting her through that, she prefers that.”

Brown was in the hospital for a week after the first surgery and in recovery for seven to eight months, undergoing both occupational and physical therapy. She had to go on short-term disability from her job as a human resources clerk at Memphis Light, Gas and Water Division, where she has worked for 13 years.

After the second procedure Monday, Brown, a born and raised Memphian who lives in South Memphis, was scheduled to go home within 72 hours.

“The time is nothing compared to three years ago,” she said.

After her first surgery, Arthur continued to monitor the aneurysm on the left side of Brown’s brain, while also working with Sequent Medical, a California-based medical device company, on a less invasive option.

Arthur had met two Sequent principals in 2011 after he gave a presentation at a medical conference in Europe.

They were Tom Wilder, president and CEO of Sequent Medical Inc., and Dr. Bill Patterson, who developed the Woven EndoBridge (WEB), an intravascular therapy for aneurysms.

They asked if he’d be the principal investigator on the clinical trial for WEB.

“No one had ever asked me to run an international trial at multiple, different centers,” Arthur said.

Arthur accepted and began what would be a more than five-year effort to perform the first FDA-approved surgery on Brown. The WEB has been available in Europe since 2010.

Methodist University Hospital was the first among the 27 clinical sites to enroll a patient, and Arthur was the first doctor to perform the surgery in August 2014. Those who enrolled in the clinical trial had a minimum year of follow up to make sure their aneurysms were fixed.

In September 2018, Arthur and Sequent Medical executives presented their findings to an FDA panel in Washington, D.C., who voted for the device’s approval.

When Brown was considering the WEB device for her second surgery, Arthur described the procedure and showed her a small woven metal basket that would fill her aneurysm and prevent it from rupturing.

The WEB is designed to treat aneurysms that occur at bifurcations or terminuses, where the artery splits into two other arteries and an aneurysm grows off the top.

“The arteries are God’s or nature’s own way of getting things to everywhere in your body, so you hop on the freeway and get to anywhere you need to go,” Arthur said.

Using a catheter inserted through either the groin or wrist, Arthur guides the WEB, a small sphere made out of woven metal fibers, to the aneurysm and blocks the blood flow to prevent a rupture that could cause a stroke.

“The results of the trial, which we’re getting ready to publish, are really good — 150 patients, an outstanding safety record and a very good effectiveness record,” Arthur said. “It’s ironic we did the first trial at (Methodist) University Hospital and the first commercial case right here at University Hospital in Memphis.”

The risk, like with the traditional method, is the potential for the aneurysm to rupture during the procedure, or for one of the arteries to be unintentionally blocked, resulting in stroke.

“That’s the risk with anything you do. If you’re sticking things in people’s brains you can screw it up,” Arthur said. “I speak from personal experience.”

More than 40 doctors from around the country are in Memphis watching the first procedures through a live-stream at the Medical Education & Research Institute (MERI) across the street, so they can learn how to perform the procedure.

The second set of cases will be performed beginning Thursday in New York and expand to other cities thereafter. There are about 100 surgeries scheduled in the next month.

Five doctors in the Methodist Le Bonheur Healthcare system are trained and available to perform the WEB procedure.

“I put my trust in God and then Dr. Arthur,” Brown said. “When I first got here (Monday) morning, I kept thinking about three years ago for some reason. I wasn’t fearful, but I kept thinking about how he wouldn’t have to go into my skull the way he did. I’m so grateful.”

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Often, chronic pain is invisible to those on the outside, which can make interactions difficult, especially when it flares without warning. This can include anything from arthritis or fibromyalgia to lyme disease. Just because others can’t see it doesn’t mean you don’t feel it.

We’ve put together a guide on how to travel if you’re living with chronic pain – which can be tension headaches, back or hip pain, knee replacements, and complications from surgery. We’ll cover what to pack, questions to ask, and much more.

Before the Trip: How to Pack for Travel When You Suffer From Chronic Pain

Giving yourself extra time to pack for traveling when you have chronic pain will help you prepare for your journey, and reduce stress because you’ll know you have everything you need to manage it.

Be sure to fill your prescriptions well before your trip, and have enough with you for the duration of your time away. Pack them in your carry-on bag (never in your checked luggage!) and put it within quick reach. Consider taking a small bag to carry with you throughout your entire journey, so they’ll always be close at hand.

Pack other helpful items like a heating pack, a neck pillow for long flights or train rides, and a good pair of shoes if you plan to do a lot of walking or sightseeing on your trip. Bring along a note from your doctor explaining your condition, and a list of the medications you’re taking, in case you need to show it for medical assistance or to get through the TSA checkpoint at the airport.

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Neuromodulation Devices in Migraine: The Latest

Migraine is a neurobiological disease characterized by episodic disabling attacks of moderate to severe head pain, associated with nausea and/or vomiting and light or sound sensitivity; it affects up to 12% of the US population. Untreated, attacks reduce an individual’s ability to function, creating a significant impact on work and family activities. Treatment to abate attacks is required by most patients, though studies show that only a portion of patients take medications to treat migraine attacks]. Up to 40% of people with migraine would benefit from additional treatment to reduce the frequency of migraine—ie, a preventive—but studies show that only 13% of people in the United States use migraine prevention measures. Treatment options for migraine vary from over-the-counter medications to prescription treatments. Prescription medications are often stopped due to lack of tolerance and poor efficacy as stated by patients.

Neuromodulation is a technique that employs stimulating the nervous system via electric currents or a fluctuating magnetic field to modulate pain pathways. This type of treatment can have an immediate effect, making it useful for aborting migraine attacks. Daily scheduled use can modulate the nervous system and allow for a preventive effect. Numerous devices have been studied for the acute and preventive treatment of migraine. They offer patients an option that is well tolerated and may be used for both acute and preventive needs in migraine. Here is an overview of available devices approved by the US Food and Drug Administration (FDA).

The Latest FDA-Approved Neuromodulation Devices

STS
Transcutaneous supraorbital nerve stimulation (STS), also known as Cefaly, was first studied as a preventive option in episodic migraine patients, with findings of reduction in headache days in participants with migraine. A larger study was conducted, showing that once-daily use of the device for 3 months resulted in 30% reduction in migraine days in the active group. The most frequent adverse event was paresthesia in the area of stimulation; it was mostly mild and reversible, although some participants found it intolerable.

STS has also been found effective for the acute treatment of migraine in a randomized controlled trial. An open-label trial of the use of STS for the prevention of chronic migraine has also shown reduction in headache days over 4 months with use of STS for 20 minutes per day.

sTMS
Single-pulse transcranial magnetic stimulation (sTMS) is delivered with a hand-held device that creates a fluctuating magnetic field which triggers an electric current that modifies cortical excitability. In the United States, it was first FDA-approved for acute use in patients with migraine with aura, based on a randomized controlled trial showing higher pain-free rates at 2 hours in the treatment versus sham group. A multicenter, open-label US study has shown sTMS to be beneficial in the prevention and acute treatment of episodic and chronic migraine. Treatment is well tolerated, with limited adverse events reported.

nVNS
Noninvasive vagal nerve stimulation (nVNS), commercially available as gammaCore, is known to be helpful in epilepsy and depression. It was incidentally noted that patients receiving invasive VNS were reporting reduced migraine attacks, though the mechanism for this is still unclear. nVNS has been FDA-approved for the acute treatment of episodic migraine. A randomized controlled trial of nVNS for the treatment of migraine attacks showed that it was well tolerated and produced higher pain-free and pain-relief rates at 2 hours compared with sham stimulation. It was also shown to have reproducible effects when used for multiple migraine attacks.

Limitations of Neuromodulation

There are multiple challenges that should be noted when evaluating the evidence for neuromodulation in the treatment of migraine. Studies were conducted on a relatively small number of participants. Using these results to generalize to a larger, less homogeneous population can be difficult. Maintaining blinding is another limitation of studies of neuromodulation; it is difficult to design a placebo-controlled study when you are using a device that may produce paresthesia. Sham devices need to produce some effect, but not significant enough to produce an improvement in symptoms. This could lead to difficulty maintaining blinding and lead to lower or higher placebo efficacy rates, depending on the sham device.

Cost may also be a challenge. At this time, there is limited insurance coverage for these devices in migraine. And while many devices have shown benefit in improving quality of life over time, which may possibly be translated to fewer missed work days and less need for prescription acute medications, it is often difficult for patients to take on direct costs at once.

While there are several challenges, neuromodulation can be a beneficial addition to a patient’s regimen. Patients who are overusing acute medications, patients who would like to limit the use of oral medications, or patients who have a partial response to therapeutic agents either for acute or preventive treatment are particularly good candidates for the use of neuromodulation. In clinical practice, neuromodulation is often used in women who are pregnant. Though not FDA indicated, it is considered safe, and patients often feel comfortable having an option that does not involve medications.

In conclusion, while studies showing beneficial effect of neuromodulation devices are small, they seem to indicate an improvement in severity of attacks and quality of life, and the possibility of improvement in frequency of attacks, with limited adverse events. At this time, it is difficult to determine cost/benefit for patients with migraine, and these considerations should be discussed when considering the use of neuromodulation in migraine.