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Extracorporeal Shock Wave Therapy as an Adjunct Wound Treatment: A Systematic Review of the Literature

Article (PDF Available) inOstomy/wound management 60(7):26-39 · July 2014with921 Reads
Source: PubMed
Robert Dymarek at Wroclaw Medical University
  • 20.69
  • Wroclaw Medical University
Tomasz Halski at Państwowa Medyczna Wyższa Szkoła Zawodowa w Opolu
  • 21.93
  • Państwowa Medyczna Wyższa Szkoła Zawodowa w Opolu
Kuba Ptaszkowski at Wroclaw Medical University
  • 16.61
  • Wroclaw Medical University
Jakub Taradaj at Akademia Wychowania Fizycznego im. Jergo Kukuczki w Katowicach
  • 28.63
  • Akademia Wychowania Fizycznego im. Jergo Kukuczki w Katowicach
Abstract
Standard care procedures for complex wounds are sometimes supported and reinforced by physical treatment modalities such as extracorporeal shock wave therapy (ESWT). To evaluate available evidence of ESWT effectiveness in humans, a systematic review of the literature was conducted using MEDLINE, PubMed, Scopus, EBSCOhost, and PEDro databases. Of the 393 articles found, 13 met the publication date (year 2000-2013), study type (clinical study), language (English only), and abstract availability (yes) criteria. The 13 studies (n = 919 patients with wounds of varying etiologies) included seven randomized controlled trials that were evaluated using Cochrane Collaboration Group standards. Only studies with randomization, well prepared inclusion/exclusion criteria protocol, written in English, and full version available were analyzed. An additional six publications reporting results of other clinical studies including a total of 523patients were identified and summarized. ESWT was most commonly applied once or twice a week using used low or medium energy, focused or defocused generator heads (energy range 0.03 to 0.25 mJ/mm2; usually 0.1 mJ/mm2), and electrohydraulic or electromagnetic sources. Few safety concerns were reported, and in the controlled clinical studies statistically significant differences in rates of wound closure were reported compared to a variety of standard topical treatment modalities, sham ESWT treatment, and hyperbaric oxygen therapy. Based on this analysis, ESWT can be characterized as noninvasive, mostly painless, and safe. Controlled, randomized, multicenter, blind clinical trials still are required to evaluate the efficacy and cost-effectiveness of ESWT compared to sham control, other adjunctive treatments, and commonly used moisture-retentive dressings. In the future, ESWT may play an important role in wound care once evidence-based practice guidelines are developed.
26 OSTOMY WOUND MANAGEMENT® july 2014 www.o-wm.com
FEATURE
Extracorporeal Shock Wave Therapy as
an Adjunct Wound Treatment:
A Systematic Review of the Literature
Robert Dymarek, PhD, PT; Tomasz Halski, PhD, PT; Kuba Ptaszkowski, PhD, PT; Lucyna
Slupska, PhD, PT; Prof. Joanna Rosinczuk, PhD, MSc; and Prof. Jakub Taradaj, PhD, PT
Abstract
Standard care procedures for complex wounds are sometimes supported and reinforced by physical treatment modali-
ties such as extracorporeal shock wave therapy (ESWT). To evaluate available evidence of ESWT effectiveness in hu-
mans, a systematic review of the literature was conducted using MEDLINE, PubMed, Scopus, EBSCOhost, and PEDro
databases. Of the 393 articles found, 13 met the publication date (year 2000 –2013), study type (clinical study), language
(English only), and abstract availability (yes) criteria. The 13 studies (n = 919 patients with wounds of varying etiolo-
gies) included seven randomized controlled trials that were evaluated using Cochrane Collaboration Group standards.
Only studies with randomization, well prepared inclusion/exclusion criteria protocol, written in English, and full version
available were analyzed. An additional six publications reporting results of other clinical studies including a total of 523
patients were identified and summarized. ESWT was most commonly applied once or twice a week using used low or
medium energy, focused or defocused generator heads (energy range 0.03 to 0.25 mJ/mm2; usually 0.1 mJ/mm2), and
electrohydraulic or electromagnetic sources. Few safety concerns were reported, and in the controlled clinical studies
statistically significant differences in rates of wound closure were reported compared to a variety of standard topical
treatment modalities, sham ESWT treatment, and hyperbaric oxygen therapy. Based on this analysis, ESWT can be
characterized as noninvasive, mostly painless, and safe. Controlled, randomized, multicenter, blind clinical trials still are
required to evaluate the efficacy and cost-effectiveness of ESWT compared to sham control, other adjunctive treatments,
and commonly used moisture-retentive dressings. In the future, ESWT may play an important role in wound care once
evidence-based practice guidelines are developed.
Keywords: extracorporeal shock wave therapy, soft tissue wounds, wound healing, physical therapy, systematic review
Index: Ostomy Wound Management 2014;60(7):26 39
Potential Conflicts of Interest: This systematic review was prepared as a theoretical part of the project funded by the
Polish National Science Centre allocated on the basis of decision no. DEC–2011/03/N/NZ7/00327.
Dr. Dymarek is a physical therapist and assistant, Department of Nervous System Diseases, University of Medicine in Wroclaw, Wroclaw, Poland. Dr. Halski is
a physical therapist and Head of Physiotherapy, Institute of Public Higher Professional Medical School, Opole, Poland. Dr. Ptaszkowski is a physical therapist
and assistant, Department of Gynecology and Obstetrics; Dr. Slupska is a physical therapist and assistant, Department of Physiotherapy; and Prof. Rosinczuk
is a nurse and Head of Department of Nervous System Diseases, University of Medicine. Prof. Taradaj is a physical therapist, Trustee of the European Pressure
Advisory Panel, and Head of Department of Physiotherapy Basics, Academy School of Physical Education, Katowice, Poland. Please address correspondence
to: Prof. Jakub Taradaj, Department of Physiotherapy Basics, Academy School of Physical Education in Katowice, Mikolowska 72 A Street, 40-065 Katowice,
Poland; email: j.taradaj@awf.katowice.pl.
Management of soft tissue wounds remains a medical
problem and a challenge, not only for internal medicine,
dermatology, trauma, surgery, and angiology specialists, but
also for physiotherapists in their daily rehabilitation practice.1
Chronic wounds are defined as wounds that have not pro-
ceeded toward healing in an orderly and timely (more than
3 months) fashion through tissue repair to reconstitute ana-
tomic and functional integrity.2 The most common types of
chronic wounds include venous leg ulcers (VLU), diabetic
foot ulcers (DFU), pressure ulcers (PU), and arterial insuf-
ficiency ulcers (AIU). Acute wounds involve sudden skin dis-
turbance and are expected to progress through the phases of
normal healing, resulting in wound closure. Acute wounds
include burn wounds (BW), postsurgical wounds (SW), and
post-traumatic wounds (TW).1,3,4
The primary aim in the treatment of these two pathologi-
cally distinct types of wounds is to promote tissue granula-
tion and reepithelialization to achieve wound closure. Wound
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EXTRACORPOREAL SHOCK WAVE THERAPY
care modalities for chronic wounds include offloading (when
the leg is involved), cleansing with sterile normal saline solu-
tion, surgical wound debridement, topical treatment (eg, an-
tiseptic silver-containing dressing, silver sulfadiazine cream),
antibiotic treatment, split-thickness skin grafting, and com-
pression therapy — gold standards for the treatment of soft
tissues that can be successfully supported and promoted us-
ing a variety of physical methods.5-8
Biophysical basics and clinical efficiency of extracor-
poreal shock wave therapy. Extracorporeal shock wave
therapy (ESWT) is an adjunct medical procedure aimed
to improve the skin condition of patients with chronic and
acute soft tissue wounds. ESWT is defined as a sequence of
biphasic, high-energy acoustic pulses that generate tran-
sient pressure disturbance and propagate rapidly in three-
dimensional space; this therapy is associated with a sudden
rise of pressure applied directly into tissues without any
damaging effect.9-11
ESWT utilizes two basic types of generators: radial and
focused. They differ in terms of shock wave propagation and
the physical characteristics of the energy. Radial ESWT is
produced by pneumatic devices located inside the generator
that create linear pressure with low energy values. The energy
is produced by the pressure wave, while compressed air ac-
celerates the cartridge strikes at the top of the applicator.12
The energy generated by the pressure wave is absorbed into
the skin approximately 3 cm deep and spreads a wider beam
to a larger target area (see Figure 1). Focused ESWT is gener-
ated by electromagnetic, electrohydraulic, and piezoelectric
sources. Pressure pulses rise rapidly in range of 10–100 MPa
and concentrate the acoustic energy beam with a penetration
depth of approximately 12 cm (see Figure 2).9,12,13
Some authors describe a third type of defocused ESWT:
an acoustic planar wave generated by electromagnetic and
electrohydraulic devices. It is characterized by lower energy
values delivered into the soft tissues and a superficial and
quite large (3–5 cm2) impact zone.14,15 ESWT types have been
differentiated on the basis of the level of energy applied at
the focal point per one pulse during treatment session — ie,
energy flux density (EFD), which is determined as low en-
ergy when <0.12 mJ/mm2 and high energy when >0.12 mJ/
mm2.13 Table 1 summarizes the basic characteristics of fo-
cused and radial ESWT.
Because of ESWT’s direct microtraumatic effects, the
possibility exists for bleeding, petechiae, hematoma and/or
seroma formation, and pain. A randomized, placebo-con-
trolled, single-blind, multicenter study16 conducted among
272 patients with lateral epicondylitis to analyze potential
side-effects after application of shock waves found transi-
tory reddening of the skin (21.1%), pain (4.8%), and small
hematomas (3.0%) most commonly occurred. Migraine was
registered in four and syncope in three instances after ESWT.
The possibility of migraine being triggered by ESWT and the
risk of syncope should be taken into account in the future.
Application of ESWT in general usage, including wound
treatment, can be performed with local anesthesia (LA).
However, two prospective, randomized, observer-blinded
pilot trials17,18 found ESWT is less effective when patients re-
ceived LA. Regardless of these initial findings, the use of LA is
justified, especially among patients who are unable to tolerate
the procedure because of pain during the ESWT session.19
Klonschinski el al’s20 randomized, clinical, nonblinded study
that included 20 healthy participants (10 male, 10 female;
mean age 27 years, range 17–36 years) investigated whether
the biological effects of ESWT differ between application
with and without LA. Focused ESWT (2,000 pulses) was per-
formed in three single sessions with different EFD levels: 0.06
mJ/mm2, 0.09 mJ/mm2, or 0.18 mJ/mm2. The results indicat-
ed that increasing EFD led to increasing pain (P <0.001). LA
reduced ESWT-related pain (P <0.02) and prevented an ES-
WT-related drop in the pressure pain threshold (P <0.001).
Presently, ESWT is deemed an effective and safe method
of treating a wide range of pathological, in particular muscu-
loskeletal, conditions.13,15,19 The list of indications for ESWT
treatment is continuously evolving and adapting to different
clinical fields, including chronic and acute soft tissue wounds.
Potential of ESWT mechanisms in animal wound heal-
ing. The potential of the therapeutic mechanisms and clini-
cal efficacy and safety of ESWT in musculoskeletal disorders
has been well investigated. Clinical investigations aimed at
achieving a positive effect in accelerating wound healing are
in the initial stages, but results are encouraging.
Animal model experiments14 illustrate ESWT for soft tis-
sue wound healing can promote positive molecular and im-
munochemical reactions focused on improving blood flow
microcirculation, activating anti-inflammatory response,
and enhancing the tissue regeneration process. In a random-
ized controlled study, Goertz et al21 analyzed the biological
Key Points
• Extracorporealshockwavetherapy(ESWT)isa
physical, adjunctive wound treatment modality.
• Theauthorsconductedasystematicliteraturereview
to evaluate the available evidence of clinical studies
using ESWT in the management of acute and chronic
wounds.
• Availableliterature,includingsevenrandomized
controlled clinical studies, suggests ESWT facilitates
healing compared to control treatments studied.
• Theauthorsconcludethatadditional,well-designed
controlled clinical studies are needed to confirm the
efficacy, evaluate the cost-effectiveness, and develop
evidence-based practice guidelines for the use of
ESWT in wound care.
Ostomy Wound Management 2014;60(7):26–39
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FEATURE
mechanisms of ESWT in blood flow enhancement in mice
with full-thickness burns (n = 51). The mice were random-
ized into five groups: burns but no ESWT (control group);
low-energy ESWT after burn injury (0.04 mJ/mm2); very
low-energy shock waves after burn injury (0.015 mJ/mm2);
mice without burns exposed to low-energy ESWT; and mice
without burns and with no ESWT application. ESWT was
performed on days 1, 3, and 7 (500 pulses, 1 Hz). Groups
receiving ESWT showed accelerated angiogenesis and an
increased number of rolling and sticking leukocytes in the
wound area (P = 0.005). The authors concluded shock waves
have a positive effect on several parameters of wound healing
after burns, especially with regard to angiogenesis and leuko-
cyte behavior. Moreover, shock waves increased the number
of rolling and sticking leukocytes as a part of an improved
metabolism in the healing process. However, obtained results
should be supported by clinical studies.
Results of a controlled experimental trial by Hayashi et
al22 determined that single low-energy ESWT (focused, 0.25
mJ/mm2, 100 pulses, 4 Hz) in diabetic mice (n = 32) with
skin wounds accelerated healing through the expression of
endothelial nitric oxide synthase (eNOS) and generation of
new vessels with the neovascularization process as an effect
of vascular endothelial growth factor (VEGF) activation (P
<0.05). The authors concluded these results raised the pos-
sibility that eNOS may be involved in the beneficial effects
of ESWT. In a controlled study, Kuo et al23 investigated the
effectiveness of ESWT in healing partial-thickness wounds
in the presence of diabetes mellitus among male rats (n =
50) divided into five groups: nondiabetic control, diabetic
control without ESWT, rats with one ESWT session on day 3
post-wounding, rats with two ESWT sessions on days 3 and
7, and rats with three ESWT sessions on days 3, 7, and 10.
ESWT was performed using 800 pulses at 0.09 mJ/mm2. The
authors confirmed significant VEGF and eNOS expression
and a determined promotion of proliferating cell nuclear
antigen (PCNA) associated with increased revascularization
and tissue regeneration in the ESWT-treated rats, especially
in the diabetic control without ESWT and one ESWT ses-
sion on day 3 post-wounding groups, as compared with the
control (P <0.01).
Moreover, several experimental model trials (total sample:
98 rats) suggest low-energy ESWT may promote cell prolif-
eration, increase collagen deposition, enhance granulation
Figure 1. Schematic illustration of wave propagation with physical characteristics of radial extracorporeal shock
wave therapy (ESWT).
Figure 2. Schematic illustration of wave propagation with physical characteristics of focused ESWT.
july 2014 OSTOMY WOUND MANAGEMENT® 29
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EXTRACORPOREAL SHOCK WAVE THERAPY
tissue formation, and improve blood supply through neovas-
cularization to the post-ischemic tissue zone of skin flaps.24-27
Another mechanism that may promote wound healing is
anti-inflammatory action by a quick increase of the neuronal
nitric oxide synthase (nNOS) activity and basal nitric oxide
(NO) production. An experimental trial conducted by Ciam-
pa et al28 examined the effect of ESWT (focused, 500 to 1,500
pulses at 0.03 mJ/mm2 and 0.11 mJ/mm2) on the modulation
of nNOS catalytic activity and NO production in rat glio-
ma C6 cells taken as a cellular model. The authors reported
ESWT rapidly increased NO production by enhancing cata-
lytic activity of nNOS, with the maximum effect achieved by
use of 500 pulses at 0.03 mJ/mm2 (P <0.005).
It has been speculated that ESWT increased the levels of
inflammatory cells — ie, pro-inflammatory cytokines and
proteases. In their randomized, placebo-controlled trial,
Davis et al29 investigated the role of ESWT on the early pro-
inflammatory response using a severe, full-thickness, highly
inflammatory cutaneous burn wound in a murine model (n
= 40). A single unfocused ESWT session was performed us-
ing 200 pulses at 0.01 mJ/mm2 and 5 Hz. In this case, ESWT
treatment significantly reduced the number of both infiltrat-
ing neutrophils and macrophages after injury. Furthermore,
expression of proinflammatory cytokines, chemokines. and
matrix metalloproteinases was globally suppressed (P <0.05).
In their controlled trial, Kuo et al30 used a random pattern,
extended dorsal skin flap rodent model that included male
rats (n = 36) divided into three groups: control group with-
out treatment (A), rats with one ESWT session immediately
after surgery (B), and rats with two ESWT sessions immedi-
ately and the day after surgery (C). ESWT was performed us-
ing 500 pulses at 0.15 mJ/mm2. Results indicated the necrotic
area in the flaps in group B was significantly smaller com-
pared with group A (P <0.01). The authors concluded the
action mechanisms of ESWT involved modulation of oxygen
radicals, attenuation of leukocyte infiltration, reduction of
tissue apoptosis, and recruitment of skin fibroblasts, which
results in increased flap tissue survival.
Some data suggest an ESWT source may be used to sup-
press the transforming growth factor-β1 (TGF-β1) and in-
crease the production of tissue granulation. In their con-
trolled experiment among 14 healthy horses with surgically
Table 1. Basic description of focused and radial extracorporeal shock wave therapy
fESWT=focused extracorporeal shock wave therapy; rESWT=radial extracorporeal shock wave therapy.
30 OSTOMY WOUND MANAGEMENT® july 2014 www.o-wm.com
FEATURE
created wounds, Link et al31 found ESWT treatment was as-
sociated with reduced TGF-β1 expression during the entire
study period compared to control wounds. Moreover, insu-
lin-like growth factor-1 (IGF-1) expression was significantly
increased for ESWT-treated and untreated wounds at 28 days
following wound creation, compared with findings on days 7,
14, 21, and 35 (P <0.05).
Inspired by the lack of relevant literature regarding a
clear and well-prepared algorithm, especially on wound
therapy using shock waves, a system-
atic review of the literature was con-
ducted to evaluate evidence of ESWT
effectiveness in humans.
Methods
Computer research of the following
databases was performed: MEDLINE,
PubMed, Scopus, EBSCOhost, and PE-
Dro. The main keywords used for selec-
tion purposes were: wound healing, ve-
nous leg ulcer, diabetic foot ulcer, pressure
ulcer, arterial insufficiency ulcer, burn
wound, post-traumatic wound, postsur-
gical wound, chronic wound, extracor-
poreal shock wave therapy, shock wave
treatment, focused shock wave (fESWT),
radial shock wave (rESWT), and defo-
cused shock wave (dESWT). Only articles
published between 2000 and 2013 that
involved clinical trials on human sub-
jects, written in English, and with full-
version available were included. Articles
published before 2000, based on animal
experiments, written in languages other
than English, and versions with only ab-
stracts were excluded. After completing
the first stage of selection based on the
main keywords, the abstracts of identi-
fied articles were assessed according to
the eligibility criteria.
For the purpose of evaluating study
methodological quality and validity, all
included publications were divided into
two groups: the first consisted of well-
designed randomized trials and the sec-
ond of other clinical trials.
All articles were assessed with re-
gard to study methodology (types of
wounds, patient characteristics, type of
treatment, parameters of ESWT), the
level of evidence (methods of random-
ization, patient allocation, blind inter-
vention, follow-up analysis), and the
results of treatment with ESWT (initial
wound size, duration of wound, results of ESWT sessions,
side effects after ESWT).
The findings were coordinated by an European Pressure
Advisory Panel (EPUAP) trustee. The research team was
composed of physical therapists, a nurse, a dermatologist,
and a vascular surgeon experienced in wound healing treat-
ment. The risk of bias was independently assessed with ac-
cordance to the guidelines for systematic reviews presented
by Cochrane Collaboration Group.
Figure 3. Literature search results.
Figure 4. Diagram of typical methodology of extracorporeal shock wave ther-
apy application in wound management.
july 2014 OSTOMY WOUND MANAGEMENT® 31
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EXTRACORPOREAL SHOCK WAVE THERAPY
Results
A total of 393 articles were found. Articles published be-
fore 2000 (n = 127), based on animal experiments (n = 90),
written in languages other than English (n = 73), and abstract
not available (n = 90) were excluded. No systematic reviews
and meta-analyses were found. Thirteen clinical trials32-44
were accepted for analysis and involved a total population of
919 patients. These studies included seven randomized con-
trolled trials (RCTs),32-38 one clinical controlled trial (CCT),39
three prospective clinical trials (PCTs),40-42 and two clinical
case reports (CCRs)43,44 (see Figure 3).
ESWT efficacy was evaluated in patients with chronic
VLU,39,40,42-44 DFU,33,34,37,39 PU,36,40,42 AIU,40,44 and acute BW,38,40-
42 TW,39,40,42 and SW in patients with coronary artery bypass
grafting (CABG)32 or split-thickness skin grafting (STSG).35 The
authors of the vast majority of analyzed studies designed them
with control groups that received standard wound care (SWC)
alone at a study facility,32,34,35,38,39 consisting of nonocclusive sur-
gical dressings and antibiotic treatment,32 application of topical
nonadherent silicone mesh and antiseptic gel,35 and wound de-
bridement and antiseptic silver dressing.34,38,39 The other con-
trol groups received SWC including offloading the affected
leg, wound cleansing with sterile normal saline solution,
and application of silver sulfadiazine cream combined with
hyperbaric oxygen therapy (HBOT)33,37 or received inactive
sham ESWT.36 In all the studies, participants received ESWT
plus SWC procedures supported by the administration of
additional antibiotics at the discretion of the treating physi-
cian. In all studies, the pre-ESWT wound dressing regimen
remained unchanged and was continued after each treat-
ment session.32-44
The Cochrane-based methodological quality45 of the re-
viewed, well-designed RCTs ranged between 8 and 15 points
(11.1 ± 3.13; median 10.0) out of a total of 16 points (the
more points, the higher quality of the study. See Table 2).
The studies received best scores in having similar groups at
baseline, regarding the most prognostic indicators (C),32-38
describing dropout rate and its acceptability (I),32-38 having
Figure 5. Example chart of extracorporeal shock wave therapy in wound healing.
32 OSTOMY WOUND MANAGEMENT® july 2014 www.o-wm.com
FEATURE
comparable timing of outcome assessment in all groups (J),32-
38 and including only one type of wound (M).32-38 In almost all
studies, the outcome assessor was blinded to the intervention
(F),32,33,35-38 and the duration of the study for at least 4 (O)33-38
or 10 (N)33-36,38 weeks was presented in seven and six reviewed
studies, respectively. In six studies, the described treatment
methods in the experimental and control groups were basi-
cally correspondent, with no co-interventions (G).33-38
On the other hand, the worst scores included lack of
blinding of a patient to the intervention (D)32-34,37 and care
provider (E),32-38 failure to include an intention-to-treat
analysis (K),32-34,37 and failure to achieve complete closure of
all wounds (P).32-34,36,37 Only three double-blind studies fea-
tured designs where patients (D)35,36,38 and outcome assessors
(F)35,36,38 were blinded to the intervention.
In three of the studies, methodological issues concerning
adequate methods of randomization (A)33,34 and concealing
the treatment allocation (B)32-34 remained unclear. In two
studied experiments, compliance to the intervention was
acceptable in all groups (H).33,34 In most studies, ESWT was
applied to at least 10 participants (L).32-35,37,38 Wounds com-
pletely closed in only two of the studies (P).35,38
Overall, four of the studies in this review were awarded
high scores of at least 10 points35,38 from the listed method-
ological quality criteria; three were of low quality, scoring
832,34 or 9 points.33 Three of the high-scoring studies addressed
SW, DFU, and BW, reporting complete epithelialization that
led to wound closure after 9.638 or 13.9 days35 of ESWT treat-
ment. In the lowest scoring of the four, which discussed PU,
the authors observed a healed area in 67.45% of the study
participants after a total of 6 to 8 weeks of ESWT treatment.36
Two of the low-quality studies featured DFU; their re-
sults showed a range of 31.0% to 53.5% completely healed
wounds in the ESWT groups, compared with 22.0% to 33.3%
in the controls.33,34 In the low-quality study that addressed
SW, the authors noted an improvement of wound healing,
indicated by better postoperative wound infection, includ-
ing additional treatment, presence of serous discharge, ery-
thema, purulent exudates, separation of deep tissue, isolation
of bacteria, and duration of inpatient stay (ASEPSIS) scores
and decreased necessity for antibiotic treatment.32
Evidence from well-designed RCTs (see Table 3 and Table
4). In Dumfarth et al’s32 controlled study, 100 patients were
randomly assigned to prophylactic low-energy ESWT (n =
50) or control without ESWT (n = 50). All consecutive par-
ticipants underwent CABG surgery and were receiving intra-
operative antibiotic treatment. A single session of ESWT was
performed at the site of vein harvesting immediately after the
wound was closed under sterile conditions using absorbable
subcutaneous sutures and staples. ESWT was generated by
an electromagnetic wave focusing source using an EFD at 0.1
mJ/mm2 at a frequency of 5 pulses per second (5 Hz), and
25 pulses per cm of wound length. Total ESWT treatment
time was 10 minutes. Ultrasonic transmission gel (USG) was
used as contact medium. The primary endpoint was to assess
wound healing quantified by score points including ASEPSIS.
Secondary endpoints were the need for surgical revisions of
the vein graft harvesting site and need for antibiotic treat-
ment of wound healing disturbances. Researchers noticed
lower ASEPSIS scores, indicative of improved wound heal-
ing, in patients receiving ESWT (4.4 ± 5.3) compared with
control group patients (11.6 ± 8.3) (P = 0.0001). Moreover,
ESWT was characterized by a significantly lower incidence of
wound healing disorders, with the necessity for antibiotic in-
tervention of 4%, compared with control of 22% (P = 0.015).
No significant differences in episodes of surgical revision of
the leg wound and no adverse events were observed.
In a randomized, single-blind, controlled study, Wang et al33
assessed ESWT efficacy in treating chronic DFU. Seventy-two
(72) patients were randomized to receive either ESWT (n = 34
out of 36 with DFU) or HBOT (control; n = 36 DFU). ESWT
was performed without anesthesia, and the DFU was covered
with sterile cellulose barrier. USG sterile gel was applied to the
area of skin in contact with the ESWT generator head. Focused
ESWT was provided every 2 weeks for a total of three treat-
ments over 6 weeks using an electrohydraulic shock wave de-
vice with an EFD at 0.11 mJ/mm2 and 300 + 100 pulses/cm2
of wound; the frequency was not documented. HBOT was
performed once a day, five times a week, for a total of 20 treat-
ments. All patients received the same local wound care regimen
that included wound cleansing and silver sulfadiazine cream.
At the end of the study (3 months), ESWT-treated wounds
healed completely in 31% of cases, improved in 58%, and were
unchanged in 11%, compared to 22% completely healed, 50%
improved, and 28% unchanged after HBOT (P = 0.001). Sig-
nificant improvement was noted in the local blood flow perfu-
sion (P = 0.04) of persons in the ESWT group, compared with
the results of the HBOT group (P = 0.30). Bacteriostatic effect
was documented in both ESWT and HBOT patients. Histo-
morphological examination of the biopsy specimens showed
lower cell concentration and less cell proliferation and activity
after HBOT (P = 0.42) as compared to ESWT (P = 0.002). Im-
munohistochemical analysis showed a significant increase in
eNOS (P <0.001), VEGF (P <0.001), and PCNA (P = 0.005), as
well as a lower expression of transference-mediated digoxigen-
in-deoxy-uridine-triphosphate nick end-labeling (TUNEL)
(P <0.001) in the ESWT than in the HBOT group (P >0.05).
Authors did not observe any adverse events and complications
following ESWT.
In a prospective, randomized, controlled trial, Moretti
et al34 studied 30 persons with neuropathic DFU; 15 were
treated with SWC and ESWT and 15 received SWC alone.
No local anesthetic was used during ESWT treatment,
which was generated by a focused electromagnetic ESWT
applicator using an EFD at 0.03 mJ/mm2 and 100 pulses/
cm2 of wound; the frequency was not described. ESWT pro-
tocol consisted of one session every 72 hours, resulting in
a total of three treatments in 9 days. Each ESWT session
july 2014 OSTOMY WOUND MANAGEMENT® 33
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EXTRACORPOREAL SHOCK WAVE THERAPY
lasted <1 to 2 minutes. Researchers noted complete DFU
closure in 53.33% of the ESWT-treated patients, compared
with 33.33% patients in the control group; the healing time
was also shorter for ESWT patients (60.8 ± 4.7 days) com-
pared to controls (82.2 ± 4.7 days) (P <0.001). Significant
improvement of the re-epithelialization index was observed
among the ESWT group (2.97 ± 0.34 mm2/die) and control
patients (1.30 ± 0.26 mm2/die) (P <0.001). Some adverse ef-
fects (eg, symptoms of local infection) were noted, and oral
antibiotics were prescribed. Two patients, one in each group,
developed complications that resolved within 5 to 7 days, and
the patients were allowed to remain in the study.
In a randomized, prospective, double-blind trial, Ot-
tomann et al35 enrolled 28 patients with acute traumatic
wounds and burns at a minimum size of 200 cm2 that re-
quired STSG. All participants were blinded and randomized
to either a group receiving (n = 13) or not receiving ESWT
(n = 15). In both groups, graft donor sites were treated with
SWC. A single session of ESWT was performed immediately
after STSG harvest and delivered intraoperatively on the do-
nor site of the anesthetized patient. ESWT was generated by
a defocused electrohydraulic source using an EFD at 0.1 mJ/
mm2 and 100 pulses/cm2 of donor site surface area; the fre-
quency was not documented. The total average ESWT time
was 13 minutes. Sterile USG-conducting gel applied onto
a sterile plastic drape was used as a contact medium. The
primary outcome was time to complete donor site healing,
defined as >95% reepithelialization. Average hospitalization
time was 15 days, with a follow-up period of 12 weeks after
hospital discharge. All donor sites healed, but significantly
faster reepithelialization was documented in the ESWT (13.9
± 2.0 days) than in the control group (16.7 ± 2.0 days) (P =
0.0001). No post-ESWT related complications were noted in
the control group.
Larking et al36 conducted a double-blind, randomized,
cross-over study, with a population of nine severely disabled
patients with chronic PU. All study participants were ran-
domly allocated by a blinded assessor to active or placebo
ESWT. Three weeks of observation with weekly measure-
ments was conducted before the start of the interventions.
After 6 weeks, including a 2-week washout phase, the ESWT
group and sham ESWT group were swapped. In both groups,
SWC was continued. ESWT treatment was generated by a de-
focused electrohydraulic system using an EFD at 0.1 mJ/mm2
and 200 + 100 pulses/cm2 of PU area at a frequency of 5 Hz.
ESWT protocol for both phases of active and sham ESWT
consisted of one session every week, resulting in a total of
four treatments during 4 weeks. Sterile USG gel was applied
to the clean wound and the surface of the ESWT applicator
head, and a sterile drape was placed on the wound site. Re-
sults indicated improved healing in all patients with chronic
PU without any significant differences between groups, re-
gardless of commencing the study with active (67.45% av-
erage healed area) or sham ESWT (64.25% average healed
area). A statistically significant difference was observed be-
tween the period of PU improvement following the start of
ESWT after 8 weeks in the ESWT-first study group and after
6 weeks in the sham-first study group (P <0.05). Authors de-
scribed an enlargement of three PU during ESWT phase, two
of which were previously classified for surgical debridement
that was not necessary after ESWT. Authors hypothesized the
ESWT seemed to heal wounds more rapidly by causing the
tissue with poor viability to break down.
In a prospective, open-label, randomized, single-blinded
study, Wang et al37 randomized 77 patients with chronic DFUs
into an ESWT (n = 39 out of 44 DFU) and an HBO treatment
group (n = 38 out of 40 DFU). ESWT was performed without
anesthesia, and the DFUs were covered with a sterile cellulose
barrier. USG sterile gel was applied to the area of skin in con-
tact with the ESWT generator head. ESWT was generated by
a defocused electromagnetic applicator using an EFD at 0.23
mJ/mm2 and 500 pulses/cm2 of wound, with the frequency at
4 pulses per second (4 Hz). ESWT sessions were performed
twice per week for a total of six treatments over 3 weeks. In
the control group, HBOT was performed once a day, five ses-
sions a week, resulting in a total of 40 treatments. All patients
in both groups received basically the same local wound care
protocol, which included wound cleansing and silver sulfa-
diazine cream application, with a possibility of administer-
ing antibiotic treatment. After 3 weeks, 57% of wounds in
the ESWT and 25% of wounds in the HBOT groups were
completely healed (P = 0.003). Wounds in 32% of ESWT and
15% of HBOT group were improved (P = 0.071). No signifi-
cant differences in improvement of local blood flow perfu-
sion were noted between groups (P = 0.245), but the change
from baseline in the ESWT group was significant (P = 0.002).
Histopathological examination of biopsy samples showed
lower cell apoptosis and higher cell proliferation, concentra-
tion, and activity in the ESWT group, but no statistics were
reported. No systemic or local neurovascular adverse events
were noted.
A randomized, controlled, double-blind clinical study was
conducted by Ottomann et al38 among 44 burn patients with
superficial second-degree BWs. The study participants were
randomized to ESWT (n = 22) or no ESWT intervention (n
= 22). All patients were blinded to treatment allocation and
analyzed as intent-to-treat. Patient median total body sur-
face area (TBSA) involved by thermal injury was 3% (range
1%–8%) in the ESWT and 4% (range 1%–50%) in the con-
trol group. Participants in the ESWT group were significantly
older (average age 52.2 ± 16.6 years) than participants in the
control group (average age 37.5 ± 13.3 years) (P = 0.002).
A single session of ESWT was performed with a defocused
electrohydraulic device using an EFD at 0.1 mJ/mm2 and 100
pulses/cm2 of BW area at a frequency of 5 Hz. Sterile USG
gel was applied onto a sterile plastic drape placed over the
wound, which also was covered with USG gel. The primary
endpoint — reepithelialization >95% — was assessed by an
34 OSTOMY WOUND MANAGEMENT® july 2014 www.o-wm.com
FEATURE
independent, blinded observer. All BWs were healed after an
average 11.0 ± 2.4 days; 9.6 ± 1.7 days in the ESWT and 12.5
± 2.2 days in the control group (P <0.0005). Infections were
noted in 9% of ESWT and 14% of control group patients.
Evidence obtained from other clinical studies (see Table
5 and Table 6). Saggini et al39 conducted a controlled clini-
cal study among 40 patients with VLUs, DFUs, and TW. All
study participants were allocated to either a SWC and ESWT
group (n = 30 out of 32 wounds) or a SWC only control group
(n = 10 out of 10 wounds). No general or local anesthesia or
other injections were used during the ESWT treatment, which
was performed with a focused electrohydraulic system using
an EFD at 0.037 mJ/mm2 and 100 pulses/cm2 of each wound
area at a frequency of 4 Hz. The ESWT protocol consisted
of one session per 2 weeks, resulting in a total of four to 10
sessions. A single-layer sterile gauze was placed on the USG
gel, which was applied to the wound surface and the ESWT
applicator head. Researchers recorded the following results
for the ESWT sessions and control procedures, respectively:
complete wound closure 53.3% and 10.0%, reduced necrotic
fibrin 30.7% and 12.5%, and post-treatment wound area de-
creased from 10.41 cm2 to 2.03 cm2 (P <0.01). Additionally,
the authors determined greater improvement in granulation
tissue among 30.7% of ESWT recipients compared to worsen-
ing among 7.5% of patients from the control group (P <0.01).
Most improvements were noted following the first four to six
ESWT sessions. No complications or side effects such as mi-
crotraumatic effect, bleeding, hematomas, sarcomas, or pain-
ful sensations were documented after ESWT sessions.
Schaden et al40 prospectively enrolled 208 patients with
etiologically different nonhealing wounds: SW (n = 82), TW
(n = 67), VLU (n = 14), PU (n = 7), AIU (n = 6), and BW (n
= 7). ESWT was applied via defocused electrohydraulic gen-
erator using an average dosage of EFD at 0.01 mJ/mm2 and
100 pulses/cm2 depending on the wound area at a frequency
of 5 Hz. An ESWT session was performed once every 2 weeks,
resulting in a total of one to 10 treatment sessions. A plastic
drape covered with sterile USG coupling gel was used after
necrotic tissue was removed. ESWT was the primary wound
therapy performed with adjunctive SWC management. Of
the 176 patients who completed the study, 156 (88.6%) had
completely healed wounds. Mean period of ESWT stimula-
tion needed for complete epithelialization was 43.5 days.
Complete wound closure was significantly associated with
the wound area in 81.0% and 61.8% of the patients with 10
cm2 and >10 cm2 wound area, respectively (P = 0.005). Also,
Table 2. Randomized, controlled clinical study criteria and assessment results45
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EXTRACORPOREAL SHOCK WAVE THERAPY
complete tissue epithelialization was significantly associated
with wound duration in 83.0% and 57.1% of completely
healed participants with 1 month and >1 month duration,
respectively (P <0.001). Wound epithelialization improved in
81.0% of acute and 56.3% of chronic wounds (P = 0.001). Re-
searchers did not report any adverse events following ESWT.
In a clinical, observational, prospective pilot study by Arno
et al41 involving patients with acute BW <5% TBSA (N = 15),
participants were provided ESWT on the third and fifth post-
burn accident day. ESWT was performed with a defocused
electrohydraulic machine using an EFD at 0.15 mJ/mm2 and
500 pulses/cm2 of BW area, with unspecified frequency values.
ESWT sessions were provided twice a week, resulting in a total
of two treatment sessions in sterile conditions, without anesthe-
sia or antibiotics. Some potential adverse events — eg, bleeding,
hematomas, petechiae, and painful sensations — were docu-
mented. Researchers documented 80% of patients completely
healed after 3 weeks of ESWT treatment, but 15% required sur-
gical debridement and grafting and 5% displayed hypertrophic
scarring after burn healing. Additionally, blood perfusion levels
in laser Doppler imaging were enhanced after a single session of
ESWT (P value not reported). Authors did not describe any side
effects or adverse events, and the patients tolerated ESWT well.
Wolf et al42 performed an open, prospective clinical study
among 282 patients with various chronic soft tissue wounds
who received ESWT stimulation in conjunction with SWC
procedures. Participants included 93 SW (36.1%), 83 TW
(33.3%), 38 VLU (14.7%), 13 DFU (5%), 11 AIU (4.3%),
nine PU (3.5%), and eight BW (3.1%) patients. ESWT was
performed with a defocused electrohydraulic device using an
EFD at 0.1 mJ/mm2 and median number of 167 pulses/cm2
at a frequency of 5 Hz. ESWT sessions were performed one
to two times every 2 weeks, resulting in a total of <10 treat-
ment sessions. To improve skin contact, the USG sterile gel
was placed on the wound surface and covered with a surgical
drape. SWC was systematically continued in all patients after
each ESWT session. Authors reported 24 participants lost to
follow-up. The majority of patients (74.03%) demonstrated
complete wound closure after SWC plus ESWT after a me-
dian time of 31.8 months and two treatment sessions. No side
effects or tissue damage following ESWT were documented.
Fioramonti et al,43 who published the first clinical case re-
port, saw positive results of ESWT in the treatment of a VLU
in a 63-year-old patient with chronic venous insufficiency
(CVI) and two ulcers on the right leg (3 cm2 on the external
malleolar region and 8 cm2 on the medial pretibial region)
Table 3. Extracorporeal shock wave therapy methods used in randomized, controlled trials
SW=postsurgical wound; CABG= coronary artery bypass grafting; STSG=split-thickness skin grafting; DFU=diabetic foot ulcer; PU=pressure ulcer;
BW=burn wound; ESWT= extracorporeal shock wave therapy; SWC=standard wound care; HBO=hyperbaric oxygen therapy
36 OSTOMY WOUND MANAGEMENT® july 2014 www.o-wm.com
FEATURE
and one on the left leg (6 cm2 on the medial pretibial region).
Only the VLUs on the right leg were treated with ESWT; the
left leg was designated the control and managed with SWC.
ESWT was performed with a focused electrohydraulic source
using an EFD at 0.037 mJ/mm2 and median number of 100
pulses/cm2 at a frequency of 4 Hz. ESWT sessions were pro-
vided once a week, amounting to a total of six treatment ses-
sions. Complete VLU healing of the right extremity wound
was reported after six ESWT treatment sessions and com-
pared with a 6-week period of SWC on the left VLU, where
healing was still incomplete. Researchers did not document
any complications and adverse events after ESWT sessions.
The case report by Stieger et al44 evaluated the efficiency
of ESWT in a case of a 56-year-old patient with secondary
lymphedema, class III morbid obesity, and a VLU of at least
6-years’ duration characterized by a severely fibrotic, partially
fibrin-coated ulcer of 150 cm2 total wound area exhibiting
minimal granulation, severe perifocal reddening, and macer-
ation that extended from the pretibial part of the right lower
leg to the lateral calf. Various treatments had been provided,
including surgical procedures, compression therapy, nega-
tive pressure therapy, and wound dressings. Sterile USG con-
ducting gel was applied to a cleaned wound and covered with
polyurethane film. To improve ESWT transmission, USG gel
was applied on that film again. ESWT was performed with a
defocused electromagnetic generator using an EFD at 0.25 mJ/
mm2 and 10 pulses/cm2 at a frequency of 4 Hz to a total area
of 200 cm2 (150 cm2 of VLU area plus the wound margins).
ESWT sessions were performed once a week as an adjuvant
therapy; SWC procedures remained unchanged for the dura-
tion. After five ESWT sessions, wound granulation and reepi-
thelialization improved, and complete wound closure was ob-
served after a total of 30 ESWT sessions. No adverse events or
pain were reported during ESWT.
Discussion
The purpose of this study was to evaluate evidence of
ESWT effectiveness in humans. Results of the systematic lit-
erature review suggest there is substantial published evidence
documenting that ESWT application is safe and effective for
the treatment of different etiologically soft tissue wounds.
In the analyzed studies, ESWT was used to facilitate heal-
ing of chronic DFU,33,34,37,39 PU,36,40,42 VLU,39,40,42-44 and AIU
wounds,40,42 as well as acute wounds involving BW,38,40-42
TW,39,40,42 and SW resulting from CABG32 or STSG proce-
dures.35 ESWT applied to soft tissue wounds produced a wide
Table 4. Summary of randomized, controlled clinical studies
RCT=randomized controlled trial; SB=single-blind; DB= double-blind; SW-postsurgical wound; CABG=coronary artery bypass grafting; STSG-split-thick-
ness sk in graf ting ; DFU= diabetic foot ulcer; PU =press ure ulc er; BW= bur n wound; ESWT= extracorporeal s hock wave therapy ; SWC= standard wound
care; HBO=hyperbaric oxygen therapy
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EXTRACORPOREAL SHOCK WAVE THERAPY
variety of positive results, including complete wound closure
and reepithelialization,33-35,36-44 improvement of blood flow
perfusion,33,37,41 enhancement of tissue granulation, reduction
of necrotic fibrin tissue,39,44 shortened period of wound treat-
ment,35,38,43 and decreased necessity for antibiotic treatment.32
Better results were reported for patients who received
additional ESWT treatment sessions in contrast to SWC
alone,32,34,35,38,39,43 HBOT concomitant to adjunctive SWC,33,37
or sham ESWT sessions.38 Most studies reported no or few ad-
verse events or complications.32,33,35,37-44 Adverse events and side
effects documented following ESWT included signs of ulcer
infections34,38 and enlarged wounds with ischemic edges.36
In most of the studies reviewed, ESWT treatment sessions
were performed without hospitalization and without anes-
thesia.33,37,39,41,43 Methodological similarities included ensur-
ing sterile conditions and use of a sterile ultrasonic gel as
contact medium and the use of a sterile barrier: a sterile USG
gel was applied to a cleaned wound to improve transmis-
sion of acoustic ESWT waves and/or the wound was covered
with sterile barrier in the form of cellulose33,37,39 or plastic
drape.32,34,35,38-40,44 Also, the same USG gel was applied onto
the drape as a medium to provide full skin contact. In many
studies, the ESWT applicator head was placed directly over
the surface of the wound32-44 (see Figure 4).
All of the reviewed studies used low- and medium-energy
ESWT treatment, with the shock waves generated with elec-
trohydraulic33,35,36,38-43 or electromagnetic sources.32,34,37,44 Two
types of ESWT generator heads were generally used: defo-
cused35-38,40-42,44 or focused.32-34,39,43 The EFD in the studied
cases was characterized by a range from 0.03 to 0.25 mJ/mm2
(0.11 ± 0.07 mJ/mm2)34,44 but the most regular value of EFD
was 0.1 mJ/mm2.32,33,35,36,38,40,42
The frequency was set at 436,39,43,44 or 5 pulses per second
(Hz)32,37,38,40,42; however, a few of the studies did not describe
that parameter.33-35,42 In most studies, the number of pulses
in a single ESWT session ranged from 10 to 500 pulses/cm2
(206.4 ± 172.3 pulses/cm2),41,44 but the most frequent value
was 100 pulses/cm2 of wound area.34,35,38-41,43
Table 5. Extracorporeal shock wave therapy methods used in non-randomized clinical studies
VLU=venous leg ulcer; TW= post-traumatic wound; DFU=diabetic foot ulcer; DHW=disturbed healing wound; PU=pressure ulcer; AIU=arterial insuffi-
ciency ulcer; BW=burn wound; SW=postsurgical wound; ESWT=extracorporeal shock wave therapy; SWC=standard wound care
38 OSTOMY WOUND MANAGEMENT® july 2014 www.o-wm.com
FEATURE
According to the review of clinical research studies, in
the case of chronic wounds ESWT sessions were typically
once36,42-44 or twice per week,34,37,41 as well as once every 2
weeks.33,39,40,42 The total number of treatment sessions ranged
between three33,34 and six.37,43 However, in some studies
ESWT therapy was continued for a longer period (1039,40,42
to 30 sessions44). In studies that included patients who had
presented with acute SWs, a single intraoperative session of
ESWT treatment was applied.32,35
The average time of a single ESWT session was 1 to 3 min-
utes, depending on the size of the wound.34,36,39-42 The dura-
tion of a single intraoperative ESWT session in the case of
acute wounds ranged between 1032 to 13 minutes.35 An out-
line of ESWT application for wound treatment with regard to
the methodological and practical issues, as well as biological
effects and potential therapeutic properties, is presented in
Figure 5.
Conclusions
The results of this literature review suggest ESWT can be
used as an adjunct therapy for healing chronic and acute soft tis-
sue wounds. Substantial supporting clinical evidence confirms
ESWT utility and the range of positive results, such as completed
wound closure and reepithelialization, enhanced tissue granula-
tion, reduced necrotic fibrin tissue, improved blood flow perfu-
sion and angiogenesis, reduced period of total wound treatment,
and decreased necessity of antibiotic treatment.
Nevertheless, additional well-designed clinical studies and
meta-analyses are necessary to investigate ESWT safety, ef-
ficacy, and cost-effectiveness in patients suffering from wide
range of skin wounds. Despite the results obtained from
well-designed studies showing positive wound healing out-
comes, further studies should address methodological study
shortcomings such as adequate methods of randomization,
concealment of treatment allocation, and clear information
about blinding, as well as inclusion of intent-to-treat and
follow-up analysis.
Sham-controlled, randomized, multicenter, blinded clini-
cal trials with the highest methodological quality and scien-
tific data reliability are needed to ascertain ESWT efficacy
and develop explicit evidence-based guidelines and recom-
mendations. The results of this study show ESWT can be
characterized as a noninvasive, painless, and safe physical
treatment modality that seems beneficial in healing soft tis-
Table 6. Summary of non-controlled clinical studies
CCT=controlled clinical trial; PCT=prospective clinical trial; CCR,=clinical case report; VLU=venous leg ulcer; TW=post-traumatic wound; DFU= diabetic
foot ulcer; DHW= disturbed healing wound; PU=pressure ulcer; AIU=ar terial insufficiency ulcer; BW=burn wound; SW=postsurgical wound;
ESWT=extracorporeal shock wave therapy; SWC=standard wound care; TBSA=total body surface area
july 2014 OSTOMY WOUND MANAGEMENT® 39
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EXTRACORPOREAL SHOCK WAVE THERAPY
sue wounds. In the future, ESWT may play an important role
in wound care; however, evidence-based practical guidelines
should be developed first. n
Acknowledgments
The authors acknowledge this systematic review was pre-
pared as a theoretical part of the project funded by the Polish
National Science Centre allocated on the basis of decision no.
DEC–2011/03/N/NZ7/00327.
References
1. Jones KR, Fennie K, Lenihan A. Evidence-based management of chronic
wounds. Adv Skin Wound Care. 2007;20(11):591–600.
2. Werdin F, Tenenhaus M, Rennekampff HO. Chronic wound care. Lancet.
2008;372(9653):1860–1862.
3. Lo SF, Hu WY. The principles of chronic wound assessment and measure-
ment. Hu Li Za Zhi. 2007;54(2):62–67.
4. Demidova-Rice TN, Hamblin MR, Herman IM. Acute and impaired wound
healing: pathophysiology and current methods for drug delivery, part 1: nor-
mal and chronic wounds: biology, causes, and approaches to care. Adv Skin
Wound Care. 2012;25(7):304–314.
5. Thakral G, LaFontaine J, Najafi B, Talal TK, Kim P, Lavery LA. Electrical stimu-
lation to accelerate wound healing. Diabet Foot Ankle. 2013. doi: 10.3402/dfa.
v4i0.22081.
6. Herberger K, Franzke N, Blome C, Kirsten N, Augustin M. Efficacy, toler-
ability and patient benefit of ultrasound-assisted wound treatment ver-
sus surgical debridement: a randomized clinical study. Dermatology.
2011;222(3):244–249.
7. Taradaj J, Franek A, Brzezinska-Wcislo L, Cierpka L, Dolibog P, Chmielewska
D, et al. The use of therapeutic ultrasound in venous leg ulcers: a randomized,
controlled clinical trial. Phlebology. 2008;23(4):178–83.
8. Franek A, Kostur R, Polak A, Taradaj J, Szlachta Z, Blaszczak E, et al. Us-
ing high-voltage electrical stimulation in the treatment of recalcitrant pressure
ulcers: results of a randomized, controlled clinical study. Ostomy Wound Man-
age. 2012;58(3):30–44.
9. Shrivastava SK, Kailash. Shock wave treatment in medicine. J Biosci.
2005;30(2):269–275.
10. Xin ZC, Liu J, Wang L, Li HX. Progress of low-energy shockwave therapy in
clinical application. Beijing Da Xue Xue Bao. 2013;45(4):657–660.
11. Qureshi AA, Ross KM, Ogawa R, Orgill DP. Shock wave therapy in wound
healing. Plast Reconstr Surg. 2011;128(6):721e–727e.
12. Mittermayr R, Antonic V, Hartinger J, Kaufmann H, Redl H, Téot L, et al. Extra-
corporeal shock wave therapy (ESWT) for wound healing: technology, mecha-
nisms, and clinical efficacy. Wound Repair Regen. 2012;20(4):456–465.
13. Speed C. A systematic review of shockwave therapies in soft tissue condi-
tions: focusing on the evidence. Br J Sports Med. 2013. doi: 10.1136/bjs-
ports-2012-091961.
14. Notarnicola A, Tamma R, Moretti L, Fiore A, Vicenti G, Zallone A, et al. Effects
of radial shock waves therapy on osteoblasts activities. Musculoskelet Surg.
2012;96(3):183–189.
15. Romeo P, Lavanga V, Sansone V. Clinical application of extracorporeal shock
wave therapy in musculoskeletal disorders: a review. Altern Integ Med. 2013.
doi: 10.4172/2327-5162.1000109.
16. Haake M, Böddeker IR, Decker T, Buch M, Vogel M, Labek G, et al. Side-
effects of extracorporeal shock wave therapy (ESWT) in the treatment of ten-
nis elbow. Arch Orthop Trauma Surg. 2002;122(4):222–228.
17. Labek G, Auersperg V, Ziernhöld M, Poulios N, Böhler N. Influence of lo-
cal anesthesia and energy level on the clinical outcome of extracorporeal
shock wave-treatment of chronic plantar fasciitis. Z Orthop Ihre Grenzgeb.
2005;143(2):240–246.
18. Rompe JD, Meurer A, Nafe B, Hofmann A, Gerdesmeyer L. Repetitive low-
energy shock wave application without local anesthesia is more efficient than
repetitive low-energy shock wave application with local anesthesia in the
treatment of chronic plantar fasciitis. J Orthop Res. 2005;23(4):931–941.
19. Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J
Orthop Surg Res. 2012. doi: 10.1186/1749-799X-7-11.
20. Klonschinski T, Ament SJ, Schlereth T, Rompe JD, Birklein F. Application of lo-
cal anesthesia inhibits effects of low-energy extracorporeal shock wave treat-
ment (ESWT) on nociceptors. Pain Med. 2011;12(10):1532–1537.
21. Goertz O, Lauer H, Hirsch T, Ring A, Lehnhardt M, Langer S, et al. Extracor-
poreal shock waves improve angiogenesis after full thickness burn. Burns.
2012;38(7):1010–1018.
22. Hayashi D, Kawakami K, Ito K, Ishii K, Tanno H, Imai Y, et al. Low-energy
extracorporeal shock wave therapy enhances skin wound healing in diabetic
mice: a critical role of endothelial nitric oxide synthase. Wound Repair Regen.
2012;20(6):887–895.
23. Kuo YR, Wang CT, Wang FS, Chiang YC, Wang CJ. Extracorporeal shock-
wave therapy enhanced wound healing via increasing topical blood perfusion
and tissue regeneration in a rat model of STZ-induced diabetes. Wound Re-
pair Regen. 2009;17(4):522–530.
24. Yan X, Yang G, Cheng L, Chen M, Cheng X, Chai Y, et al. Effect of extracorpo-
real shock wave therapy on diabetic chronic wound healing and its histologi-
cal features. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2012;26(8):961–967.
25. Huemer GM, Meirer R, Gurunluoglu R, Kamelger FS, Dunst KM, Wanner S,
et al. Comparison of the effectiveness of gene therapy with transforming
growth factor-beta or extracorporeal shock wave therapy to reduce isch-
emic necrosis in an epigastric skin flap model in rats. Wound Repair Regen.
2005;13(3):262–268.
26. Kuo YR, Wu WS, Hsieh YL, Wang FS, Wang CT, Chiang YC, et al. Extracor-
poreal shock wave enhanced extended skin flap tissue survival via increase
of topical blood perfusion and associated with suppression of tissue pro-
inflammation. J Surg Res. 2007;143(2):385–392.
27. Mittermayr R, Hartinger J, Antonic V, Meinl A, Pfeifer S, Stojadinovic A, et al.
Extracorporeal shock wave therapy (ESWT) minimizes ischemic tissue necro-
sis irrespective of application time and promotes tissue revascularization by
stimulating angiogenesis. Ann Surg. 2011;253(5):1024–1032.
28. Ciampa AR, de Prati AC, Amelio E, Cavalieri E, Persichini T, Colasanti M, et
al. Nitric oxide mediates anti-inflammatory action of extracorporeal shock
waves. FEBS Lett. 2005;579(30):6839–6845.
29. Davis TA, Stojadinovic A, Anam K, Amare M, Naik S, Peoples GE, et al. Extra-
corporeal shock wave therapy suppresses the early proinflammatory immune
response to a severe cutaneous burn injury. Int Wound J. 2009;6(1):11–21.
30. Kuo YR, Wang CT, Wang FS, Yang KD, Chiang YC, Wang CJ. Extracorporeal
shock wave treatment modulates skin fibroblast recruitment and leukocyte
infiltration for enhancing extended skin-flap survival. Wound Repair Regen.
2009;17(1):80–87.
31. Link KA, Koenig JB, Silveira A, Plattner BL, Lillie BN. Effect of unfocused ex-
tracorporeal shock wave therapy on growth factor gene expression in wounds
and intact skin of horses. Am J Vet Res. 2013;74(2):324–332.
32. Dumfarth J, Zimpfer D, Vögele-Kadletz M, Holfeld J, Sihorsch F, Schaden W,
et al. Prophylactic low-energy shock wave therapy improves wound healing
after vein harvesting for coronary artery bypass graft surgery: a prospective,
randomized trial. Ann Thorac Surg. 2008;86(6):1909–1913.
33. Wang CJ, Kuo YR, Wu RW, Liu RT, Hsu CS, Wang FS, et al. Extracorpo-
real shockwave treatment for chronic diabetic foot ulcers. J Surg Res.
2009;152(1):96-103
34. Moretti B, Notarnicola A, Maggio G, Moretti L, Pascone M, Tafuri S, et al. The
management of neuropathic ulcers of the foot in diabetes by shock wave
therapy. BMC Musculoskelet Disord. 2009. doi: 10.1186/1471-2474-10-54.
35. Ottomann C, Hartmann B, Tyler J, Maier H, Thiele R, Schaden W, et al.
Prospective randomized trial of accelerated re-epithelization of skin graft
donor sites using extracorporeal shock wave therapy. J Am Coll Surg.
2010;211(3):361–367.
36. Larking AM, Duport S, Clinton M, Hardy M, Andrews K. Randomized control
of extracorporeal shock wave therapy versus placebo for chronic decubitus
ulceration. Clin Rehabil. 2010;24(3):222–229.
37. Wang CJ, Wu RW, Yang YJ. Treatment of diabetic foot ulcers: a comparative
study of extracorporeal shockwave therapy and hyperbaric oxygen therapy.
Diabetes Res Clin Pract. 2011;92(2):187–193.
38. Ottomann C, Stojadinovic A, Lavin PT, Gannon FH, Heggeness MH, Thiele R,
et al. Prospective randomized phase II Trial of accelerated reepithelialization
of superficial second-degree burn wounds using extracorporeal shock wave
therapy. Ann Surg. 2012;255(1):23–29.
39. Saggini R, Figus A, Troccola A, Cocco V, Saggini A, Scuderi N. Extracorporeal
shock wave therapy for management of chronic ulcers in the lower extremi-
ties. Ultrasound Med Biol. 2008;34(8):1261–1271.
40. Schaden W, Thiele R, Kölpl C, Pusch M, Nissan A, Attinger CE, et al. Shock
wave therapy for acute and chronic soft tissue wounds: a feasibility study. J
Surg Res. 2007;143(1):1–12.
41. Arnó A, García O, Hernán I, Sancho J, Acosta A, Barret JP. Extracorpore-
al shock waves, a new non-surgical method to treat severe burns. Burns.
2010;36(6):844–849.
42. Wolff KS, Wibmer A, Pusch M, Prusa AM, Pretterklieber M, Teufelsbauer H, et
al. The influence of comorbidities and etiologies on the success of extracor-
poreal shock wave therapy for chronic soft tissue wounds: midterm results.
Ultrasound Med Biol. 2011;37(7):1111–1119.
43. Fioramonti P, Onesti MG, Fino P, Fallico N, Scuderi N. Extracorporeal shock
wave therapy for the treatment of venous ulcers in the lower limbs. Ann Ital
Chir. 2012;83(1):41–44.
44. Stieger M, Schmid JP, Bajrami S, Hunziker T. Extracorporeal shock
wave therapy as a treatment of a non-healing chronic leg ulcer. Hautarzt.
2013;64(6):443–446.
45. van Tulder M, Furlan A, Bombardier C, Bouter L, Editorial Board of the Co-
chrane Collaboration Back Review Group. Updated method guidelines for
systematic reviews in the cochrane collaboration back review group. Spine.
2003;28(12):1290–1299.
Project
Clinical, pathomorphological, immunocytochemical and molecular characterization of the effects of extracorporeal shock waves (ESW) in patients with chronic wounds: a prospective, single-blinded, pl…" [more]
Project
To assess electrophysiological and thermal changes after single extracorporeal shock wave stimulation on upper limb spasticity in patients after ischemic stroke.
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