bryanc's published research

[Bill Hartman]

So I'm buzzin' through Pubmed reviewing some recent abstracts and who's research do I come across but our very own bryanc's. Very cool.

Am J Sports Med. 2004 Oct-Nov;32(7):1660-7.

Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial.

Chung B, Wiley JP.

University of Calgary Sport Medicine Centre, Faculty of Kinesiology, Calgary, Alberta, Canada.

BACKGROUND: Extracorporeal shock wave therapy is a relatively new therapy used in the treatment of chronic tendon-related pain. Few randomized controlled trials have been performed on it, and no studies have examined the effectiveness of extracorporeal shock wave therapy as a frontline therapy for tendon-related pain. HYPOTHESIS: Subjects treated with active extracorporeal shock wave therapy will have higher rates of treatment success than subjects treated with sham extracorporeal shock wave therapy. DESIGN: Double-blind randomized controlled trial. METHODS: Sixty subjects who had previously untreated lateral epicondylitis for less than 1 year and more than 3 weeks were included in this study. Subjects were randomly allocated to receive 1 session per week for 3 weeks of either sham or active extra-corporeal shock wave therapy. Subjects in the active therapy group received 2000 pulses (energy flux density, 0.03-0.17 mJ/mm(2)). All subjects were provided with a forearm-stretching program. After 8 weeks of therapy, subjects were classified as either treatment successes or treatment failures according to fulfillment of all 3 criteria: (1) at least a 50% reduction in the overall pain visual analog scale score, (2) a maximum allowable overall pain visual analog scale score of 4.0 cm, and (3) no use of pain medication for elbow pain for 2 weeks before the 8 week follow-up. Visual analog scale scores were also collected for pain at rest, during sleep, during activity, at its worst, and at its least, as well as for quality of life (using the EuroQoL questionnaire) and grip strength. RESULTS: Success rates in the sham and active therapy groups were 31% and 39%, respectively. No significant difference was detected between groups (chi(2)(1)= 0.3880, P = .533). Mean change in quality of life over 8 weeks was an increase of 1.3 and 3.3 for sham and active therapy groups, respectively, and mean change in grip strength over 8 weeks was an increase of 7.4 kg and 6.8 kg for sham and active therapy groups, respectively. CONCLUSIONS: Despite improvement in pain scores and pain-free maximum grip strength within groups, there does not appear to be a meaningful difference between treating lateral epicondylitis with extracorporeal shock wave therapy combined with forearm-stretching program and treating with forearm-stretching program alone, with respect to resolving pain within an 8-week period of commencing treatment
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Bill

[Jean-Paul]

Cool! Way to go Bryan. I could certainly recognize your style based on having read your posts over the last couple of years.

What happens to your study from here? Do you think that this treatment would be effective if combined with another treatment, or is it simply considered useless therapy and thrown out the window?

[bryanc]

We did continue follow-up of our subjects for one year. The subjects who got sham therapy were offered active therapy as well at the 8 week point, and through the magic of statistics, the trial remained randomized despite the unblinding. We found that if you got shockwave therapy within 16 weeks of your onset of pain, that you would have a higher change of having significant reduction in your pain than if you had sham therapy, but that initiating treatment between 16 weeks and 1 year of onset, it didn't seem to matter. That 1-year study is under peer review right now for the Clinical Journal of Sport Medicine.

Shockwave therapy continues to baffle. The evidence points in the 'doesn't work' direction for using it as a frontline therapy. The studies looking at using it as a last-resort therapy are more promising, but still very conflicted. Whether it has a multiplicative effect that would render it an effective adjunct therapy with something else is an entirely different question--though I can't think of a reason why it would from what little we understand about how shockwave therapy works (if it were to work); and those studies haven't been done because it seems like one would be flogging the dead horse to try to justify why a therapy that does nothing would suddenly do something when added to another therapy.

However, it becomes very difficult to refute the anecdotal evidence of individuals who I have treated (not for the study) who have seemingly miraculous recoveries. I've often wondered if there's either something different about these people that makes them succeed on the therapy or if their 'mind power' is that much 'stronger' for some unknown reason. There is also the idea that shockwave therapy may mediate central nervous system changes--i.e. the therapy resets what the brain considers to be painful in that area. The origins of tendon pain continue to change as well in the literature from actual collagen 'damage' to the formation of neovessels in the tendon that, when obliterated, resolve pain (i.e. there's not a whole lot wrong with the tendon, it's just become sensitive to pain). And then on top of that, one has to ask whether the pain is actually protective from rupture and whether removing the pain is actually okay to do; or if we'll suddenly see an increase in the number of ruptures after we implement pain-relieving therapy (tendon ruptures tend to occur without preceeding pain).

So, it's all blurry right now. I'd say from my own study that you should not use shockwave therapy as a frontline therapy--unless, possibly, you've had pain for less than 16 weeks, in which case you have a pretty good chance of getting better faster than the 'spontaneous cure' rate. HOWEVER, within a year, all subjects were pretty much pain free--so unless there's a huge pressing need to have less pain within a 2 month period, it seems you get better anyways.

From other studies, if you can afford it (in the US, the therapy costs $1000 per visit, with a course of 3-5 visit required) and surgery is your only remaining option that there is some support in the literature to use it as a last-resort treatment (particularly for plantar fasciitis), given that shockwave therapy has no side effects other than some residual soreness for a few days after each session and is probably a better solution (if it works for you) than surgery.