Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

OBJECTIVE: The aim of the study is to examine the effectiveness of extracorporeal shockwave therapy in reducing pain, improving functionality, joint range of motion, quality of life, fatigue, and health status self-perception in people with myofascial pain syndrome. METHODS: PubMed, the Cochrane Library, CINAHL, the Physiotherapy Evidence Database, and SPORTDiscus were systematically searched for only randomized clinical trials published up to June 2, 2022. The main outcome variables were pain, as reported on the visual analog scale and pressure pain threshold, and functionality. A quantitative analysis was conducted using the inverse variance method and the random effects model. RESULTS: Twenty-seven studies were included ( N = 595 participants in the extracorporeal shockwave therapy group). The effectiveness of extracorporeal shockwave therapy for relieving pain was superior for the extracorporeal shockwave therapy group compared with the control group on the visual analog scale (MD = -1.7 cm; 95% confidence interval = -2.2 to -1.1) and pressure pain threshold (mean difference = 1.1 kg/cm 2 ; 95% confidence interval = 0.4 to 1.7) and functionality (standardized mean difference = -0.8; 95% confidence interval = -1.6 to -0.04) with high heterogeneity. However, no differences were found between extracorporeal shockwave therapy and other interventions as dry needling, exercises, infiltrations, and lasers interventions. CONCLUSIONS: Extracorporeal shockwave therapy is effective in relieving pain and improving functionality in patients with myofascial pain syndrome compared with control and ultrasound therapy. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Determine the effectiveness of radial and focal extracorporeal shockwaves on pain perception, the pressure pain threshold, and functionality in people with myofascial pain syndrome; (2) Describe the intervention protocol of extracorporeal shockwave therapy to improve pain perception in people with myofascial pain syndrome; and (3) Describe the advantages and disadvantages of extracorporeal shockwave therapy versus other intervention such as dry needling. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Efficacy of Transcranial Direct Current Stimulation on Pain Intensity and Functionality in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of the study is to investigate whether transcranial direct current stimulation is superior to control groups or other interventions for pain relief and improving functionality in knee osteoarthritis patients. METHODS: PubMed, the Physiotherapy Evidence Database, the Cochrane Library, ProQuest, and Scopus databases were searched from inception to July 2022 to identify randomized clinical trials. The main outcomes were subjective perception of pain intensity measured either with the visual analog scale or with the numeric rating scale; and the functionality, assessed with the Western Ontario and McMaster Universities Osteoarthritis Index. As secondary outcomes, pressure pain threshold, conditioned pain modulation, and its safety were evaluated. RESULTS: We identified 10 randomized clinical trials (634 participants). The results showed an important effect favoring transcranial direct current stimulation for pain relief (mean difference = -1.1 cm, 95% confident interval = -2.1 to -0.2) and for improving functionality (standardized mean difference = -0.6, 95% confident interval = -1.02 to -0.26). There was also a significant improvement in pressure pain threshold (mean difference = 0.9 Kgf/cm 2 , 95% confident interval = 0.1 to 1.6). The certainty of evidence according to Grades of Recommendation Assessment, Development and Evaluation was generally moderate. CONCLUSIONS: Our findings suggest that transcranial direct current stimulation is a safe treatment for reducing pain intensity, improving functionality, and the pressure pain thresholds in patients with knee osteoarthritis.

Effectiveness of transcranial direct current stimulation on balance and gait in patients with multiple sclerosis: systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Motor impairments are very common in neurological diseases such as multiple sclerosis. Noninvasive brain stimulation could influence the motor function of patients. OBJECTIVE: The aim of this meta-analysis was to evaluate the effectiveness of transcranial direct current stimulation (tDCS) on balance and gait ability in patients with multiple sclerosis. Additionally, a secondary aim was to compare the influence of the stimulation location of tDCS on current effectiveness. METHODS: A search was conducted for randomized controlled trials published up to May 2023 comparing the application of tDCS versus a sham or control group. The primary outcome variables were balance and gait ability. RESULTS: Eleven studies were included in the qualitative analysis, and ten were included in the quantitative analysis, which included 230 patients with multiple sclerosis. The average effect of tDCS on gait functionality was superior to that of the control group (SMD = -0.71; 95% CI, -1.05 to -0.37). However, the overall results of the tDCS vs. sham effect on static balance did not show significant differences between groups (MD = 1.26, 95% CI, -1.31 to 3.82). No significant differences were found when different locations of tDCS were compared. CONCLUSIONS: These results reveal that tDCS is an effective treatment for improving gait ability with a low quality of evidence. However, the application of tDCS has no effect on static balance in patients with multiple sclerosis with very low quality of evidence. Similarly, there seems to be no difference regarding the stimulation area with tDCS.

Exoskeleton-based training improves walking independence in incomplete spinal cord injury patients: results from a randomized controlled trial.

BACKGROUND: In recent years, ambulatory lower limb exoskeletons are being gradually introduced into the clinical practice to complement walking rehabilitation programs. However, the clinical evidence of the outcomes attained with these devices is still limited and nonconclusive. Furthermore, the user-to-robot adaptation mechanisms responsible for functional improvement are still not adequately unveiled. This study aimed to (1) assess the safety and feasibility of using the HANK exoskeleton for walking rehabilitation, and (2) investigate the effects on walking function after a training program with it. METHODS: A randomized controlled trial was conducted including a cohort of 23 patients with less than 1 year since injury, neurological level of injury (C2-L4) and severity (American Spinal Cord Injury Association Impairment Scale [AIS] C or D). The intervention was comprised of 15 one-hour gait training sessions with lower limb exoskeleton HANK. Safety was assessed through monitoring of adverse events, and pain and fatigue through a Visual Analogue Scale. LEMS, WISCI-II, and SCIM-III scales were assessed, along with the 10MWT, 6MWT, and the TUG walking tests (see text for acronyms). RESULTS: No major adverse events were reported. Participants in the intervention group (IG) reported 1.8 cm (SD 1.0) for pain and 3.8 (SD 1.7) for fatigue using the VAS. Statistically significant differences were observed for the WISCI-II for both the "group" factor (F = 16.75, p < 0.001) and "group-time" interactions (F = 8.87; p < 0.01). A post-hoc analysis revealed a statistically significant increase of 3.54 points (SD 2.65, p < 0.0001) after intervention for the IG but not in the CG (0.7 points, SD 1.49, p = 0.285). No statistical differences were observed between groups for the remaining variables. CONCLUSIONS: The use of HANK exoskeleton in clinical settings is safe and well-tolerated by the patients. Patients receiving treatment with the exoskeleton improved their walking independence as measured by the WISCI-II after the treatment.

Extracorporeal shock wave for plantar flexor spasticity in spinal cord injury: A case report and review of literature.

BACKGROUND: Approximately 65%-78% of patients with a spinal cord injury (SCI) develop any symptom of spasticity. The aim of this study was to investigate the tolerability and short-term effects of radial extracorporeal shock wave therapy (rESWT) on plantar flexor spasticity in a patient with incomplete SCI. CASE SUMMARY: An 18-year-old man with an incomplete SCI completed five sessions of rESWT. The primary outcomes were the changes in ankle-passive range of motion (A-PROM) and passive resistive force to ankle dorsiflexion. The outcomes were assessed at baseline (T0), immediately after treatment (T1) and 1 wk after the end of treatment (T2). The A-PROM increased by 15 degrees at T1 and 25 degrees at T2 compared with T0. The passive resistive force to ankle dorsiflexion at low velocity decreased by 33% at T1 and 55% at T2 in the gastrocnemius muscle and by 41% at T1 and 39% at T2 in the soleus muscle compared with T0. At high velocity, it also decreased by 44% at T1 and 30% at T2 in the gastrocnemius muscle compared with T0. However, in the soleus muscle, the change was minor, with a decrease of 12% at T1 and increased by 39% at T2 compared with T0. CONCLUSION: In this patient, the findings showed that rESWT combined with conventional therapy was well-tolerated and could be effective in improving A-PROM and passive resistive force to ankle dorsiflexion in the short-term. Further randomized controlled clinical trials with longer period of follow-up are necessary to confirm the results obtained in patients with SCI.

Electrical microcurrent stimulation therapy for wound healing: A meta-analysis of randomized clinical trials.

BACKGROUND: Electrical microcurrent therapy (EMT) consists of the application of low intensity (µA) currents that are similar to endogenous electric fields generated during wound healing. AIMS: To examine the effectiveness and safety of EMT for improving wound healing and pain in people with acute or chronic wounds. METHOD: Randomized clinical trials (RCTs) assessing the effectiveness of EMT in wound healing published up to August 1st, 2020 were included. The main outcomes were wound surface area, healing time, and number of wounds healed. Secondary outcomes were pain perception and adverse events. A quantitative analysis was conducted using the inverse variance and Mantel-Haenszel methods. RESULTS: Eight RCTs were included in the qualitative summary and seven in the quantitative analysis (n = 337 participants). EMT plus standard wound care (SWC) produced a greater decrease in wound surface [mean difference (MD) = -8.3 cm2; CI 95%: -10.5 to -6.0] and healing time (MD = -7.0 days; CI 95%: -11.9 to -2.1) that SWC alone, showing moderate and low certainty in the evidence, respectively. However, no differences were observed in the number of healed wounds [risk ratio = 2.0; CI 95%: 0.5 to 9.1], with very low quality of evidence. EMT decreased perceived pain (MD = -1.4; CI 95%: -2.7 to -0.2), but no differences in adverse effects were noted between groups (risk difference = 0.05; CI 95%: -0.06 to 0.17). CONCLUSIONS: EMT is an effective, safe treatment for improving wound area, healing time, and pain. Further clinical trials that include detailed intervention parameters and protocols should be designed to lower the risk of bias.

Effect of posture and body weight loading on spinal posterior root reflex responses.

The posterior root muscle response (PRM) is a monosynaptic reflex that is evoked by single pulse transcutaneous spinal cord stimulation (tSCS). The main aim of this work was to analyse how body weight loading influences PRM reflex threshold measured from several lower limb muscles in healthy participants. PRM reflex responses were evoked with 1-ms rectangular monophasic pulses applied at an interval of 6 s via a self-adhesive electrode (9 × 5 cm) at the T11-T12 vertebral level. Surface electromyographic activity of lower limb muscles was recorded during four different conditions, one in decubitus supine (DS) and the other three involving standing at 100%, 50%, and 0% body weight loading (BW). PRM threshold intensity, peak-to-peak amplitude, and latency for each muscle were analysed in different conditions study. PRM reflex threshold increased with body weight unloading compared with DS, and the largest change was observed between DS and 0% BW for the proximal muscles and between DS and 50% BW for distal muscles. Peak-to-peak amplitude analysis showed only a significant mean decrease of 34.6% (SD 10.4, p = 0.028) in TA and 53.6% (SD 15.1, p = 0.019) in GM muscles between DS and 50% BW. No significant differences were observed for PRM latency. This study has shown that sensorimotor networks can be activated with tSCS in various conditions of body weight unloading. Higher stimulus intensities are necessary to evoke reflex response during standing at 50% body weight loading. These results have practical implications for gait rehabilitation training programmes that include body weight support.

Transcranial direct current stimulation combined with robotic therapy for upper and lower limb function after stroke: a systematic review and meta-analysis of randomized control trials.

BACKGROUND: Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation method able to modulate neuronal activity after stroke. The aim of this systematic review was to determine if tDCS combined with robotic therapy (RT) improves limb function after stroke when compared to RT alone. METHODS: A search for randomized controlled trials (RCTs) published prior to July 15, 2021 was performed. The main outcome was function assessed with the Fugl-Meyer motor assessment for upper extremities (FM/ue) and 10-m walking test (10MWT) for the lower limbs. As secondary outcomes, strength was assessed with the Motricity Index (MI) or Medical Research Council scale (MRC), spasticity with the modified Ashworth scale (MAS), functional independence with the Barthel Index (BI), and kinematic parameters. RESULTS: Ten studies were included for analysis (n = 368 enrolled participants). The results showed a non-significant effect for tDCS combined with RT to improve upper limb function [standardized mean difference (SMD) = - 0.12; 95% confidence interval (CI): - 0.35-0.11)]. However, a positive effect of the combined therapy was observed in the lower limb function (SMD = 0.48; 95% CI: - 0.15-1.12). Significant results favouring tDCS combined with RT were not found in strength (SMD = - 0.15; 95% CI: - 0.4-0.1), spasticity [mean difference (MD) = - 0.15; 95% CI: - 0.8-0.5)], functional independence (MD = 2.5; 95% CI: - 1.9-6.9) or velocity of movement (SMD = 0.06; 95% CI: - 0.3-0.5) with a "moderate" or "low" recommendation level according to the GRADE guidelines. CONCLUSIONS: Current findings suggest that tDCS combined with RT does not improve upper limb function, strength, spasticity, functional independence or velocity of movement after stroke. However, tDCS may enhance the effects of RT alone for lower limb function. tDCS parameters and the stage or type of stroke injury could be crucial factors that determine the effectiveness of this therapy.

Transcutaneous Spinal Cord Stimulation Enhances Quadriceps Motor Evoked Potential in Healthy Participants: A Double-Blind Randomized Controlled Study.

Transcutaneous electrical spinal cord stimulation (tSCS) is a non-invasive technique for neuromodulation and has therapeutic potential for motor rehabilitation following spinal cord injury. The main aim of the present study is to quantify the effect of a single session of tSCS on lower limb motor evoked potentials (MEPs) in healthy participants. A double-blind, sham-controlled, randomized, crossover, clinical trial was carried out in 15 participants. Two 10-min sessions of tSCS (active-tSCS and sham-tSCS) were applied at the T11-T12 vertebral level. Quadriceps (Q) and tibialis anterior (TA) muscle MEPs were recorded at baseline, during and after tSCS. Q and TA isometric maximal voluntary contraction was also recorded. A significant increase of the Q-MEP amplitude was observed during active-tSCS (1.96 ± 0.3 mV) when compared from baseline (1.40 ± 0.2 mV; p = 0.01) and when compared to sham-tSCS at the same time-point (1.13 ± 0.3 mV; p = 0.03). No significant modulation was identified for TA-MEP amplitude or for Q and TA isometric maximal voluntary isometric strength. In conclusion, tSCS applied over the T11-T12 vertebral level increased Q-MEP but not TA-MEP compared to sham stimulation. The specific neuromodulatory effect of tSCS on Q-MEP may reflect optimal excitation of this motor response at the interneuronal or motoneuronal level.

Extracorporeal shockwave therapy improves pain and function in subjects with knee osteoarthritis: A systematic review and meta-analysis of randomized clinical trials.

OBJECTIVE: To examine the safety and effectiveness of extracorporeal shockwave therapy (ESWT) for reducing pain and improving functionality in people with knee osteoarthritis (KOA). METHODS: The Cochrane Library, PubMed, CINAHL, Physiotherapy Evidence Database (PEDro) and Google Scholar were systematically searched for randomized trials published up to September 30th of 2019. The main outcome measures to evaluate the treatment effect were pain, as reported on a visual analogue scale (VAS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcome measures were the range of motion (ROM) and walking tests. A quantitative analysis was conducted using the inverse variance method and the random effects model. RESULTS: Fourteen studies were included (n = 782 participants and 877 knees). Moderate quality of evidence showed that ESWT causes a decrease on the pain VAS [mean difference (MD) = 1.7 cm; confidence interval (CI) 95%: 1.1-2.3] and WOMAC (MD = 13.9 points; CI 95%: 6.9-20.8). The effect of ESWT using medium energetic density was greater than with low or high density in the WOMAC (Chi2 = 9.8, p = 0.002) and bordered statistical significance on the VAS (Chi2 = 3.8, p = 0.05). Very low quality of evidence showed that ESWT causes moderate improvement in the knee ROM (MD = 17.5°; CI 95%: 9.4-25.5) and walking test [standardized mean difference (SMD) = 0.58; CI 95%: 0.35-0.81]. CONCLUSIONS: ESWT is an effective treatment for improving pain and functionality in patients with KOA in the short term with few minor side effects. Further clinical trials should include longer follow-up periods and be designed to lower the risk of bias.