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Analysis of pain intensity and postural control for assessing the efficacy of shock wave therapy and sonotherapy in Achilles tendinopathy – A randomized controlled trial

      Highlights

      • Pain-relieving effects of shock wave therapy in Achilles tendinopathy were observed.
      • Relationship existed between radial shock wave therapy and better postural control.
      • Posturography may contribute to functional assessment of the Achilles tendon.

      Abstract

      Background

      The troublesome symptoms of Achilles tendinopathy prompt patients to seek effective forms of conservative treatment. The main aim of the study was to determine the therapeutic efficacy of shock wave and ultrasound therapies for Achilles tendinopathy in reducing pain intensity. Treatment efficacy was also assessed using objective posturographic measurements.

      Methods

      Thirty-nine patients patients were randomly allocated to one of three experimental groups that received shock wave therapy (group A), ultrasound therapy (group B) and placebo ultrasound (group C). Posturographic measurements and subjective assessment of pain intensity were taken prior to therapy and at weeks 1 and 6 of therapy completion.

      Findings

      A comparison of percentage change in activity-related pain from baseline to 6 weeks post-therapy revealed a significantly greater pain reduction in group A compared to group B. The three-way ANOVA demonstated an effect of treatment type on all posturographic variables. The Bonferroni post-hoc test showed the means of all variables were significantly smaller for group A than group B. Limb condition also had an effect on the center-of-pressure trajectories in anteroposterior plane; the post-hoc test showed the mean values of the variables were significantly greater for the non-affected compared to affected limb.

      Interpretation

      Shock wave therapy was significantly more effective than sonotherapy for alleviation of activity-related pain of Achilles tendinopathy. An association was also shown between shock wave therapy and more efficient postural control in patients with Achilles tendinopathy. The parameters of center-of-pressure trajectories in the sagittal plane were significantly greater for the non-affected compared to affected limb.
      The trial was prospectively registered in the Australian and New Zealand Clinical Trials Registry (no. ACTRN12617000860369; registration date: 9.06.2017).

      Keywords

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      References

        • Abdelkader N.A.
        • Helmy M.N.K.
        • Fayaz N.A.
        • Saweeres E.S.B.
        Short- and intermediate-term results of extracorporeal shockwave therapy for noninsertional Achilles tendinopathy.
        Foot Ankle Int. 2021; 42: 788-797https://doi.org/10.1177/1071100720982613
        • Bah I.
        • Fernandes N.
        • Chimenti R.
        • Ketz J.
        • Flemister A.
        • Buckley M.
        Tensile mechanical changes in the Achilles tendon due to insertional Achilles tendinopathy.
        J. Mech. Behav. Biomed. Mater. 2020; 112https://doi.org/10.1016/J.JMBBM.2020.104031
        • Baker K.G.
        • Robertson V.J.
        • Duck F.A.
        A review of therapeutic ultrasound: biophysical effects.
        Phys. Ther. 2001; 81: 1351-1358https://doi.org/10.1093/ptj/81.7.1351
        • Bickel M.
        The role of interleukin-8 in inflammation and mechanisms of regulation.
        J. Periodontol. 1993; 64: 456-460
        • Bolgar M.R.
        • Baker C.E.
        • Goss F.L.
        • Nagle E.
        • Robertson R.J.
        Effect of exercise intensity on differentiated and undifferentiated ratings of perceived exertion during cycle and treadmill exercise in recreationally active and trained women.
        J. Sports Sci. Med. 2010; 9 (/pmc/articles/PMC3761819/): 557
        • de Bruijn R.
        Deep transverse friction; its analgesic effect.
        Int. J. Sports Med. 1984; 5: 35-36https://doi.org/10.1055/S-2008-1025944/BIB
        • Carulli C.
        • Tonelli F.
        • Innocenti M.
        • Gambardella B.
        • Muncibì F.
        • Innocenti M.
        Effectiveness of extracorporeal shockwave therapy in three major tendon diseases.
        J. Orthopaed. Traumatol.: Off. J. Italian Soc. Orthopaed. Traumatol. 2016; 17: 15-20https://doi.org/10.1007/S10195-015-0361-Z
        • Chao Y.
        • Tsuang Y.
        • Sun J.
        • Chen L.
        • Chiang Y.
        • Wang C.
        • Chen M.
        Effects of shock waves on tenocyte proliferation and extracellular matrix metabolism.
        Ultrasound Med. Biol. 2008; 34: 841-852https://doi.org/10.1016/J.ULTRASMEDBIO.2007.11.002
        • Chaves P.
        • Simões D.
        • Paço M.
        • Pinho F.
        • Duarte J.
        • Ribeiro F.
        Cyriax’s deep friction massage application parameters: evidence from a cross-sectional study with physiotherapists.
        Musculoskel. Sci. Pract. 2017; 32: 92-97https://doi.org/10.1016/J.MSKSP.2017.09.005
        • Chester R.
        • Costa M.L.
        • Shepstone L.
        • Cooper A.
        • Donell S.T.
        Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain-a pilot study.
        Man. Ther. 2008; 13: 484-491https://doi.org/10.1016/j.math.2007.05.014
        • Chimenti R.L.
        • Cychosz C.C.
        • Hall M.M.
        • Phisitkul P.
        Current concepts review update: insertional Achilles tendinopathy.
        Foot Ankle Int. 2017; 38: 1160-1169https://doi.org/10.1177/1071100717723127
        • Cook J.L.
        • Purdam C.R.
        Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.
        Br. J. Sports Med. 2009; 43: 409-416https://doi.org/10.1136/bjsm.2008.051193
        • Cuschieri S.
        The CONSORT statement.
        Saudi J Anaesth. 2019; 13: S27-S30https://doi.org/10.4103/SJA.SJA_559_18
        • Erroi D.
        • Sigona M.
        • Suarez T.
        • Trischitta D.
        • Pavan A.
        • Vulpiani M.C.
        • Vetrano M.
        Conservative treatment for insertional Achilles.
        Musc. Ligam. Tend. J. 2017; 7: 98-106
        • Faquin B.S.
        • Candido C.R.C.
        • Mochizuki L.
        • Okazaki V.H.A.
        Effect of visual and vestibular information on spatial perception on gait.
        Human Movement. 2018; 19: 39-45https://doi.org/10.5114/HM.2018.74058
        • Finnamore E.
        • Waugh C.
        • Solomons L.
        • Ryan M.
        • West C.
        • Scott A.
        Transverse tendon stiffness is reduced in people with Achilles tendinopathy: a cross-sectional study.
        PLoS One. 2019; 14https://doi.org/10.1371/JOURNAL.PONE.0211863
        • Florit D.
        • Pedret C.
        • Casals M.
        • Malliaras P.
        • Sugimoto D.
        • Rodas G.
        Incidence of tendinopathy in team sports in a multidisciplinary sports Club over 8 seasons.
        J. Sports Sci. Med. 2019; 18: 780-788
        • Frairia R.
        • Berta L.
        Biological effects of extracorporeal shock waves on fibroblasts. A review.
        Musc. Ligam. Tend. J. 2012; 1: 138-147
        • Gatz M.
        • Schweda S.
        • Betsch M.
        • Dirrichs T.
        • de la Fuente M.
        • Reinhardt N.
        • Quack V.
        Line- and point-focused extracorporeal shock wave therapy for Achilles tendinopathy: a placebo-controlled RCT study.
        Sports Health. 2021; 13: 511-518https://doi.org/10.1177/1941738121991791
        • Hsu A.R.
        • Holmes G.B.
        Preliminary treatment of Achilles tendinopathy using low-intensity pulsed ultrasound.
        Foot Ankle Spec. 2016; 9: 52-57https://doi.org/10.1177/1938640015599038
        • Joseph M.F.
        • Taft K.
        • Moskwa M.
        • Denegar C.R.
        Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding.
        J. Sport Rehabil. 2012; 21: 343-353https://doi.org/10.1123/JSR.21.4.343
        • Khan K.
        • Cook J.
        • Taunton J.
        • Bonar F.
        Overuse tendinosis, not tendinitis part 1: a new paradigm for a difficult clinical problem.
        Phys. Sportsmed. 2000; 28: 38-48https://doi.org/10.3810/PSM.2000.05.890
        • Król P.
        • Franek A.
        • Król T.
        • Stanula A.
        • Dolibog P.
        • Durmała J.
        • Polak A.
        • Kuszewski M.
        • Stania M.
        Ground reaction force analysis for assessing the efficacy of focused and radial shockwaves in the treatment of symptomatic plantar heel spur.
        J. Back Musculoskel. Rehabil. 2021; 34: 279-287https://doi.org/10.3233/BMR-191739
        • Le Bars D.
        • Dickenson A.H.
        • Besson J.M.
        Diffuse noxious inhibitory controls (DNIC). I. Effects on dorsal horn convergent neurones in the rat.
        PAIN. 1979; 6: 283-304https://doi.org/10.1016/0304-3959(79)90049-6
        • Maffulli G.
        • Padulo J.
        • Iuliano E.
        • Furia J.
        • Rompe J.
        • Maffulli N.
        Extracorporeal shock wave therapy in the management of insertional Achilles tendinopathy: the ASSERT database.
        Musc. Ligam. Tend. J. 2018; 8: 416-422
        • Maffulli N.
        • Khan K.M.
        • Puddu G.
        Overuse tendon conditions: time to change a confusing terminology.
        Arthroscopy. 1998; 14: 840-843https://doi.org/10.1016/S0749-8063(98)70021-0
        • Nagymáté G.
        • Orlovits Z.
        • Kiss R.
        Reliability analysis of a sensitive and independent stabilometry parameter set.
        PLoS One. 2018; 13https://doi.org/10.1371/JOURNAL.PONE.0195995
        • Notarnicola A.
        • Maccagnano G.
        • Tafuri S.
        • Forcignanò M.
        • Panella A.
        • Moretti B.
        CHELT therapy in the treatment of chronic insertional Achilles tendinopathy.
        Lasers Med. Sci. 2014; 29: 1217-1225https://doi.org/10.1007/S10103-013-1510-3
        • Ogden J.A.
        • Tóth-Kischkat A.
        • Schultheiss R.
        Principles of shock wave therapy.
        Clin. Orthop. Relat. Res. 2001; 387: 8-17https://doi.org/10.1097/00003086-200106000-00003
        • Pinitkwamdee S.
        • Laohajaroensombat S.
        • Orapin J.
        • Woratanarat P.
        Effectiveness of extracorporeal shockwave therapy in the treatment of chronic insertional Achilles tendinopathy.
        Foot Ankle Int. 2020; 41: 403-410https://doi.org/10.1177/1071100719898461
        • Rasmussen S.
        • Christensen M.
        • Mathiesen I.
        • Simonson O.
        Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy.
        Acta Orthop. 2008; 79: 249-256https://doi.org/10.1080/17453670710015058
        • von Rickenbach K.
        • Borgstrom H.
        • Tenforde A.
        • Borg-Stein J.
        • McInnis K.
        Achilles tendinopathy: evaluation, rehabilitation, and prevention.
        Curr. Sports Med. Reports. 2021; 20: 327-334https://doi.org/10.1249/JSR.0000000000000855
        • Rompe J.
        • Nafe B.
        • Furia J.
        • Maffulli N.
        Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial.
        Am. J. Sports Med. 2007; 35: 374-383https://doi.org/10.1177/0363546506295940
        • Rompe J.
        • Nafe B.
        • Furia J.P.
        • Maffulli N.
        Eccentric loading, shock-wave treatment, or a wait- and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial.
        Am. J. Sports Med. 2007; 35: 374-383https://doi.org/10.1177/0363546506295940
        • Rompe J.
        • Furia J.
        • Maffulli N.
        Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy: a randomized, controlled trial.
        J. Bone Joint Surg. - Ser. A. 2008; 90: 52-61https://doi.org/10.2106/JBJS.F.01494
        • Rompe J.
        • Furia J.
        • Maffulli N.
        Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial.
        Am. J. Sports Med. 2009; 37: 463-470https://doi.org/10.1177/0363546508326983
        • Santamato A.
        • Beatrice R.
        • Micello M.F.
        • Fortunato F.
        • Panza F.
        • Bristogiannis C.
        • Cleopazzo E.
        • Macarini L.
        • Picelli A.
        • Baricich A.
        • Ranieri M.
        Power Doppler ultrasound findings before and after focused extracorporeal shock wave therapy for Achilles tendinopathy: a pilot study on pain reduction and neovascularization effect.
        Ultrasound Med. Biol. 2019; 45: 1316-1323https://doi.org/10.1016/j.ultrasmedbio.2018.12.009
        • Schmidle S.
        • de Crignis A.C.
        • Stürzer M.
        • Hermsdörfer J.
        • Jahn K.
        • Krewer C.
        Influence of stance width on standing balance in healthy older adults.
        J. Neurol. 2022; https://doi.org/10.1007/S00415-022-11144-5
        • Scholes M.
        • Stadler S.
        • Connell D.
        • Barton C.
        • Clarke R.
        • Bryant A.
        • Maliaras P.
        Men with unilateral Achilles tendinopathy have impaired balance on the symptomatic side.
        J. Sci. Med. Sport. 2018; 21: 479-482https://doi.org/10.1016/J.JSAMS.2017.09.594
        • Silbernagel K.G.
        • Gustavsson A.
        • Thomeé R.
        • Karlsson J.
        Evaluation of lower leg function in patients with Achilles tendinopathy.
        Knee Surg. Sports Traumatol. Arthrosc. 2006; 14: 1207-1217https://doi.org/10.1007/s00167-006-0150-6
        • Simplicio C.L.
        • Purita J.
        • Murrell W.
        • Santos G.S.
        • dos Santos R.G.
        • Lana J.F.S.D.
        Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine.
        J. Clin. Orthopaed. Trauma. 2020; 11: S309-S318https://doi.org/10.1016/j.jcot.2020.02.004
        • Singh A.
        • Calafi A.
        • Diefenbach C.
        • Kreulen C.
        • Giza E.
        Noninsertional tendinopathy of the Achilles.
        Foot Ankle Clin. 2017; 22: 745-760https://doi.org/10.1016/J.FCL.2017.07.006
        • Slugg R.
        • Meyer R.
        • Campbell J.
        Response of cutaneous A- and C-fiber nociceptors in the monkey to controlled-force stimuli.
        J. Neurophysiol. 2000; 83: 2179-2191https://doi.org/10.1152/JN.2000.83.4.2179
        • Stania M.
        • Król B.
        • Franek A.
        • Błaszczak E.
        • Dolibog P.
        • Polak A.
        • Dolibog P.
        • Durmała J.
        • Król P.
        A comparative study of the efficacy of radial and focused shock wave therapy for tennis elbow depending on symptom duration.
        Arch. Med. Sci. 2020; 1–10https://doi.org/10.5114/aoms.2019.81361
        • Sukubo N.
        • Tibalt E.
        • Respizzi S.
        • Locati M.
        • D’Agostino M.
        Effect of shock waves on macrophages: a possible role in tissue regeneration and remodeling.
        Intern. J. Surg. (London, England). 2015; 24: 124-130https://doi.org/10.1016/J.IJSU.2015.07.719
        • Sussmilch-Leitch S.P.
        • Collins N.J.
        • Bialocerkowski A.E.
        • Warden S.J.
        • Crossley K.M.
        Physical therapies for Achilles tendinopathy: systematic review and meta-analysis.
        J. Foot Ankle Res. 2012; 5: 1https://doi.org/10.1186/1757-1146-5-15
        • Taylor J.
        • Dunkerley S.
        • Silver D.
        • Redfern A.
        • Talbot N.
        • Sharpe I.
        • Guyver P.
        Extracorporeal shockwave therapy (ESWT) for refractory Achilles tendinopathy: a prospective audit with 2-year follow up.
        Foot (Edinburgh, Scotland). 2016; 26: 23-29https://doi.org/10.1016/J.FOOT.2015.08.007
        • Testa M.
        • Rossettini G.
        Enhance placebo, avoid nocebo: how contextual factors affect physiotherapy outcomes.
        Man. Ther. 2016; 24: 65-74https://doi.org/10.1016/J.MATH.2016.04.006
        • Tsai W.C.
        • Tang S.F.T.
        • Liang F.C.
        Effect of therapeutic ultrasound on tendons.
        Am. J. Phys. Med. Rehabil. 2011; 90: 1068-1073https://doi.org/10.1097/PHM.0B013E31821A70BE
        • Vahdatpour B.
        • Forouzan H.
        • Momeni F.
        • Ahmadi M.
        • Taheri P.
        Effectiveness of extracorporeal shockwave therapy for chronic Achilles tendinopathy: a randomized clinical trial.
        J. Res. Med. Sci.: Off. J. Isfahan Univ. Med. Sci. 2018; 23https://doi.org/10.4103/JRMS.JRMS_413_16
        • Vulpiani M.
        • Vetrano M.
        • Savoia V.
        • Pangrazio E.
        • Trischitta D.
        • Ferretti A.
        Jumper’s knee treatment with extracorporeal shock wave therapy: a long-term follow-up observational study.
        J. Sports Med. Phys. Fitness. 2007; 47: 323-328
        • Waldecker U.
        • Hofmann G.
        • Drewitz S.
        Epidemiologic investigation of 1394 feet: coincidence of hindfoot malalignment and Achilles tendon disorders.
        Foot Ankle Surg.: Off. J. Eur. Soc. Foot Ankle Surg. 2012; 18: 119-123https://doi.org/10.1016/J.FAS.2011.04.007
        • Wang C.
        • Wang F.
        • Yang K.
        • Weng L.
        • Hsu C.
        • Huang C.
        • Yang L.
        Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits.
        J. Orthopaed. Res.: Off. Publ. Orthopaed. Res. Soc. 2003; 21: 984-989https://doi.org/10.1016/S0736-0266(03)00104-9
        • Waugh C.
        • Morrissey D.
        • Jones E.
        • Riley G.
        • Langberg H.
        • Screen H.
        In vivo biological response to extracorporeal shockwave therapy in human tendinopathy.
        Eur. Cells Mater. 2015; 29: 268-280https://doi.org/10.22203/ECM.V029A20
        • Winter D.
        • Patla A.
        • Prince F.
        • Ishac M.
        • Gielo-Perczak K.
        Stiffness control of balance in quiet standing.
        J. Neurophysiol. 1998; 80: 1211-1221https://doi.org/10.1152/JN.1998.80.3.1211
        • Yan B.L.
        • Wan Y.
        • Zhang H.
        • Pan M.T.
        • Zhou C.
        Extracorporeal shockwave therapy for patients with chronic Achilles tendinopathy in long or short course.
        Biomed. Res. Int. 2020; 2020https://doi.org/10.1155/2020/7525096
        • Yiou E.
        • Caderby T.
        • Delafontaine A.
        • Fourcade P.
        • Honeine J.
        Balance control during gait initiation: state-of-the-art and research perspectives.
        World J. Orthoped. 2017; 8: 815-828https://doi.org/10.5312/wjo.v8.i11.815
        • Zhang S.
        • Li H.
        • Yao W.
        • Hua Y.
        • Li Y.
        Therapeutic response of extracorporeal shock wave therapy for insertional Achilles tendinopathy between sports-active and nonsports-active patients with 5-year follow-up.
        Orthopaed. J. Sports Med. 2020; 8https://doi.org/10.1177/2325967119898118