This thesis assesses the effectiveness of shock wave therapy for dysfunctional disorders of the musculoskeletal system. While we are well aware of the physical principles and history of shock wave generators, opinion differs on the treatment effectiveness mechanisms. The theoretical part of this work explains the effects of shock waves on various types of tissue, the differentiation of the cells, and the analgetic effect of therapy. It summarizes the indications, side effects and contraindications of shock wave therapy. The research part of this thesis deals with the effectiveness of shock wave therapy at the Department of Rehabilitation and Sports Medicine at the Motol University Hospital, which specialises in various musculoskeletal disorders. This thesis evaluates the correlation between the effectiveness of shock wave therapy and length of time the patient has experienced difficulties before undergoing treatment. This thesis also reviews whether the number of treatment applications has the capability to influence the outcome of therapy. The study is controlled by a control group of 22 patients. The total effectiveness of shock wave therapy is p = 1,12*10-10 . The shock wave therapy effectiveness of patients with heel spur is p = 0,00176. The shock wave therapy effectiveness of patients with...

Syfte Syftet med föreliggande studie var att försöka klargöra om stötvågsbehandling har någon effekt på smärta och handgreppstyrka hos patienter med lateral epikondylalgia. Frågeställningar 1. Har stötvågsbehandling någon effekt på smärta hos patienter med lateral epikondylalgia, i så fall vilken? 2. Har stötvågsbehandling någon effekt på handgreppsstyrka hos patienter med lateral epikondylalgia, i så fall vilken? Metod Sökning av litteratur utfördes i PubMed, Cochrane, Cinahl och PEDro. Detta resulterade i 14 artiklar, som granskades och bedömdes enligt PEDro Scale. Poängbedömningen utifrån PEDro Scale omsattes till Statens Beredning för medicinsk Utrednings (SBU) mall för bevisvärde. Utifrån artiklarnas sammantagna bevisvärde bestämdes evidensnivån enligt SBU:s fyra nivåer. Resultat Enligt GRADE-systemet förelåg det ett starkt vetenskapligt belägg för att stötvågsbehandling har en smärtlindrande effekt vid lateral epikondylalgia. Studier av likartad vetenskaplig kvalitet påvisar motsägande resultat avseende om stötvågsbehandling är bättre än placebo, kortison eller tenotomi. Detta innebär att det vetenskapliga underlaget är otillräckligt och att mer forskning behövs. Enligt GRADE-systemet förelåg det ett starkt vetenskapligt belägg för att stötvågsbehandling leder till förbättrad handgreppsstyrka vid lateral epikondylalgia. Vidare förelåg det ett starkt vetenskapligt belägg för att stötvågsbehandling inte är bättre än någon annan behandling gällande ökning av handgreppsstyrka vid lateral epikondylalgia. Slutsats Stötvågsbehandling har en smärtlindrande effekt hos patienter med lateral epikondylalgia. Det finns dock ingen evidens för att stötvågsbehandling är bättre ur smärthänseende än någon annan behandling såsom placebo, kortison eller tenotomi. Stötvågsbehandling leder till förbättrad handgreppsstyrka men är inte bättre än placebo, kortison eller tenotomi på att öka handgreppsstyrkan hos patienter med lateral epikondylalgia. / Aim The aim of the present study was to try to find out whether shock wave therapy has any effect on pain and grip strength in patients with lateral epicondylitis. Objectives 1. Does shock wave therapy reduce pain in patients with lateral epicondylitis? 2. Does shock wave therapy improve grip strength in patients with lateral epicondylitis? Method A literature review was performed in the databases PubMed, Cochrane, Cinahl and PEDro. Fourteen articles were found and critically reviewed. These articles were scored according to the PEDro scale and the scores were translated into a scale of evidence by the Statens Beredning för medicinsk Utredning (SBU) and the level of evidence was determined based on the four different grades presented by the SBU. Results According to the GRADE-system there was a strong scientific evidence for a reduction of pain using shock wave therapy in patients with lateral epicondylitis. Contradictory results whether shock wave therapy was better than placebo, corticosteoroid injection or tenotomy have been reported in studies of similar scientific quality. This means that more research is needed in this field. According to the GRADE-system there was a strong scientific evidence for an improvement of grip strength using shock wave therapy. Furthermore, there was a strong scientific evidence for that shock wave is not better than any other therapy in terms of improving grip strength in patients with lateral epicondylitis. Conclusion Shock wave therapy reduces pain in patients with lateral epicondylitis. There is, however, no evidence for shock wave therapy to be superior to any other treatment such as placebo, corticosteoroid injection or tenotomy. Shock wave therapy improves grip strenght but is not better than placebo, corticoidsteroid injection or tenotomy in increasing grip strength in patients with lateral epicondylitis.

Orientador: William Dias Belangero / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-28T23:43:39Z (GMT). No. of bitstreams: 1 Faria_LidiaDornelasde_M.pdf: 3066212 bytes, checksum: 6cb5506682740e2fcb2de4b1694998a3 (MD5) Previous issue date: 2015 / Resumo: A Terapia por ondas de choque (TOC) é uma alternativa não invasiva utilizada como método de indução a formação óssea que consiste em pulsos sonoros de alta energia transmitidas de modo focal a um tecido específico. Artigos demonstram aumento de vascularização, que ativação de proteínas como BMP (bone morphogenic protein) e Erk (extracellular signal-regulated kinase) induzindo diferenciação osteogênica após sua utilização no tecido ósseo. O presente estudo visou avaliar os níveis das proteínas Erk e Akt (akutely transforming), envolvidas na cascata protéica responsiva a deformação celular gerada por estímulo mecânico e consequente transformação em estímulo bioquímico induzindo a osteogênese. Os animais selecionados para o estudo foram anestesiados e divididos em dois diferentes grupos, onde no dia 1, o primeiro grupo foi submetido a TOC em sessão única de 500 impulsos gerados por aparelho eletrohidráulico a 0,12mJ/mm²na tíbia intacta e o segundo não recebeu TOC. Na sequência, os animais foram divididos em 3 subgrupos para cada tempo de segmento de 7, 14 e 21 dias A determinação dos níveis das proteínas propostas foi realizada por meio de immunoblotting. A fosforilação das proteínas Erk e Akt dos tecidos ósseos das tíbias extraídas dos ratos aumentou nos grupos submetidos a TOC após 7, 14 e se manteve elevado até o 21° dia quando comparado ao controle / Abstract: Extracorporeal shock wave therapy (ESWT) is a non-invasive alternative used as a method for inducing bone formation that consists of high-energy acoustic pulses transmitted in a focal way to a specific tissue. Studies show increase in vascularization which activate proteins such as BMP and Erk inducing osteogenic differentiation after its use in the bone tissue. The present study aimed at evaluating the levels of Erk and AKT proteins involved in the protein cascade responsive to cell deformation in biochemical stimulus inducing osteogenesis. The animals selected for the study were under anesthesia and divided in two different groups where on day 1 the first group was submitted to ESWT in one 500 pulse-session generated by an electrohydraulic device at 0,12mJ/mm² in intact tibia and fibula and the second did not receive ESWT. Then the animals were divided into 3 sub-groups, one for each segment times of 7, 14 and 21 days. Immunoblotting analysis was performed to determine the levels of the proposed proteins. The Erk and Akt protein phosphorylation of the bone tissues of extracted tibia from the animals increased in the groups submitted to ESWT and kept elevated until the 21st day when compared to the control group / Mestrado / Fisiopatologia Cirúrgica / Mestra em Ciências

Chapter–I Introduction Shock waves appear in nature whenever the different elements in a fluid approach one another with a velocity larger than the local speed of sound. Shock waves are essentially non-linear waves that propagate at supersonic speeds. Such disturbances occur in steady transonic or supersonic flows, during explosions, earthquakes, tsunamis, lightening strokes and contact surfaces in laboratory devices. Any sudden release of energy (within few μs) will invariably result in the formation of shock wave since it is one of the efficient mechanisms of energy dissipation observed in nature. The dissipation of mechanical, nuclear, chemical, and electrical energy in a limited space will result in the formation of a shock wave. However, it is possible to generate micro-shock waves in laboratory using different methods including controlled explosions. One of the unique features of shock wave propagation in any medium (solid, liquid or gases) is their ability to instantaneously enhance pressure and temperature of the medium. Shock waves have been successfully used for disintegrating kidney stones, non-invasive angiogenic therapy and osteoporosis treatment. In this study, we have generated a novel method to produce micro-shock waves using micro-explosions. Different biological applications were developed by further exploring the physical properties of shock waves. Chapter – II Bacterial transformation using micro-shock waves In bacteria, uptake of DNA occurs naturally by transformation, transduction and conjugation. The most widely used methods for artificial bacterial transformation are procedures based on CaCl2 treatment and electroporation. In this chapter, controlled micro-shock waves were harnessed to develop a unique bacterial transformation method. The conditions have been optimized for the maximum transformation efficiency in E. coli. The highest transformation efficiency achieved (1 × 10-5 transformants per cell) was at least 10 times greater than the previously reported ultrasound mediated transformation (1 × 10-6 transformants per cell). This method has also been successfully employed for the efficient and reproducible transformation of Pseudomonas aeruginosa and Salmonella Typhimurium. This novel method of transformation has been shown to be as efficient as electroporation with the added advantage of better recovery of cells, economical (40 times cheaper than commercial electroporator) and growth-phase independent transformation. Chapter – III Needle-less vaccine delivery using micro-shock waves Utilizing the instantaneous mechanical impulse generated behind the micro-shock wave during controlled explosion, a novel non-intrusive needleless vaccine delivery system has been developed. It is well established, that antigens in the epidermis are efficiently presented by resident Langerhans cells, eliciting the requisite immune response, making them a good target for vaccine delivery. Unfortunately, needle free devices for epidermal delivery have inherent problems from the perspective of patient safety and comfort. The penetration depth of less than 100 µm in the skin can elicit higher immune response without any pain. Here the efficient utilization of the device for micro-shock wave mediated vaccination was demonstrated. Salmonella enterica serovar Typhimurium vaccine strain pmrG-HM-D (DV-STM-07) was delivered using our device in the murine salmonellosis model and the effectiveness of the delivery system for vaccination was compared with other routes of vaccination. The device mediated vaccination elicits better protection as well as IgG response even in lower vaccine dose (ten-fold lesser), compare to other routes of vaccination. Chapter – IV In vitro and in vivo biofilm disruption using shock waves Many of the bacteria secrete highly hydrated framework of extracellular polymer matrix on encountering suitable substrates and get embedded within the matrix to form biofilm. Bacterial colonization in biofilm form is observed in most of the medical devices as well as during infections. Since these bacteria are protected by the polymeric matrix, antibiotic concentration of more than 1000 times of the MIC is required to treat these infections. Active research is being undertaken to develop antibacterial coated medical implants to prevent the formation of biofilm. Here, a novel strategy to treat biofilm colonization in medical devices and infectious conditions by employing shock waves was developed. Micro-shock waves assisted disintegration of Salmonella, Pseudomonas and Staphylococcus biofilm in urinary catheters was demonstrated. The biofilm treated with micro-shock waves became susceptible to antibiotics, whereas the untreated was resistant. Apart from medical devices, the study was extended to Pseudomonas lung infection model in mice. Mice exposed to shock waves responded well to ciprofloxacin while ciprofloxacin alone could not rescue the mice from infection. All the mice survived when antibiotic treatment was provided along with shock wave exposure. These results clearly demonstrate that shock waves can be used along with antibiotic treatment to tackle chronic conditions resulting from biofilm formation in medical devices as well as biological infections. Chapter – V Shock wave responsive drug delivery system for therapeutic application Different systems have been used for more efficient drug delivery as well as targeted delivery. Responsive drug delivery systems have also been developed where different stimuli (pH, temperature, ultrasound etc.) are used to trigger the drug release. In this study, a novel drug delivery system which responds to shock waves was developed. Spermidine and dextran sulfate was used to develop the microcapsules using layer by layer method. Ciprofloxacin was loaded in the capsules and we have used shock waves to release the drug. Only 10% of the drug was released in 24 h at pH 7.4, whereas 20% of the drug was released immediately after the particles were exposed to shock waves. Almost 90% of the drug release was observed when the particles were exposed to shock waves 5 times. Since shock waves can be used to induce angiogenesis and wound healing, Staphylococcus aureus skin infection model was used to show the effectiveness of the delivery system. The results show that shock wave can be used to trigger the drug release and can be used to treat the wound effectively. A brief summary of the studies that does not directly deal with the biological applications of shock waves are included in the Appendix. Different drug delivery systems were developed to check their effect in Salmonella infection as well as cancer. It was shown for the first time that silver nanoparticles interact with serum proteins and hence the antimicrobial properties are affected. In a nutshell, the potential of shock waves was harnessed to develop novel experimental tools/technologies that transcend the traditional boundaries of basic science and engineering.