Evidence Supporting Extracorporeal Shockwave Therapy for Acute and Chronic Soft Tissue Wounds
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Chronic wounds are placing a great burden on patients, their families, society in general, and the healthcare system in particular. Five to $10 billion is spent annually in the United States for the treatment of chronic wounds,8 and in Europe, this expenditure accounts for nearly 2% of the healthcare budget.9 Disturbed wound healing may have different underlying etiologies but generally has a similar appearance. More than 80% of all chronic wounds are attributable to venous/arterial insufficiency, high blood pressure, infection, and diabetes mellitus.8 Other contributing factors include poor nutritional status, immunosuppression, and tobacco use. Most common chronic wounds involve the lower extremity.10
The primary goal of wound treatment and management is durable wound closure and complete healing. In acute wounds, standard of practice includes wound bed preparation, surgical and enzymatic debridement with subsequent application of specialized dressings to provide a moist environment, or surgical closure primarily or with skin grafts or flaps depending on the nature and extent of wounding. To accomplish the same goal of rapid healing in chronic wounds, a multidisciplinary approach is required including diabetes control, nutritional support, wound care with modern dressings (eg, semipermeable films, gels, hydrocolloids, and calcium alginates), use of antibiotics to treat infection, mechanical off-loading, compression therapy for venous stasis and lymphedema, and targeted treatments that promote angiogenesis and vasculogenesis. These therapies are time and labor intensive and costly particularly given the time (weeks to months) it generally takes to achieve wound healing. Therefore, the need for new, safe, efficient and cost-effective treatment is clear and much research has been devoted to development of such a wound therapy. Many adjunctive therapies have been developed and implemented in the care of acute and chronic wounds, including hyperbaric oxygen therapy (HBOT), ultrasound, recombinant human platelet-derived growth factor-BB (rPDGF-BB), negative pressure wound therapy (NPWT); however, safety and efficacy of these and other modalities have yet to be determined.
Wound healing is a well-coordinated, interconnected sequence of biological events on multiple levels—systemic, cellular, and molecular. Wound healing involves a broad variety of cells and events, which are interdependent with overlapping duration and the presence of cell-to-cell signaling molecules within the traumatized tissue. Re-establishment of a functional vasculature is the most critical determinant of restored tissue structure during wound healing,11 which largely occurs via angiogenesis, specifically endothelial sprouting from the pre-existing local vasculature12–14 and vasculogenesis, and de novo formation of the small blood vessels.15–16
The fortuitous initial experimental observations by Valchanov et al17 who discovered that ESWT activates osteoblasts and is associated with concomitant increase in bone density and calcification led to the first clinical studies of therapeutic shockwave application for bone indications. Around the same time (1980s), evidence emerged regarding the feasibility of ESWT to stimulatate wound healing. However, a rigorous, systematic research approach for investigation of the effects of ESWT on wound healing and underlying mechanism(s) of action began only more recently.