Update on the Treatment of Erectile Dysfunction
T.C. Peak, ... W.J.G Hellstrom, in Reference Module in Biomedical Sciences, 2015
Extracorporeal Shock Wave Therapy (ESWT)
Extracorporeal shock wave therapy (ESWT) has emerged as one of the newest treatment modalities for ED. Unlike all other current treatments, which are palliative, ESWT offers the possibility of permanent restoration of EF. When ESWT is applied to an organ, the relatively weak, yet focused, shock waves interact with the targeted deep tissues, causing mechanical stress and microtrauma. This stress and microtrauma induces biological reactions that result in the release of angiogenic factors that trigger neovascularization of the tissue with subsequent improvement of the blood supply. One study examined its use in 20 men with mild to moderate ED due to cardiovascular disease and without any neurogenic etiology. All previously responded to PDE5 inhibitors. During the study, these men had two treatment sessions per week for 3 weeks, a 3-week no-treatment interval, and a second 3-week treatment period of 2 treatments per week. Fifteen of these men showed improvement with an average increase in IEFF-EF of 7.4 points. Furthermore, this group of successfully treated men had increased penile blood flow and nocturnal penile tumescence upon analsysis. At 6 months, 10 of these men were still able to achieve spontaneous erections sufficient for penetration without the use of PDE5 inhibitors (Gruenwald et al., 2013). Another study incorporated 29 non-responders to PDE5 inhibitors in their treatment group for ESWT. It found that 76% (22 of 29) of patients had an improved IIEF-EF domain score of at least 5 points with an increase to 18.8 from a baseline of 8.8 (Marks et al., 2006). Eight patients achieved normal erections, and the other 21 were converted to PDE5 inhibitor responders (Wang et al., 2000). Understandably, further study of this modality is needed before any definitive conclusions can be made.
Achilles Tendon Disorders Including Tendinosis and Tears
Craig I. Title, Lew C. Schon, in Baxter's the Foot and Ankle in Sport (Second Edition), 2008
Role of Ultrasound and Shock Wave Therapy
The use of extracorporeal shock wave therapy (ESWT) for the treatment of Achilles tendinitis has not been widely studied. Most information on shock wave therapy comes from research on kidney stone lithotripsy, upper extremity tendinitis, and plantar fasciitis. Shock wave therapy works by creating a pressure change that propagates rapidly through a medium. When transmitted through a water medium, it can either directly create high tension at a given structure or indirectly create microcavitations. Theories behind its analgesic effect in orthopedic applications include an alteration of the permeability of neuron cell membranes and induction of an inflammatory-mediated healing response by increasing local blood flow.33 Studies on ESWT on Achilles tendinitis have shown a success rate of approximately 30% to 40%.34,35 In our experience, we have found a similar success rate of approximately 30% in athletes, although more severe cases are indicated for surgery. Even with this lower success rate, we try ESWT for 3 months on all patients before surgery because this treatment has minimal side effects. Depending on the immediate results, we may allow sports play with only 1 or 2 weeks off. If the athlete is in midseason, then this modality is his or her best chance to resume play. If the athlete is at the end of the season, then we may try shock wave therapy and a boot brace for 2 to 6 weeks and then allow the athlete to resume impact activities. After the season, when there is more time for recovery, decisions regarding further treatment can be made. Contraindications to ESWT quoted in the literature include pregnancy, coagulopathies, bone tumors, bone infection, and skeletal immaturity.33
Saggini et al.36 noted successful outcomes after two treatments with no complications using shock wave therapy on Achilles tendinitis. Several later studies reported promising results after ESWT with those affected with chronic Achilles tendinitis.37-39 The cost of shock wave treatment can be an important consideration because the therapy may not be covered by insurance. With lower-energy shock wave machines, three treatments are used, at a cost of $500 to $800 each. One treatment (at a cost of about $1500) is the norm for the higher-energy machines. The temporary pain with this procedure is considerable and requires an ankle block or general anesthesia, which increases both the risk and the cost.
Achilles Tendon
Shannon Munteanu, in Management of Chronic Conditions in the Foot and Lower Leg, 2015
Extracorporeal Shock Wave Therapy
Extracorporeal shock wave therapy (ECSWT) was originally developed for use as a non-invasive treatment for kidney, gallbladder or liver stones, but in the past 15 years has become a popular, albeit controversial, treatment for soft-tissue disorders. The mechanism of action of ECSWT was not completely known, but the rationale for its use is stimulation of soft-tissue healing and inhibition of pain receptors (Rompe et al. 2007, 2009).
Four RCTs have investigated the effectiveness of low-level ECSWT for chronic (symptoms greater than 3 months) Achilles tendinopathy (Costa et al. 2005; Rasmussen et al. 2008; Rompe et al. 2007, 2009). There is no consensus regarding its use (Rompe et al. 2009). The treatment regimen has been three to four treatments at weekly intervals (Rasmussen et al. 2008; Rompe et al. 2007, 2009). However, one trial (Costa et al. 2005) treated patients at monthly intervals for 3 months. The dose per session used was 1500 pulses (up to 0.2 mJ / mm2) (Costa et al. 2005) or 2000 pulses (0.10 to 0.51 mJ / mm2) (Rasmussen et al. 2008; Rompe et al. 2007, 2009).
In these trials, the comparator intervention has varied from a no-treatment approach (Rompe et al. 2007) to sham ECSWT (Costa et al. 2005; Rasmussen et al. 2008), to eccentric calf muscle exercise (Rompe et al. 2007). An additional study has compared a combined treatment of ECSWT plus eccentric calf muscle exercise with eccentric calf muscle exercise alone (Rompe et al. 2009). The outcome measurements have been performed at 7 to 16 weeks post-treatment in these studies.
The results of these studies have produced equivocal results as the findings differ as a function of the comparator intervention (Table 6-3). When the comparator intervention has been a sham, there are conflicting results. Rasmussen et al. (2008) compared ECSWT with sham and showed that ECSWT significantly reduced symptoms of Achilles tendinopathy at 12 weeks (American Orthopedic Foot and Ankle Society Score between group mean difference = 10.0, 95% CI 3.2 to 15.8). However, Costa et al. (2005) did not report any significant differences between participants (with mid-portion and insertional complaints) for self-reported pain during walking, at rest, or during sport at 12 weeks in the real and sham ECSWT groups. One explanation for the difference in findings between these two studies is that the monthly (rather than weekly) treatment regimen used by Costa et al. (2005) may have resulted in an underdosing of the ECSWT.
ECSWT has been shown to be an effective intervention for Achilles tendinopathy, when compared with a no-treatment approach or when combined in a multimodal treatment approach. Rompe et al. (2007) compared ECSWT with a wait-and-see approach, and an eccentric calf muscle exercise programme. Participants treated with ECSWT reported better improvements in pain and function compared with those in the wait-and-see group at 4 months (VISA-A score between group mean difference = 15.4, 95% CI 7.8 to 23.0). In the same trial (Rompe et al. 2007), ECSWT showed equivalent effectiveness to an eccentric calf muscle exercise programme (VISA-A score mean difference = 5.2, 95% CI −3.9 to 14.3).
In another study (Rompe et al. 2009), a multimodal treatment of ECSWT combined with eccentric calf muscle exercise showed superior effectiveness relative to an eccentric calf muscle exercise programme alone; in this trial the VISA-A score was significantly better in the combined treatment group at 4 months (mean difference = 13.5, 95% CI = 5.5 to 22.5). Further, 82% (28 of 34) of participants who had received the combined treatment reported being ‘completely recovered’ or ‘much improved’ at 4 months as opposed to 56% (19 out of 34) of participants who performed the eccentric calf muscle exercise alone (RR success = 1.5, 95% CI = 1.1 to 2.1). However, at 1 year there was no difference between the groups.
Taken together, these studies suggest that low-level ECSWT is an effective intervention for chronic Achilles tendinopathy. ECSWT is more effective than no treatment and shows comparable effectiveness to an eccentric calf muscle exercise programme, suggesting that it may be indicated as an alternative treatment for Achilles tendinopathy in patients who are unable to perform eccentric calf muscle exercise. Further, adding ECSWT to an eccentric calf muscle exercise programme results in improved patient outcomes. However, further research is required to determine the optimum dosage of ECSWT for Achilles tendinopathy, and to clarify its effectiveness against a sham treatment.
