1. LOGO Dose related effect of ESWT in lateral elbow epicondylitis Department of Orthopaedics Busan Paik Hospital Inje University, Busan, Korea Jang-Suk Choi, M.D., Young-chang Kim. M.D. Heel-chul Gwak, M.D., Jung-han Kim. M.D. Ill-Je Jo, M.D.

2. Introduction (1)  Tennis elbow is defined as pain on the facet of the lateral epicondyle.  Degenerative or failed healing tendon response characterised by the increased presence of fibroblasts, increased amounts of proteoglycans and glycos- aminoglycans, vascular hyperplasia, and disorganised collagen in the origin of the extensor carpi radialis brevis tendon. (Regan W. et al. Am J Sports Med 1992) (Kraushal B, J Bone Joint Surg [Am] 1999) (Nirschl R, Pettrone F. J Bone Joint Surg [Am] 1979) (Erak S, Day R, Wang A J Hand Surg [Br] 2004)

3. Introduction (2)  Prevalence of 1~3% in the general population, but this increases to 19% in 30~60 year olds. (Verhaar J.; Int Orthop 1994) (Teitz CC et al. JBJS 1997) (Stasinopoulos D, Johnson MI Br J Sports Med 2005)  Few of the treatments used rest on scientific evidence and none has been proved more effective than the others. (Sharma P, Maffulli N JBJS 2005) (Boyer MI, Hastings H J Shoulder Elbow Surg 1999)

4. Introduction (3)  There are a variety of conservative methods for treatment of lateral epicondylitis (tennis elbow), such as rest, physiotherapy, injection of steroid et al. (Regan W Am J Sports Med 1992) (Sevier TL, Wilson JK Sports Med. 1999)  Extracorporeal shock wave therapy is one of these conservative treatments for which scientific evidence regarding efficacy is lacking (Böddeker I, Haake M. Der Orthopäde. 2000) (Fritze J Versicherungsmedizin. 1998)

5. Introduction (4)  But, recent systematic review of the literature on extracorporeal shock wave therapy for lateral epicondylitis identified twenty clinical trials, all of which demonstrated successful results. (Rompe JD et al. Z Orthop Ihre Grenzgeb. 1996) (Perlick L. Z Orthop Ihre Grenzgeb. 1999)  Numerous authors proposed extracorporeal shock wave therapy as an alternative to surgery (Krischek O, Arch Orthop Trauma Surg. 1999) (Rompe JD J Bone Joint Surg Br. 1996) (Haake M J Bone Joint Surg Am 2002)

6. Introduction (5) 1. Mechanical effect (primary effect) : initial phase, positive pressure : hyper-stimulation analgesia (the gate control mechanism) → painful level ↑ → role in initial pain relief (Placzek R et al.. J Bone Joint Surg, Am 2007) 2. Physiologic effect (secondary effect) : delayed phase, negative pressure(tensile force) angiogenesis-mediating growth factors release (eNOS, VEGF, PCNA …) neovascularization, recruitment of stem cells (Kraushaar BS and Nirschl RP J Bone Joint Surg Am, 1999)

7. Introduction (6)  How much energy…?  총유효에너지량 = 단위면적당에너지 유출량 x 초점영역 x 충격파 횟수

8. Introduction (7)  In randomized retrospective study with 272 patients there is no functional improvement and pain relief (haak et al. JBJS [Am] 2002)  In randomized prospective with 93 patients, There is no significant effect between others conservative treatment and ESWT(84% vs 60%) (Crowther et al. JBJS [Br] 2002)  In double blind randomized study with 80 patients, this study show effect of ESWT that patients was divided three group by total effectiveness energy dose (Loew et al. JBJS 1997)

9. Purpose  The aim of this study was to investigate pain relief, functional improvement of lateral epicondylitis that treated ESWT.  And investigate the dose-related effects of extracorporeal shock wave therapy (ESWT) on the lateral epicondylitis of the elbow

10. Material and Methods(1)  From March 2005 to March 2007  Retrospectively select : male 26 cases/ female 40 cases : Rt. elbow 45 cases/ Lt. elbow 21 cases  Mean 45 years old (35~62 years old)  Follow up mean 12.5 months (6~20months) localized pain on lateral elbow wrist extension stress test positive patient treated with conservative treatment at least 3 month 121 patient assessed Inclusion and exclusion criteria was applied 74 patient was remained Exclued who previously treated with ESWT or operative treatment 66 patients

11. Material and Methods(2) Inclusion criteria 1. Increased pain on resisted wrist extension 2. Pain localised to the lateral epicondyle 3. Increased pain on elbow extension with full wrist flexion 4. Previous conservative treatment (physiotherapy or steroid injection) Exclusion criteria 1. A history of fracture of the affected elbow 2. Pain over the radial and posterior interosseous nerve 3. Pain and tenderness located over the radiohumeral joint 4. Positive resisted supination test 5. Exacerbation of pain on movement of the neck 6. Coagulation disorders 7. Pregnancy 8. Tumor or neurologic disorder 9. Untreated infections of the involved arm

12. Material and Methods(3)  Use Evotron® (Switech, Kreuzlingen, Switzerland)  R-05 prove is used  Without using ultrasonography random focusing method was applied to ESWT

13. Material and Methods(4)  1 time (1000cycle/10min.)  Fixed 0.12 mJ/mm2 energy flux density & R-05: 5~30mm  Treatment frequency is variable factor  Divided group : 1 st 2 nd 3 rd times treated group

14. Material and Methods(5)  Clinical evaluation (Direct survey on phone or OPD)  Pain : Check VAS score at pre treatment., Post 1,6,12 months  Function : Simple Elbow Test (SET, questionnaire of the University of Washington) Check at post Tx. 6 months, 1 year

15. Material and Methods(6)  Statistics analysis  In Intra-group, function & pain was analyzed by Wilcoxon Signed Ranks Test  In inter-group, function & pain was analyzed by ANOVA test Duncan test The level of significance was set at 0.05 analysis by Strategic Application System(SAS, SAS institute, North Carolina) 9.1 version

16. Results  Comparison within the group of VAS score after shock wave treatment InitialAfter 1 MAfter 6 MAfter 12 M Group I5.65.6 ±1.8(p=1.0)4.4±1.6(p=0.06)3.6±2.0(p=0.06) Group II6.86.7± 2.7(p=0.2)5.4 ±2.5(p=0.00)†4.7±2.3 (p=0.00) † Group III5.85.1±1.3 (p=0.07)4.1±1.3(p=0.008)‡3.6 ±1.2(p=0.004) ‡

17. Results Comparison between the groups of VAS score after shock wave treatment 0.50.30.10.030.080.3 0.10.20.01

18. Results  Comparison within the group of SET score after shock wave treatment InitialAfter 6 MAfter 12 M Group I2.22.8±0.4(p= 0.005) †3.1±0.3(p=0.000) † Group II1.42.2±0.2 (p=0.001) ‡2.4 ±0.2(p=0.005) ‡ Group III2.83.8 ±0.5(p=0.003) *4.4 ±0.6(p=0.000) *

19. Results P=0.002P=0.004 Comparison between the groups of SET score after shock wave treatment

20. Conclusion!  There is dose-related effects of extracorporeal shock wave therapy(ESWT) on the lateral epicondylitis of the elbow. There is elbow functional improvement who treated ESWT.  But about the pain, there is not dose-related effects of ESWT and there is a failure of early pain control.  This result seems to that 2 nd effect (physiologic effect) show dose-related effects, but primary effect (mechanical effect) dose not show dose-related effects  There is need to prospective study for efficiency and precision of ESWT’s effect