Name: treatment protocol for rotator cuff calcific tendinitis using a single-crystal piezoelectric focused shock wave source
Uploaded: 2022-12-23T13:45:00
Description: Watch this Scientific Journal Video about Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source at JoVE.com

The protocol follows the guidelines of the Buenos Aires British Hospital&#39;s human research ethics committee.
1. Patient evaluation
<ol>
	<li>Clinical evaluation
	<ol>
		<li>Evaluate patients clinically to rule out symptoms propagating from other anatomical regions or other associated pathology in the shoulder that may be the source of symptoms.</li>
		<li>Include shoulder inspection and palpation, evaluate the active and passive range of motion, and perform pain provocati...

This study shows encouraging results with the application of focused shock waves generated by a single-crystal piezoelectric device in a series of retrospectively evaluated patients with calcific tendinitis of the shoulder. According to the bibliographic search we carried out, this is the first study that reports results with a single-crystal piezoelectric device. Recently, Louwerens39 published a study using a piezoelectric shock wave device for the treatment of rotator cuff calcifications. Howev...

Calcium crystal deposits can appear in different regions of the musculoskeletal system, but their most frequent location is in the shoulder region. Gondos1 reported that 69% of calcification cases occur in the shoulder location. Calcific shoulder tendinopathies are characterized by the presence of hydroxyapatite deposits in the rotator cuff tendons. It is estimated that the prevalence in the general population ranges from 2.7% to 20%2.
Calcific tendinitis of the shoulder typically affects patients between 30 to 60 years old2. It is also more frequent in women (57%-76.7%) with respect to men3. The location of the calcium deposit is much more frequent in the distal tendon of the supraspinatus muscle4, while localizations in the infraspinatus, teres minor, subscapularis, and long head of the biceps have also been reported4.
Women between 30 and 60 years old, with a calcification over 1.5 cm in length, have the highest chance of being symptomatic5. Although it tends to spontaneously resolve itself, the cycle can often be halted. In these cases, symptoms of pain and disability appear, and it is necessary to take active therapeutic action.
G&#228;rtner&#39;s radiological classification6 differentiates three types of images. In type I, the image is dense, with well-defined borders corresponding to the formative phase. In the type II image, the appearance is mixed, with a deposit that can be dense but with diffuse borders, or transparent with well-defined borders. Finally, type III, characteristic of the resorptive phase, presents a transparent deposit with diffuse borders. Active therapeutic action, including shock wave applications, ultrasound-guided interventions, or surgery, must be taken in G&#228;rtner type I and II, since in type III cases, the chance of short-term spontaneous resorption is very high6.
Conservative treatment is initially preferred. This classically includes rest, analgesics, non-steroidal and steroidal anti-inflammatory drugs, rehabilitation, and local injections. Good results of conservative treatment have been shown, especially in the resorptive stage, but a failure of conservative treatment has been reported in 27% to 39% of cases7,8,9. Several prognostic factors have been recognized as having a significant influence on the results of conservative treatment7,8. The location on both shoulders, the presence of a large-volume deposit, the location of the calcification in the anterior region of the acromion, and the spread of the deposit medially beyond the level of the acromioclavicular joint, are factors of poor prognosis7,8. A G&#228;rtner stage III calcification and lack of sonographic extinction of the calcific deposit are considered predictors of good prognosis for conservative treatment7.
When conservative treatment fails, many patients end up becoming chronic carriers of shoulder pain with similar clinical characteristics to chronic rotator cuff non-calcific tendinopathies. The usual alternative to conservative treatment failure was surgery. Gschwend10 formulated three precise surgical indications for rotator cuff calcifications: symptom progression, constant and unmanageable pain, and failure of conservative treatment. Surgical treatment can be performed open or arthroscopically. Although open treatment was historically performed with good results11, arthroscopic techniques have gained popularity12,13. Musculoskeletal ultrasound and ultrasound-guided interventions (UGI) have significantly developed and been used in clinical practice in recent years14,15,16.
Extracorporeal shock wave treatment (ESWT) has emerged as an effective option prior to invasive procedures when conservative treatment has failed. Its therapeutic effect is not just mechanical, but based on mechanotransduction, a phenomenon by which cells can recognize a mechanical stimulus and react biologically17. However, shock wave treatment has limitations. Unlike lithotripsy, in which we only depend on the mechanical effect of the waves, there must also be a biological response by the patient. This response does not always occur.
The generic term &#34;extracorporeal shock waves&#34; includes two different technologies: focused shock waves and radial pressure waves17,18,19. The two technologies have therapeutic efficacy but differ in their physical characteristics and indications. Focused shock waves have a wide frequency range (from approximately 150 kHz up to 100 MHz), large pressure amplitude (up to 150 MPa) with a short rise time and small pulse width, followed by a low-stress wave (up to -25 MPa)18,19. Focused shock waves are generated by electrohydraulic, electromagnetic, and piezoelectric sources17,18,19.
Radial pressure waves are sound waves with pressure peaks of up to 30 MPa and much higher rise times than focused shock waves (about 3 &#181;s)18,19. Radial pressure waves are generated by accelerating a projectile inside a cylindrical guiding tube by compressed air. The projectile hits an applicator at the end of the tube and produces a radial pressure wave that expands into the target tissue17,18,19.
Focused shock waves have a grade &#34;A&#34; recommendation for the treatment of rotator cuff calcifications17. This means that there is high-quality scientific evidence supported by level I studies with consistent findings. In the case of radial waves, the level of recommendation for rotator cuff calcifications is &#34;I&#34;. This means that the evidence is insufficient to make a recommendation17.
Therapeutical efficacy of focused shock waves in calcific tendinopathies of the shoulder has been compared with open20 and arthroscopic21 surgery, with comparable results. However, shock waves have less frequent and less severe complications20,21, and the method is also cost-effective. Haake22 reported a significant difference between surgical costs (&#8364;13,400-23,450) and those of focused shock waves (&#8364;2,700-4,300). His results match with other studies that have shown a five- to sevenfold decrease in the cost of shock wave treatment compared to arthroscopic surgery23,24. There are also studies in which shock waves have been compared with ultrasound-guided interventions with controversial results15,25. Several publications4,17,26,27,28,29,30,31,32,33 have reported that a high level of energy is more effective when treating calcific tendinitis of the shoulder. Verstraelen27 reported that the use of high energy determines a higher rate of calcific resorption in a level I evidence study. This is a clear advantage for focused devices over radial ones because they can generate higher levels of energy. Numerous studies have reported good results with electrohydraulic4,17,34,35 and electromagnetic4,17,36,37,38 focused devices. A report has also been published using a multi-crystal piezoelectric device to treat rotator cuff calcifications39. We are not aware of any reports publishing the technique and results of single-crystal piezoelectric devices as of yet.
This report aims to describe the treatment protocol using a single-crystal piezoelectric device and to report the preliminary results.

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	<tbody>
		<tr>
			<td>BTL 6000 FSWT&#160;</td>
			<td>BTL</td>
			<td>09400B001107</td>
			<td>Focused Shock Wave Piezoelectric Source</td>
		</tr>
		<tr>
			<td>Ultrasound &#38; SWT Gel 300 mL</td>
			<td>BTL</td>
			<td>237-GEL102</td>
			<td>Alcohol free hypoallergic gel</td>
		</tr>
	</tbody>
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treatment protocol for rotator cuff calcific tendinitis using a single-crystal piezoelectric focused shock wave source

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are three types of focused shock wave generators: electrohydraulic, electromagnetic, and piezoelectric. According to our literature search, there are no reports of results with the use of single-crystal piezoelectric generators in calcific tendinitis of the shoulder. In a consecutive retrospective series of 23 patients with G&#228;rtner type I and II calcifications of the rotator cuff, we performed three applications of high-energy piezoelectric focused waves (4,000 pulses per session with a frequency of 6 Hz). At the final follow-up (average of 14 months), 82.6% of the cases showed complete resorption of the calcification in radiographic controls. In 8.7% of the cases, partial disappearance of the calcification was achieved, and in the remaining 8.7% there were no significant changes. Single-crystal piezoelectric generators have a success rate comparable to those already reported with electrohydraulic and electromagnetic devices.

A retrospective study of a series of patients with shoulder pain due to calcium deposits in the rotator cuff tendons was carried out in our institution. The inclusion criteria were G&#228;rtner stage I and II calcifications and at least 3 months of previous conservative treatment without satisfactory results. Patients with G&#228;rtner III calcifications, other associated pathology in the affected shoulder, previous local cortisone injection, and a history of surgery in the affected shoulder were excluded.
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Watch this Scientific Journal Video about Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source at JoVE.com

Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source

Calcific tendinitis of the shoulder is a relatively common condition with numerous treatment options. Here, we discuss the indications of focused shock waves generated by a single-crystal piezoelectric device, describe a treatment protocol, and present the preliminary results.

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are ...

To begin, position the patient comfortably in a way that allows exposure to the area to be treated. For a supraspinatus or infraspinatus tendon location, treat by placing the patient in the supine or sitting position. For a subscapularis place the patient in the supine position.For tares minor, place the patient in the sitting lateral decubitus or oblique decubitus position for better access to the posterior aspect of the shoulder. Then select a coupling pad size depending on the required penetration depth of the focused point. The selection of the coupling pad varies in shoulder calcification cases according to the build.The most frequently used sizes are large and medium. Next, locate the area to be treated, considering anatomical landmarks and with the help of ultrasound images if necessary. Also, position an operator to support in using the applicator and ensure working in an ergonomic position.Apply adequate contact gel to the skin in the area to be treated, then turn on the device and access the touch screen. Select the MANUAL option at the top of the screen. The controls of the various treatment parameters are displayed.Use the rotary selection knob to set the treatment parameters. Set the initial intensity of the treatment. Increase the intensity progressively as tolerated by the patient, starting with low intensity.Reach at least an energy level above 0.40 millijoules per millimeter squared to obtain reproducible results. Then select a frequency to be used, between four to six hertz. Select the number of shocks to be applied using the rotary selection knob.Apply at least 4, 000 shocks per session. Modify the frequency or the intensity during the application. Use the display located and the applicator head to easily modify the application parameters during the the treatment without having to interrupt the procedure.Retrospective study of a series of patients with shoulder pain due to calcium deposits in the rotator cuff tendons was carried out. The study group consisted of 13 female and 10 male patients with an average age of 52.8 years. The supraspinatus muscle was affected in 82.6%of cases, the infraspinatus in 13%and the subscapularis in 4.4%In all cases, only one tendon was involved.The minimum follow up was six months with an average of 14 months. In 82.6%of the cases, complete reabsorption of the calcification was achieved. In 8.7%partial disappearance with symptomatic improvement was obtained.In the remaining 8.7%there were no significant changes and an ultrasound guided puncture was performed. With the exception of one case of fainting during application and two cases of transient pain during the resorption process, there were no complications. Disappearance of calcification was observed for the tendon of the subscapularis muscle after six weeks, and also for the supraspinatus muscle tendon after 12 weeks.

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