Cabana, François

Demers-Dubuc, Stéphanie

Limage Couture, Émilie

Léonard, Guillaume

Savoirs UdeS

1  Radial shockwave therapy for a painful bone spur in an above-knee amputee  1 REHAB-D-17-00034 2 guillaume.leonard2@usherbrooke.ca 3  4 Dear Editor. Pathological bone formation such as heterotopic ossification and bone spurs 5 can be a significant problem in patients with amputated limbs who undergo physical 6 rehabilitation [1, 2]. Surgical removal can be performed in some cases. However, few 7 studies have evaluated the most appropriate time to perform resection and the risk of 8 recurrence [3]. Surgical excision of heterotopic ossification and bone spurs may also bring 9 major complications such as wound infection, damage to surrounding neurovascular 10 structures, post-operative pain and delays in rehabilitation [3]. 11 Radial shockwave therapy (RSWT) consists of high-intensity sound waves 12 interacting with body tissues. In the past few years, RSWT has been proposed for treating 13 various painful conditions such as shoulder tendinopathy and calcific tendinitis, Achilles 14 tendinopathy, chronic heel pain and painful stump neuroma [4-6]. The benefit of RSWT is 15 attributed to its effect on bone remodeling. Martini and colleagues showed that low-energy 16 SWT (14 kV and 0.15 mJ/mm²) increases osteoblastic (i.e., bone tissue formation) activity, 17 while high-energy SWT (28 kV and 0.40 mJ/mm²) increases osteoclastic (i.e., bone tissue 18 breakdown) activity [7]. 19 Some investigators suggest that RSWT could be useful for patients with 20 pathological bone formation [8, 9]. Brissot and colleagues noted that RSWT reduced pain, 21 improved range of motion and walking distance, and alleviated the need for an assistive 22 device in patients with heterotopic ossification of various origins [9]. Lohrer and associates 23 found similar results in a population of adolescents with Osgood-Schlatter syndrome (a 24 condition characterized by excessive bone growth) [10].  25 These positive effects prompted us to use RSWT in a patient with bone spur 26 formation after above-knee amputation and pain that substantially affected physical 27 rehabilitation. The patient, a 39-year-old man, had experienced multiple fractures affecting 28 the right tibia, right greater trochanter, left tibial plateau and right ulna after a motor vehicle 29 2  accident. Twenty days after the accident, the patient underwent above-knee amputation of 30 the right lower limb. Despite numerous revisions/modifications of the prosthesis (socket, 31 type of suspension), the patient continued to report severe stump pain during physical 32 rehabilitation, presumably because of the formation of a bone spur, located near the 33 amputation site. The patient finally adopted a Mauch Knee prosthesis® (seal-in liner), but 34 the presence of pain substantially restricted prosthetic wearing time. Over the next 3 years 35 after amputation, different interventions (medications, ice, scar massage, prosthesis 36 adjustments) were tried to improve walking endurance, with limited success. 37 We proposed the intervention, consisting of four RSWT treatments (Intelect Mobile 38 RPW, Chattanooga, Guildford Surrey, UK), applied once a week for 4 consecutive weeks. 39 RSWT was applied over the 2 most painful sites, on the anterior and lateral parts of the 40 stump (Fig. 1). A total of 3700 impulses were given at each site with the following 41 protocol: 50 impulses at pressure 1.5 bars and frequency 3 Hz, 50 impulses with pressure 42 1.8 bars and frequency 4 Hz, 50 impulses with pressure 2 bars and frequency 6 Hz, and 50 43 impulses with pressure 3.9 bars and frequency 10 Hz. Hence, a total of 7400 impulses were 44 given per treatment session, except for the first treatment session, when the patient received 45 a total of 3700 impulses (RSWT was applied only on the external part of the stump). 46 RSWT parameters were based on the protocol described by Lohrer and colleagues [10].  47 Before RSWT, pain was evaluated at rest as 0 on a 0-10–mm on a numerical rating 48 scale (0 = no pain; 10 = worst pain imaginable) and 8 when walking with the prosthesis. 49 One week after the RSWT treatments, the patient reported that the stump pain had 50 completely disappeared (score 0 at rest and 0 when walking with the prosthesis). These 51 pain reductions were maintained 3 months after the last RSWT treatment.   52 An algometer (FPK Algometer, Wagner Instruments, Greenwich, CT, USA) was 53 used to determine pressure pain thresholds (PPTs) over the 2 most painful regions of the 54 stump, near the bone spur (mean of 3 trials for each site). PPT values before RSWT were 55 estimated at 3.6 kg for the anterior region (region A) and 2.6 kg for the lateral region 56 (region B) of the stump. PPT values increased after 1 week of RSWT for regions A and B 57 3  (Fig. 2), which indicates decreased pain sensitivity. PPTs further increased 3 months after 58 the intervention on region B, but decreased, slightly under the initial value, for region A. 59 Before RSWT, prosthetic wearing time, as reported by the patient, was limited to 15 60 min daily, owing to pain and discomfort. After the RSWT intervention, prosthetic wearing 61 time increased to 90 min daily. The improvement in prosthetic wearing time occurred 1 62 week after the end of RSWT and was maintained at 3 months after the last RSWT 63 treatment. The patient reported that the absence of stump pain improved prosthetic wearing 64 time, which was now limited by the presence of pain in the right groin region and the lower 65 back.  66 Radiography performed 1 week before the RSWT treatments revealed a bone spur 67 of 12.1 x 6.6 mm on the anterolateral part of the distal right femur, near the amputated site 68 (Fig. 3). Radiography performed 1 month after the intervention revealed no change in the 69 size of the bone spur (Fig. 3).  70 Here, we evaluated the effect of RSWT in an above-knee amputee experiencing a 71 symptomatic bone spur near the amputation site. After 4 sessions of RSWT, the patient 72 reported considerable alleviation of pain and increased prosthetic wearing time. These 73 improvements were supported by changes in PPT, measured over the 2 most painful 74 regions of the stump, near the bone spur. According to the rehabilitation professionals and 75 to the patient, the pain related to the bone spur played a significant role in the limited 76 amount of time the patient could walk with the prosthesis. Although we cannot exclude that 77 placebo effects contributed to the positive outcomes noted in this patient, they were 78 probably negligible. Indeed, in the last 3 years, the patient had undergone several 79 unsuccessful therapeutic interventions. Hence, conditioning effects and expectations (2 key 80 factors believed to play a role in placebo responses [11]) were probably very low and most 81 certainly had a minor impact on the reported results. Nevertheless, other important 82 limitations must be acknowledged (e.g., absence of randomization, control group or formal 83 quantitative test to evaluate walking). Replicating the present results with a larger sample 84 with more rigorous research designs are needed before any final conclusions can be made. 85 4  Radiography revealed no variation in the size of the bone spur after RSWT. These 86 observations agree with those of Yalcin and associates, who noted that the radiologic 87 changes after RSWT for heel spurs were unrelated to pain reduction [8]. The incongruence 88 observed between radiography findings and subjective findings related to pain suggest that 89 RSWT could play a positive role in the rehabilitation of patients with amputated limbs and 90 stump pain related to bone spur formation but that these effects are not driven by 91 musculoskeletal changes (i.e., osteoclastic activity reducing osteophyte size). Instead, the 92 application of RSWT over the painful area of the stump could trigger beneficial responses 93 in the nervous system. Other mechanisms such as neovascularisation, reduced inflammation 94 and collagen production could be involved [12, 13] and should be investigated in future 95 studies.  96 Few studies have investigated the effect of shockwave on pathological bone 97 formation in patients with amputated limbs. Brissot and associates reported that RSWT 98 reduced pain, improved range of motion and walking distance, and reduced the need for an 99 assistive device in 26 patients with heterotopic ossification of various origins [9]. However, 100 no radiologic measurements were performed to evaluate the effect of RSWT on heterotopic 101 ossification size. Another investigation showed that patients with amputated limbs and 102 painful stomp neuroma reported greater pain reduction after RSWT than conventional 103 therapy (transcutaneous electrical nerve stimulation, desensitization and pharmacological 104 therapy) [6]. Changes in the size of the neuroma were comparable with the 2 treatments, 105 which again suggests that the positive effect of RSWT in amputees are probably not solely 106 attributable to peripheral changes [6]. 107 The results of our case suggest that RSWT could be an interesting therapeutic 108 modality for patients with post-amputation pain related to bone spurs. Radiology revealed 109 that RSWT had no effect on the size of the bone spur. Future studies, investigating the 110 potential mechanisms of action of RSWT in patients with pain related to bone spurs are 111 warranted. 112 5  Consent 113 The research protocol was approved by the ethics committee of the Research Centre on 114 Aging (Sherbrooke, PQ, Canada) and the participant provided an informed written consent 115 before participating in the study. 116 Conflict of interest 117 The authors have no conflicts concerning this article. 118 Acknowledgements 119 The authors thank Dr. Nathalie Perreault for clinical support and Catherine Crewe for 120 thoughtful comments on the manuscript. 121 Figure legends 122 Figure 1. Region A (superior view) and region B (lateral view) (represented by filled 123 circles) of the stump of the amputated right lower limb that were most painful to the 39-124 year-old male. Pressure pain thresholds were measured on these 2 regions before and after 125 radial shockwave therapy (RSWT). 126 Figure 2. Pressure pain threshold values before (baseline) and 1 week and 3 months after 127 RSWT for regions A and B of the stump. 128 Figure 3. Radiographic images of the bone spur on the amputated limb A) before and B) 129 after RSWT.  130  131 References 132 [1] Clark GS, Naso F, Ditunno JF, Jr. Marked bone spur formation in a burn amputee 133 patient. Archives of physical medicine and rehabilitation 1980;61:189-92. 134 [2] Matsumoto ME, Khan M, Jayabalan P, et al. Heterotopic ossification in civilians 135 with lower limb amputations. Archives of physical medicine and rehabilitation 136 2014;95:1710-3. 137 [3] Liu K, Tang T, Wang A, et al. Surgical revision for stump problems after traumatic 138 above-ankle amputations of the lower extremity. BMC musculoskeletal disorders 139 2015;16:48. 140 6  [4] Moya D, Ramon S, Guiloff L, et al. Current knowledge on evidence-based 141 shockwave treatments for shoulder pathology. International journal of surgery 142 2015;24:171-8. 143 [5] Bélanger AY. Extracorporeal shockwave therapy. In: Bélanger AY, editor. 144 Therapeutic Electrophysical Agents: Evidence Behind Practice 145 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2015. p. 411-28. 146 [6] Jung YJ, Park WY, Jeon JH, et al. Outcomes of ultrasound-guided extracorporeal 147 shock wave therapy for painful stump neuroma. Ann Rehabil Med 2014;38:523-33. 148 [7] Martini L, Fini M, Giavaresi G, et al. Primary osteoblasts response to shock wave 149 therapy using different parameters. Artificial cells, blood substitutes, and immobilization 150 biotechnology 2003;31:449-66. 151 [8] Yalcin E, Keskin Akca A, Selcuk B, et al. Effects of extracorporal shock wave 152 therapy on symptomatic heel spurs: a correlation between clinical outcome and radiologic 153 changes. Rheumatol Int 2012;32:343-7. 154 [9] Brissot R, Lassalle A, Vincendeau S, et al. Treatment of heterotopic ossification by 155 extracorporeal shock wave: 26 patients. Annales de readaptation et de medecine physique : 156 revue scientifique de la Societe francaise de reeducation fonctionnelle de readaptation et de 157 medecine physique 2005;48:581-9. 158 [10] Lohrer H, Nauck T, Scholl J, et al. Extracorporeal shock wave therapy for patients 159 suffering from recalcitrant Osgood-Schlatter disease. Sportverletzung Sportschaden : Organ 160 der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin 2012;26:218-22. 161 [11] Goffaux P, Leonard G, Marchand S, et al. Placebo analgesia. Pharmacology of Pain 162 2010451-73. 163 [12] Waugh CM, Morrissey D, Jones E, et al. In vivo biological response to 164 extracorporeal shockwave therapy in human tendinopathy. European cells & materials 165 2015;29:268-80. 166 [13] Wang CJ, Ko JY, Kuo YR, et al. Molecular changes in diabetic foot ulcers. Diabetes 167 research and clinical practice 2011;94:105-10. 168  169 

Radial shockwave therapy for a painful bone spur in an above-knee amputee

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