Therapeutic and functional approach for the treatment of patients with bone marrow edema in Rehabilitation Medicine

Bone marrow edema (BME) represents an imaging finding in various diseases, and often causes pain and significant dysfunction. Although few data are available about its etiology, several hypotheses have been developed to explain the pathogenetic mechanisms of BME. Increased intravascular pressure and capillary leakage within the bone marrow would lead to nerve irritation, causing pain. Bone turnover would increase locally, due to proinflammatory molecules driven by the primary cause of BME (trauma, ischemia, arthritis, etc.). In addition to imaging findings, the clinical evaluation of a subject affected by BME should rely on an accurate functional assessment, as this condition often leads to transient disability. As regards therapeutic approaches, recent research works have reported benefits from the extracorporeal shock wave treatment (ESWT) and above all bisphosphonates. A deeper knowledge of the pathophysiological bases of the BME combined with the classic physiatric approach can allow to select the subjects affected by BME who can benefit from therapies such as bisphosphonates and ESWT, and evaluate their clinical and functional effects.

Ultrasound follow up: Is an undetected spontaneous expulsion of stone fragments a sign of extracorporeal shock wave treatment failure in kidney stones?

Introduction. After extracorporeal lithotripsy (SWL), a spontaneous expulsion of fragments is often reported. The aim of this study is to demonstrate the presence of a stone free status or the presence of clinically insignificant residual fragments (CIRFs, defined as “asymptomatic, noninfectious, ≤ 3 mm fragments”) in people with undetected spontaneous expulsion. Materials and methods. Between May and September 2017, we performed a total of 87 treatments. The device used was a Storz Medical Modulith® SLK. All the patients were treated in prone position to reduce respiratory movements and underwent sonography before and four to eight weeks after the treatment. An in line ultrasound targeting was possible with all the stones. People lost to follow up or with ureteral stones were excluded. Patients were divided in groups according to gender, previous treatments, stone diameter and position. Results. We enrolled 73 patients. 57 patients had a single stone and 16 multiple stones. A mean number of 3044 shock waves was administered with a maximum average energy of 0.68mj/mmq. At follow up, 41 patients (56.2%) were found stone free or with CIRFs. The association between undetected expulsion and the presence of CIRFs is considered to be not statistically significant (p = 0.89). Among patients with CIRFs, 25/41 didn’t report expulsion. Taking in account the groups our population was divided in, according to gender (p = 0.36), previous treatments (p = 0.44), stone diameter (p = 0.28) and stone position (p = 0.35), the association between undetected spontaneous expulsion and presence of CIRFs was never statistically significant. Conclusions. An undetected spontaneous expulsion of stone fragments could not be considered a sign of SWL treatment failure. The association between undetected expulsion and presence of CIRFs is never statistically significant if gender of the patients, previous treatments, stone diameter and stone position are considered.

Analgesic Effect of Extracorporeal Shock Wave Treatment Combined with Fascial Manipulation Theory for Adhesive Capsulitis of the Shoulder: A Retrospective Study

Objectives. This study aims to explore whether extracorporeal shockwave treatment (ESWT) based on the theory of fascial manipulation (FM) at select treatment points is superior to traditional local ESWT for pain relief in adhesive capsulitis of the shoulder. Methods. Data from patients with adhesive capsulitis of the shoulder who received weekly ESWT according to fascial manipulation theory (ESWT-FM) or local extracorporeal shockwave treatment (L-ESWT) during a 5-week treatment period were evaluated. Pain-on-movement numeric rating scale (p-NRS) and range of motion (ROM) testing were performed before the treatment period, after the first treatment, and after the fifth treatment. Results. There were significant reductions in pain scores in the ESWT-FM group (p<0.05) after the first treatment, and after the fifth treatment, both groups had marked, significant improvement (p<0.05), with a significantly greater reduction in pain (p-NRS) in the ESWT-FM group compared to the L-ESWT group (p<0.05). There was no significant difference in terms of ROM in the L-ESWT group, while there was slight improvement of forward flexion in the ESWT-FM group after the fifth treatment. Conclusions. ESWT-FM provided faster pain relief and slightly more notable improvement of function compared with L-ESWT for the patients with adhesive capsulitis of shoulder.