EUROPEAN JOURNAL OF INFLAMMATION

CHRONIC ULCERS: TREATMENT WITH UNFOCUSEDEXTRACORPOREAL SHOCKWAVES

Vol. II, no. 2, 499-509 (2013)

R. SAGGINI', P. FIORAMONTF, R.G. BELLOM03, A. DI STEFANO\ L. SCARCELLO\L. DI PANCRAZI03, P. IODICE!, A. SAGGINP and N. SCUDERF

'Department ofNeuroscience and Imaging, "G. d'Annunzio" University, Chieti, Italy; 2DepartmentofPlastic and Reconstructive Surgery, University ofRome "Sapienza", Rome, Italy; 3DepartmentofMedicine and Science ofAging, "G. d'Annunzio" University, Chieti, Italy; 'School ofSpecialtiesin Physical Medicine and Rehabilitation, "G. d'Annunzio" University, Chieti, Italy; 'Department of

Dermatology, University ofRome "Tor Vergata", Rome, Italy

Received July 31, 2012 - AcceptedApril 22, 2013

The aim of this study was to evaluate the efficacy of the treatment of chronic ulcers with unfocusedshock waves. Between March 2009 and February 2012 we studied a group of 124 patients, aged between28 and 80 years, with serious wounds arisen over three months and who met the inclusion criteria fortreatment. The patients were randomly divided into groups A and B, both treated with unfocused ESWTbut with an average energy density for each impulse equal to 0.10 m.l/mm' in group A (total energy equalto 1.7 mJ for each shot) and an average energy density for each impulse equal to 0.04 m.I/mm- in groupB (total energy equal to 3.3 mJ for each shot). The pulses were administered at a frequency of 4 Hz inboth groups. Wounds were classified according to: location, width, length, percentage of granulationtissue, necrotic tissue, fibrous tissue, presence of bacterial exudation and pain (assessed by VAS). Theirevolution was monitored by photo capture. The patients were treated with a frequency of 1 session every7 days for 7 weeks. During the treatment period, the possible occurrence of side effects was monitored.Before treatment the wounds in group A had an average area equal to 3.85 em- and the average value ofthe VASpain scale was equal to 5.8 (range 2-9); the wounds in group B had an average area equal to 3.4ern"and the average value ofthe VASpain scale was equal to 5.7 (range 3-9).At the end of the treatmentprotocol the mean area in group A decreased by 80% (final mean area 0.93 em"), and the average painon VAS scale dropped by 79%; the mean area in group B decreased by 67% (final mean area 1.2 ern")and the average score on VAS scale dropped by 48%. None of the treated patients experienced adversereactions to treatment. None of the treated wounds developed infection during treatment. In conclusion,shock waves can act on difficult wounds, stimulating the reparative physiological process; therefore itrepresents an effective and safe procedure to accelerate the healing process, reducing the operating costsand avoiding more complex interventions.

Chronic ulcers are complex wounds that do notheal spontaneously and are usually associated withlocal and systemic predisposing factors (1).

Wound healing is a dynamic process influencedby homeostatic balance, inflammatory and matrix-synthesis process, and by an appropriate process

Key words: chronic ulcers, unfocused shock waves, wound healing

Mailing address: Prof. Raoul Saggini,Unit ofPhysical Medicine and Rehabilitation,"G. d'Annunzio" University,Viale Abruzzo 322,66013 Chieti, ItaliaTel.: +390871587107e-mail: saggini@unich.it

1721-727X (2013)Copyright © by BIOLIFE. s.a.s.

This publication andlor article is for individual use only and may not be furtherreproduced without written permission from the copyright holder.

Unauthorized reproduction may result in financial and other penalties499 DISCLOSURE: ALL AUTHORS REPORT NO CONFLICTS OF

INTEREST RELEVANT TO THIS ARTICLE.

500 R. SAGGINI ET AL.

of tissue remodelling. From a histological point ofview, the healing process is divided into three mainstages: inflammatory stage, proliferative stage, andmaturation or remodelling stage (2-4).Inflammation occurs in the tissue as the first

immediate response to injury. In the inflammatoryphase, vasodilation causes an increased permeabilityof blood vessels, vasocongestion and loss of serousfluids into the surrounding tissue. When the acuteresponses ofhomeostasis and inflammation are over,the wound healing begins (5).During the proliferative phase, the recovery

processes consist of: angiogenesis, fibroplasiaand epithelisation. This second stage is defined bythe production of granulation tissue composed ofcapillary bed, fibroblasts, macrophages and a loosearrangement of collagen, fibronectin, hyaluronicacid and bacteria. The proliferative stage resultsin the wound filling up with connective tissue andcovered with epithelium.In the maturation stage the wound contracts

through the internal moving ofthe surrounding tissueand skin and is reduced in size. The alteration ofone of these physiological steps leads to the chronicwound.A chronic wound is histologically determined

by lack of organization in endothelial proliferation,presence of parakeratotic keratinocytes, connectivetissue disorganization, increasing in keratinocytesand granulocytes, disorders of proteins, electrolytesand cytokines (1-6).The main causes affecting the physiological

healing process are: pressure, slipping and shearingforces, reduced mobility, sensory-motor functionimpairment, poor nutrition, advanced age, changesin hematopoiesis and external factors such aspsychosocial problems, prolonged immobilizationand infections (5). Many studies have shown thatthe predisposing bacteriological factor has a directcorrelation between high levels of bacteria inpressure ulcers and lack of tissue repair (7,8).Previous studies showed that shock waves are

effective in stimulating several endogenous growthfactors such as EGF, IGF1, VEGF and nitric oxideproduction, inducing angiogenesis and promotingthe healing of fractures, ulcers and complex lesions(1, 9-16). In their 2005 studies Gerdesmeyer et al.showed the antibacterial effect of shock waves

mediated by cavitation (17); in 2009 Kuo et al.also showed that when administered properlyextra corporeal shock wave therapy (ESWT) isable to: reduce the inflammatory response withsubsequent reduction in the number of circulatingleukocytes and of oxygen free radicals; promote theproduction of fibroblasts and the vascularization ofthe compromised skin, thus reducing the number ofapoptotic cells (18). That study assessed whetherESW treatment rescues the compromised flap tissueby suppressing the apoptosis of ischemic tissue andstimulating tissue regeneration. A random-patternextended dorsal-skin-flap (10 x 3 em) rodent modelwas used: skin grafts distal to the treated area wereapplied on 36 rats randomly divided into 3 groups(each consisting of 12 rats): the first group did notreceive treatment with ESWT, the second group wastreated with a single session of ESWT immediatelyafter surgery, and the third group was treated with2 sessions of ESWT, one immediately after surgery,the other the next day. The assay of the above-mentioned elements showed positive results in thegroups treated with shock waves compared to theuntreated one and a most significant advantage in thegroup treated with a single session of shock wavescompared to the one treated with two consecutivesessions.Human ulcer histological analysis also showed

a statistically significant increase of von Willebrandfactor (vWF), vascular endothelial growth factor(VEGF), endothelial nitric oxide synthase (e-NOS),antigen nuclear proliferation (PCNA) and theexpression of epidermal growth factor (EGF) withreduction of the expression of TUNEL, which is asignal of the cellular apoptotic cascade (19, 20).These results allow to develop patterns of

treatment in order to reduce the inflammatoryprocess and the excessive protease activity and, atthe same time, promote angiogenesis, and fibroblastproliferation as well as keratinocytes migration,inducing a correct biological process of woundhealing.

MATERIALS AND METHODS

Thestudywasapproved by the localethicscommittee,and was performed in accordance with the 1964Declaration of Helsinki. Subjects were informed about

European Journal of Inflammation 501

the procedures and purposes of the research and gave theirwritten informed consent before participating.

A randomized blind assessment controlled trial wasdesigned to study the efficacy of shock wave treatmentproduced by the unfocused probe through the analysisof the percentage of wound healing (calculated as thereduction in wound area divided for the initial areapercentage).

The study was carried out by the Department ofPhysical Medicine and Rehabilitation of"G. D' Annunzio"University in Chieti, and the Department of Plastic andReconstructive Surgery of "Sapienza" University inRome.

The secondary outcome of the study was to assessthe antibacterial effect through the evaluation of specificbuffers and the search for possible occurrence of infectionduring therapy. Inclusion criteria were as follows: vascular(blood-based and/or venous), diabetic, pressure, bum,iatrogenic, post-traumatic ulcer or ulcer in autoimmunedisease. No wound healing progression or loss ofsubstancefor at least 3 months; age over 18 years; informed consentsignature.

Exclusion criteria were: arrhythmias; pacemaker;severe bleeding disorders; cancer close to the treatmentarea; pregnancy; presence of growing cartilage; localacute inflammation; bone exposure; wound area less than

I em- or greater than IOx20 em,One hundred and twenty-four patients (67 men, 57

women), aged between 28 and 80 years, meeting theinclusion criteria were treated between March 2009and February 2012. The selected patients had chroniculcers for at least 3 to 24 months before the beginning oftherapy (mean 10 months). They were randomly dividedinto 2 treatment groups A and B; all patients receivedunfocused ESWT treatment; patients in group A weretreated with Dermagold unfocused probe (MTS EuropeGmbH, Constance, Germany), patients in group B weretreated with Evotron unfocused probe (HMT, Lengwil,Switzerland). All patients were treated with a frequencyof I session every 7 days for 7 weeks. A medical recordwith personal data, main disease (responsible for ulcer),secondary diseases, time of onset, previous treatmentsand their costs, and previous medications was completedfor each patient.

Before and after the treatment period the ulcers wereclassified according to: localization, width (in em), length(in ern), percentage of granulation tissue, necrotic tissue,fibrous tissue, presence of bacterial exudate (classifiedas absent, minimal, moderate, high) and pain, whichwere assessed by Visual Analogic Scale (VAS). Themorphological evolution was monitored, taking photosbefore each session using digital cameras with resolution

144 subjects aged between 28 and 80 with chroniculcers

20 subjects excluded because they had ulcers forless than 3 months

124 patients with all the inclusion criteria

124 randomized subjects

62 subjectsDermagoldgroup

N" 2 withdrawn (lack of protocolcompliance)

60 subjectswith full data

Fig. 1. Flow chart ofpatients enrolled in the study.

62 subjectsEvotrongroup

40 subjects withfull data

N" 22 withdrawn (lack ofprotocol compliance)

Table I. Relation between wound area and number ofshots administeredfor each session.

higher than 5 megapixels and macros function; all pictureswere taken at the shortest distance necessary to frame thelesion and the standardized squared.

After each session dressing with povidone-iodine andapplication of fat gauze, Connettivina (Fidia FarmaceuticiS.p.A, Italy) and semipermeable occlusive patches wascarried out. During the treatment period, the possibleoccurrence of side effects such as pain, petechiae andcutaneous adverse reactions related to therapy wasmonitored (21-22) (Fig. I).

Sixty-two subjects (39 men and 23 women) agedbetween 28 and 80 years (mean age 62 years), wereincluded in GroupA, two ofwhom dropped out ofthe studybecause of personal problems. Of the remaining patients,23 had diabetic ulcers, 10 pressure ulcers, 10 traumaticulcers, 19 vascular ulcers. All subjects were alwaystreated with ESWT unfocused probe with Dermagoldelectrohydraulic system (MTS Europe GmbH, Constance,Germany); the mean energy density applied for each pulsein Group A was equal to 0.1 m.l/rnrrr' (0.09/0.11 ml/mm-),with a total energy equal to 1.7 mJ for each shot.

Sixty-two subjects (28 men and 34 women) agedbetween 30 and 80 years, were included in Group B, 22ofwhom dropped out of the study after the first treatmentsession and were not included in the final evaluation.Of the remaining 40 patients (16 men and 24 women),aged between 33 and 77 years (mean age 61 years), 9had diabetic wounds, II post-trauma wounds, I patientpressure ulcer, 16 vascular wounds and 3 wounds incryoglobulinemia. All subjects were always treated withESWT unfocused probe with Evotron electrohydraulicsystem (HMT, Lengwil, Switzerland); the mean energy

502

Wound area (em") Number of shots

300

400

500

600

R. SAGGINI ET AL.

density applied in Group B was equal to 0.04 ml/rnm',with a total energy equal to 3.3 mJ for each shot.

In both Groups A and B, 300 to 600 shots wereadministered per session relating to the wound area, asshown in Table I, at a frequency of 4 Hz or 240 pulsesper minute.

All data are given as means ± SDs. Differencesbetween mean values before and after the treatmentperiod were tested for significance using Student's t-testfor paired observations. ANOYA with an interaction testwas used to compare the responses to the treatment in thetwo groups. Fischer's PLSD test for post hoc analysis wasemployed. The minimum level of statistical significancewas set at P<0.05. GraphPad Prism (version 5) software(Abacus Concepts GraphPad Software, San Diego, CA,USA) for statistical analysis was used.

RESULTS

Before treatment the average area of the 62wounds in Group A was equal to 3.85 em- As forthe location of ulcers, 21 patients had lesions on thelower limbs, 31 on the foot-ankle complex, lOin thepelvic region.At first, lesions were made of 56% granulation

tissue, 37% fibrous tissue, and 7% necrotic tissue; 29subjects showed complete autonomy in the ordinarydaily activities, 23 showed reduced autonomy, 10showed autonomy with wheelchair; pain assessmentin the early phase showed a mean VAS of 5.8, range2-9.Before treatment, the mean wound area In Group

B was equal to 3.4 cm-; as for the location of ulcers,28 were on the foot-ankle complex, 14 on lowerlimbs, in particular 2 patients had lesions on bothlower limbs.At first lesions were represented by an average

of 55% of granulation tissue; 35% of fibrous tissueand 10% of necrotic tissue; among the 40 selectedpatients, 25 had complete autonomy, 14 reducedautonomy, I patient had autonomy with a wheelchair;pain assessment in the initial phase in this Groupshowed a mean VAS of5.7, range 3-9. No patient inany group underwent antibiotic therapy during thewhole treatment period.Improvement in vascularization is quantitatively

difficult to assess, therefore the surrounding skin,being a valid indicator of tissue distress, wasmonitored to determine the successful closure orreduction in size of the lesions in both groups during

GROUP AWOUND AREA

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GROUP A

503

Meanwound area

Fig. 2. Mean wound area in Group A bef ore treatment andafter the 7th session.

the treatment. The mean area in Group A, equal to3.85 cm2 at the beginning, decreased by 80%, with afinal average value of 0.93 cm2 (p <0.001) (Fig. 2).The 23 diabetic wounds in this group showed an

85% mean decrease of the row surface area froma mean surface area of 1.45 em' to a final averagesurface area of 0.2 em' . The 10 pressure woundsshowed a 68% mean decrease of the row surfacearea rising from a mean surface area equal to 9.8 ern'to a final surface area of 3.1 em' . The 10 traumaticwounds showed an 87% decrease of the row surfacearea rising from a mean surface area of 1.2 em' toa mean surface area of 0.15 cm/. The 19 vascularwounds showed a 76% decrease of the row surfacearea rising from a mean surface area of 2.75cm2 to amean surface area of 0.65 em' (Fig. 3).None of the patients in Group A experienced

adverse reactions to therapy during the treatment.After 7 weeks of treatment 44 patients showed acomplete wound healing while the other 18 had apartial recovery. As for pain, there was a 79% meanVAS reduction (p <0.001) (4.5 points decreasecompared to the initial value) with a final averagevalue equal to 1.3 (range 0-4), as shown in Fig. 4.No wound in Group A developed infection during

therapy;such evidencemayberelated tothebactericidaleffect of this system because negativization of cultureswabs was found in 3 subjects with positive S. aureus.Each patient from Group A showed improvement inperilesional skin trophism.As for the approval of treatment, 2 patients in

group A abandoned the treatment after the fifth

Fig. 3. Mean wound area for each disease at the fi rstsession and after the Z'" week oftreatment in Group A.

VASGROUP A

Fig. 4. Pain level assessed by VAS at the / " and after the7th sessions in Group A.

session for personal reasons (Table 11).The mean surface area in Group B, equal to 3.4

em? at the beginning, decreased by 67%, with afinal average value of 1.2 ern- (p <0.00 I). Diabeticwounds in this group achieved a 60% mean decreaseof the row surface area rising from a mean surfacearea of 1.2 em' to a final average surface area of0.48cm-; traumatic wounds obtained an 85% decreaseof the row surface area rising from a mean surfacearea of 1,2 em? to a mean surface area of 0.18 ern";pressure wounds demonstrated a 72% mean decreaseof the row surface area rising from a mean surfacearea equal to 8.8 em- to a final surface area of 2.5em'; vascular wounds demonstrated a 61% decreaseof the row surface area rising from a mean surfacearea of 3.5 ern? to a mean surface area of 1.37 cm-;as for wounds in patients with cryoglobulinemia we

504 R. SAGG I:'III ET AL.

Table II. Compliance to therapy in group A where 2 patients abandoned the protocol.

WOUND AREA WOUNDAREA VAS VAS REASOl'i FOR

GROUPA AGE 1STsession 5THsession 1sTsession 5THsession WITHDRAWAL

I 73 11.5 1.7 5 4 CHANGE OF RESID ENCE

., 78 7 4.5 4 3 CHANGE OF RESID ENCE

GROUP BWOUND AREA

VASGROUP B

Fig. S.Mean wound area in Group B before treatment andafter the 7th session.

GROUP B

Meanwound area

Fig. 6. Mean wound area f or each disease at the fir stsession and after the 7th week of treatment in Group B.

found a 33% decrease of the row surface area (Figs .5 and 6).None of patients in Group B experienced adverse

reactions to treatment (bleeding, petechiae) apartfrom IS patients who withdrew from the studybecause of pain .At the end of therapy, 16 patients achieved

Fig. 7. Pain level assessed by VAS at the I" and after the7th session in Group B.

complete healing, 15 obta ined partial recovery, 9wounds (5 from vascular insufficiency, 2 in diabeti cmicroangiopathy, 2 in cryoglobulinemia) showedno improvement. As for pain, in Group B, there wasa 48% mean VAS reduction (2.7 reduction pointscompared to the initial value) with a final meanvalue equal to 3 (range 1-6) (Fig. 7).As for the approval of treatment, 22 patients

withdrew from the study after the first session forpersonal reasons as described in Table III.No wound in Group B developed infect ion

during therapy ; such evidence may be related to thebactericidal effect ofthis system because dejection ofStaphylococcus aureus in culture swabs was found.Each patient from Group B showed improvement inperilesional skin trophism.Both groups A and B showed a good response

to treatment with a sign ificant reduction in woundareas after 7 weeks and a peak of increase in termsof wound size reduction, between the third and thefourth week of treatment. During the last evaluationGroup A showed a greater area reduction than GroupB (Fig. 8 and 9).

European Journal of Inflammation

Table III. Compliance to therapy in group B where 22 patients abandoned the protocol.

505

WOUND WOUND AREA VAS VAS REASON FORGROUPB AGE AREA 2nd session I" session 2nd session WITHDRAWALI" sessionDIFFICULTY INI 68 2 1.7 7 7 MOVING and PAINCHANGE OF2 77 1.5 1.5 4 5 RESIDENCE and PAINCHANGE OF3 28 3 2.7 7 4 RESIDENCE and PAINDIFFICULTY IN4 80 3.4 3 5 4 MOVINGCHANGE OF5 77 13 12.5 7 6 RESIDENCE and PAINDIFFICULTY IN6 45 2 1.5 8 7 MOVINGDIFFICULTY IN7 71 1.7 1.6 7 7 MOVING and PAINCHANGE OF8 71 2 1.7 4 4 RESIDENCE and PAINDIFFICULTY IN9 45 10.3 9.5 8 7 MOVINGCHANGE OF10 45 5 4.7 9 9 RESIDENCE and PAINCHANGE OFII 52 4 3.4 4 3 RESIDENCE and PAINCHANGE OF12 54 2.5 2.2 4 4 RESIDENCE and PAINCHANGE OF13 28 2 2 5 4 RESIDENCE and PAINDIFFICULTY IN14 80 2.7 2.5 5 7 MOVING and PAINDIFFICULTY IN15 72 3 3 6 7 MOVINGCHANGE OF16 70 3.5 3.2 8 7 RESIDENCE and PAINDIFFICULTY IN17 55 4.4 4.3 5 7 MOVINGDIFFICULTY IN18 45 3 2.7 5 5 MOVING and PAINDIFFICULTY IN19 47 2 1.7 7 6 MOVING and PAINCHANGE OF20 73 3.5 3.2 6 4 RESIDENCECHANGE OF21 38 3 2.5 4 I RESIDENCE and PAINDIFFICULTY IN22 73 2 1.4 7 5 MOVING

506 R. SAGGINI ET AL.

Two-way ANOVAwith RM by columns5

4

3

2

1

...... GROUPA

... GROUP B

O......."T"""-"T"""--r---r--r--r--r-

Fig. 8. Comparison ofthe responses to treatment between group A and group B.

Fig. 9. Evolution in tissue regeneration in a patient (male, 77 y, 90kg, 1.70h) with pressure wound in gluteal region.Before (a), after (b) treatment and at 5-monthfollow-up (c).

DISCUSSION

Chronic wound treatment is becoming animportant economic and social issue related to theincrease in the average population age because ofthe necessary costs for management, not only infinancial terms but also in human resources (1, 23),patients quality of life and psychological impact onthem (24).Therefore, it would be interesting to find

therapeutic solutions able to aid the healing processby reducing, at the same time, the amount ofdressings applied, the need for assistance in woundcare and the need for surgery.

Nowadays, chronic wound treatment is based onmechanical debridement, use of flaps or skin grafts,advanced dressings and, in an experimental way,application of a particular type of acoustic wave,defined shock wave. ESWT basically representsa cellular activator because of its ability to induceangiogenesis, to stimulate the increase in growthfactors and promote cell differentiation (25-26).The results showed that in both groups there was

a significant decrease in the percentage (p <0.001)of the row surface area with a greater value in GroupA compared to Group B, respectively equal to80% and 67%. Moreover, pain reduction, assessedby VAS, was statistically significant (p <0.001) inboth groups, but with a larger value in group A (4.5)

European Journal of Inflammation 507

versus group B (2.7).Application oflow energy unfocused shock waves

for difficult wounds was confirmed by histologicalstudies ofanimal skin models (10, 12, 16,27,28) anda pilot study on humans carried out by Saggini et al.2008 (1). In our study, clinical trials on humans agreein terms of efficacy, with histological data in animalmodels found by Kuo in 2009.Pain reduction obtained in both groups confirmed

the effectiveness of ESWT in stimulating analgesiathrough modulation ofpain chemical mediators suchas blocking of pain signal transmission induced bysubstance P (29-35).Dividing the analysis of results according to

wound ethiology, there was a significant responsein diabetic and traumatic wounds compared to thevascular and ischemic ones, data is shown for bothgroups A and B. These results are probably to berelated, according to other studies (1), to systemiccompromise which leads to greater disability inpatients with ischemic and vascular lesions. Thegreat importance of effectiveness of shock wavesin pressure-ischemia wounds should be consideredbecause of their ability to decrease the number ofinterventions for clutches or skin flaps as evidencedby Larking et al. 2010; this also intersects with thebactericidal effect by induction of implosion ofbubbles which exert a mechanical stress on bacterialcell membrane, promoting death, as supported byGerdesmeyer et al. 2005 (17).Improvement of perilesional skin trophism in

both groups is significant, but the results of groupA are certainly better as they are related to a highertotal density of energy transferred from the probein each therapeutic session. Moreover, the temporalsequence of therapeutic applications, a session ofshock waves every 7 days in both groups showed apeak ofthe largest increase in terms ofsize reparativespace between the third and fourth week oftreatment.Our hypothesis is that this can be attributable to themechanisms of energy transfer that the summationof ESWT, as activator and promoter of cell growthfactors, is able to manifest through a summation ofenergy transfer in a specific time. This time is notcharacterized by a single application or a doublerepeated application at a distance of 24 hours: in ouropinion, an expression ofmore energy transfers after7 days of rest is required in order to express a better

quality in tissue response. ESWT can thereforebe compared with other therapies, for examplehyperbaric, which require one or two sessions perweek for several months (18-20, 27).

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