Recomendaes sobre o tratamento com ondas de choque em afeces osteomusculares

Ttulo: Recomendaes sobre o tratamento com ondas de choque em afeces osteomusculares Origem: Unimed SC Autor: Dr. Carlos Augusto Cardim de Oliveira Especialidade: Ortopedia, Auditoria Mdica Data de criao: Outubro/2004 Data da ltima atualizao: maio/ 2006 Data para nova atualizao: Cdigos AMB: Cdigos CBHPM: 3.11.02.31-0 CID-10 envolvidos: M65.2; M65.9; M70.3; M75.2 Situao (consagrada/ em Consagrada estudo): OBJETIVO Descrever as principais indicaes para o emprego da litotripsia extracorprea por ondas de choque em pacientes com afeces osteomusculares. PROFISSIONAL ALVO Ortopedistas e Auditores Mdicos FUNDAMENTAO Os termos dor lateral do cotovelo e cotovelo do tenista so usados referindo-se a epicondilite lateral ou peritendinite do ombro, afeco cuja prevalncia de 13% e que causa bastante desconforto ao paciente e custos expressivos com seu tratamento. O pico de incidncia situa-se entre os 40 e 50 anos, os sintomas costumam durar de 18 meses a dois anos e alguns casos acabam sendo tratados cirurgicamente. A causa da dor parece estar diretamente relacionada leso insero msculo-tendinosa do extensor lateral comum ao epicndilo lateral, eventualmente com leses e reas degenerativas do ligamento colateral. As ondas de choque so geradas a partir de energia eltrica convertida em ondas eletro-acsticas de impedncias diferentes, que podem ser dirigidas a um determinado ponto. Desde 1976 estas ondas tm sido utilizadas na forma de litotripsia para desintegrar clculos renais e biliares. A partir de 1990 estudos realizados na Alemanha descreveram seu uso em pacientes com doenas msculo-esquelticas (fraturas de difcil consolidao, tendinite do ombro,

epicondilite medial e lateral, fascite plantar, calcanhar doloroso, epicondilite mero-radial, pseudoartrose). O mecanismo pelo qual o procedimento teraputico agiria ainda no est completamente elucidado. A tcnica, a dosagem e a freqncia a serem empregadas para cada afeco ainda no esto padronizadas, assim como no est plenamente estabelecida a necessidade de anestesia local antes do procedimento. (1) METODOLOGIA Fonte de dados Bancos de dados informatizados: Medline, Clinical Evidence, Cochrane Library, MD consult e outros especificados nas referncias bibliogrficas, quando as informaes obtidas nos primeiros no responderam a todas as questes. Palavras-chave Extracorporeal shock wave therapy. Desenhos dos estudos buscados Revises sistemticas, ensaios controlados, guidelines baseados em evidncias e revises narrativas no sistemticas quando as informaes obtidas no responderam a todas as questes. RESUMO DAS PUBLICAES SELECIONADAS Haake M, Konig IR, Decker T, Riedel C, Buch M, Muller HH; Extracorporeal Shock Wave Therapy Clinical Trial Group. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial. Bone Joint Surg Am. 2002 Nov;84-A(11):1982-91. BACKGROUND: On the basis of observational trials, numerous investigators have recommended extracorporeal shock wave therapy as an alternative treatment for chronic lateral epicondylitis of the elbow. However, there has been no evidence of its efficacy from well-designed randomized clinical trials. The objective of this study was to find out whether extracorporeal shock wave therapy in combination with local anesthesia was superior to placebo therapy in combination with local anesthesia. METHODS: A randomized multicenter trial with a parallel-group design was conducted. Following administration of local anesthesia, either extracorporeal shock wave therapy with three treatments of 2000 pulses each and a positive energy flux density (ED+) of 0.07 to 0.09 mJ/mm (2) or placebo therapy was applied on an outpatient basis. Treatment allocation was blinded for patients and for observers. The primary end point was based on

the rate of success, as determined with the Roles and Maudsley score and whether additional treatment was required, twelve weeks after the intervention. Crossover was possible after assessment of the primary end point. Secondary end points were the Roles and Maudsley score, subjective pain rating, and grip strength after six and twelve weeks and after twelve months. The planned number of 272 patients was included in the study. RESULTS: The primary end point could be assessed for 90.8% of the patients. The success rate was 25.8% in the group treated with extracorporeal shock wave therapy and 25.4% in the placebo group, adifference of 0.4% with a 95% confidence interval of -10.5% to 11.3%. Similarly, there was no relevant difference between groups with regard to the secondary end points. Improvement was observed in two-thirds of the patients from both groups twelve months after the intervention. Few side effects were reported. CONCLUSIONS: Extracorporeal shock wave therapy as applied in the present study was ineffective in the treatment of lateral epicondylitis. The previously reported success of this therapy appears to be attributable to inappropriate study designs. Different application protocols might improve clinical outcome. We recommend that extracorporeal shock wave therapy be applied only in high-quality clinical trials until it is proved to be effective. Hammer DS, Adam F, Kreutz A, Kohn D, Seil R. Extracorporeal shock wave therapy (ESWT) in patients with chronic proximal plantar fasciitis: a 2-year follow-up. Foot Ankle Int. 2003 Nov;24(11):823-8. The aim of this study was to compare the effect of extracorporeal shock wave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a further conventional conservative treatment. Forty-seven patients (49 feet) with a previously unsuccessful non surgical treatment of at least 6 months were randomized to two groups. Heel cups had to be worn throughout the study. Group 1 (25 heels) was treated immediately with three sessions of ESWT (3000 shock waves/session of 0.2 mJ/mm2) at weekly intervals. The patients of group 2 (24 heels) continued non surgical treatment (iontophoresis with diclofenac and an oral non steroidal anti-inflammatory drug) for 12 weeks. After this period they were treated using the protocol of group 1. No significant difference of pain and walking time after further non surgical treatment (3 months) was seen in group 2. At 12 weeks after ESWT, the pain estimation on the visual analogue scale (VAS) for activities of daily living diminished significantly by 62.9% in group 1 and by 63.0% in group 2. The comfortable walking time had increased significantly in both groups. Two years after ESWT, pain during activities of daily living decreased by 94% in group 1 and by 90% in group 2 on the VAS and the comfortable walking time had increased significantly in both groups. Randomized Controlled Trial

Gerdesmeyer L, Wagenpfeil S, Haake M, Maier M, Loew M, Wortler K, Lampe R, Seil R, Handle G, Gassel S, Rompe JD. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA. 2003 Nov 19;290(19):2573-80. CONTEXT: Extracorporeal shock wave therapy (ESWT) has been used to treat calcific tendonitis of the shoulder, but trials of ESWT for this purpose have had methodological deficiencies and thus there is limited evidence for its effectiveness. OBJECTIVE: To determine whether fluoroscopy-guided ESWT improves function, reduces pain, and diminishes the size of calcific deposits in patients with chronic calcific tendonitis of the shoulder. DESIGN, SETTING, AND PARTICIPANTS: Double-blind, randomized, placebo-controlled trial conducted between February 1997 and March 2001 among 144 patients (of 164 screened) recruited from referring primary care physicians, orthopedic surgeons, and sports physicians in 7 orthopedic departments in Germany and Austria. INTERVENTIONS: Either high-energy ESWT, low-energy ESWT, or placebo (sham treatment). The 2 ESWT groups received the same cumulative energy dose. Patients in all 3 groups received 2 treatment sessions approximately 2 weeks apart, followed by physical therapy. MAIN OUTCOME MEASURES: The primary end point was the change in the mean Constant and Murley Scale (CMS) score from baseline to 6 months after the intervention. Secondary end points were changes in the mean CMS scores at 3 and 12 months, as well as changes in self-rated pain and radiographic change in size of calcific deposits at 3, 6, and 12 months. RESULTS: Of 144 patients enrolled, all completed treatment as randomized and 134 completed the 6-month follow-up. Both high-energy and low-energy ESWT resulted in significant improvement in the 6-month mean (95% confidence interval [CI]) CMS score compared with sham treatment (highenergy ESWT: 31.0 [26.7-35.3] points; low-energy ESWT: 15.0 [10.2-19.8] points; sham treatment: 6.6 [1.4-11.8] points; P<.001 for both comparisons). Patients who received high-energy ESWT also had significant 6-month CMS improvements compared with those who received low-energy ESWT (P<.001). We found similar results for both the 3-month and 12-month CMS comparisons, as well as for self-rated pain and radiographic changes at 3, 6, and 12 months. CONCLUSIONS: Both high-energy and low-energy ESWT appeared to provide a beneficial effect on shoulder function, as well as on self-rated pain and diminished size of calcifications, compared with placebo. Furthermore, high-energy ESWT appeared to be superior to low-energy ESWT. Multicenter Study Randomized Controlled Trial Melikyan EY, Shahin E, Miles J, Bainbridge LC. Extracorporeal shock-wave treatment for tennis elbow. A randomised double-blind study. J Bone Joint Surg Br. 2003 Aug;85(6):852-5.

The efficacy of extracorporeal shock-wave therapy for tennis elbow was investigated using a single fractionated dosage in a randomised, doubleblind study. Outcomes were assessed using the Disabilities of Arm, Shoulder and Hand questionnaire, measurements of grip strength, levels of pain, analgesic usage and the rate of progression to surgery. Informed consent was obtained before patients were randomised to either the treatment or placebo group. In the final assessment, 74 patients (31 men and 43 women) with a mean age of 43.4 years (35 to 71), were included. None of the outcome measures showed a statistically significant difference between the treatment and control groups (p > 0.05). All patients improved significantly over time, regardless of treatment. Our study showed no evidence that extracorporeal shock-wave therapy for tennis elbow is better than placebo. Speed CA, Nichols D, Wies J, Humphreys H, Richards C, Burnet S, Hazleman BL. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial. J Orthop Res. 2003 Sep;21(5):937-40. BACKGROUND: Extracorporeal shock wave therapy (ESWT) is an increasingly popular therapeutic approach in the management of a number of tendinopathies. Benefit has been shown in calcific tendinitis of the rotator cuff, but evidence for its use in non-calcific disorders is limited. AIMS: To perform a double blind randomised controlled trial of moderate dose shock wave therapy in plantar fasciitis. METHODS: Adults with plantar fasciitis for at least 3 months were randomised to receive either active treatment (0.12 mJ/mm(2)) or sham therapy, monthly for 3 months. Pain in the day, nocturnal pain and morning start-up pain were assessed at baseline, before each treatment and 1 and 3 months after completion of therapy. RESULTS: Eighty-eight subjects participated and no differences existed between the groups at baseline. At 3 months, 37% of the subjects in the ESWT group and 24% in the sham group showed a positive response (50% improvement from baseline) with respect to pain. Positive responses in night pain occurred in 41% and 31% in the ESWT and sham groups, respectively. Positive responses in start-up pain occurred in 37% and 36% in the ESWT and sham groups, respectively. Both groups showed significant improvement over the course of the study, but no statistically significant difference existed between the groups with respect to the changes were seen in any of the outcome measures over the 6-month period. CONCLUSIONS: There appears to be no treatment effect of moderate dose ESWT in subjects with plantar fasciitis. Efficacy may be highly dependent upon machine types and treatment protocols. Further research is needed to develop evidence based recommendation for the use ESWT in musculoskeletal complaints.

Pan PJ, Chou CL, Chiou HJ, Ma HL, Lee HC, Chan RC. Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: a functional and sonographic study. Arch Phys Med Rehabil. 2003 Jul;84(7):988-93. OBJECTIVES: To evaluate the therapeutic effect of extracorporeal shock wave therapy (ESWT) in shoulders with chronic calcific tendinitis, to compare the functional outcomes of ESWT and transcutaneous electric nerve stimulation (TENS) therapy, and to investigate which types of calcium deposit effectively respond to ESWT. DESIGN: Randomized controlled trial. SETTING: Outpatient clinics of the departments of physical medicine and rehabilitation and of orthopedics and traumatology of a veterans hospital in Taiwan. PARTICIPANTS: Sixty patients with continuous shoulder pain for 6 months or more and with radiographically and sonographically verified calcific tendinitis. Patients were randomly allocated to receive ESWT (33 shoulders) or TENS treatment (30 shoulders). INTERVENTIONS: ESWT was performed with 2000 shock waves at 2Hz and energy level between.26 and.32mJ/mm(2) per session. Treatment was given in 2 sessions, 14 days apart. TENS therapy was given 3 times a week for 4 weeks.Main Outcome Measures: Mean Constant score, visual analog scale (VAS), manual muscle test, and changes of sonographic size and shape of calcium deposits were calculated for 4 time points: at baseline, 2 weeks, 4 weeks, 12 weeks posttherapy. RESULTS: In both groups, Constant score and VAS improved significantly at 2, 4-, and 12-week follow-ups (P<.05), and the size of calcium deposits decreased significantly at the 4- and 12-week follow-ups. Moreover, the arcshaped calcific plaques of the rotator cuff were markedly meliorated with ESWT. CONCLUSIONS: ESWT is more effective in the treatment of chronic calcific tendinitis of the shoulder than is TENS therapy, especially for arc-type calcific plaque. Multicenter Study Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, Hausdorf J, Zamzow K, Schade-Brittinger C, Mueller HH. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ. 2003 Jul 12;327(7406):75. OBJECTIVE: To determine the effectiveness of extracorporeal shock wave therapy compared with placebo in the treatment of chronic plantar fasciitis. DESIGN: Randomised, blinded, multicentre trial with parallel group design. SETTING: Nine hospitals and one outpatient clinic in Germany. PARTICIPANTS: 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo. MAIN OUTCOME MEASURES: Primary end point was the success rate 12 weeks after intervention based on the Roles and Maudsley score. Secondary end points encompassed subjective pain ratings and walking ability up to a year after the last intervention. RESULTS: The primary end point could be assessed in 94% (n=256) of

patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group (95% confidence interval - 8.0% to 15.1%). No difference was found in the secondary end points. Few side effects were reported. CONCLUSIONS: Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis.

Cosentino R, De Stefano R, Selvi E, Frati E, Manca S, Frediani B, Marcolongo R. Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulder: single blind study. Ann Rheum Dis. 2003 Mar;62(3):248-50. OBJECTIVE: To evaluate the clinical and radiological response of chronic calcific tendinitis of the shoulder to extracorporeal shock wave therapy (ESWT) in a single blind study. METHODS: 70 patients showing chronic, symptomatic, calcifying tendinitis of the shoulder were examined. A single blind randomised study was performed with 35 patients undergoing a regular treatment (group 1) and 35 a simulated one (group 2). Pain and functional assessment was carried out according to Constant and Murley. Variations in the dimension of the calcification were evaluated by anteroposterior x ray films. RESULTS: A significant decrease of pain and a significant increase in shoulder function was seen in group 1. Examination by x ray showed partial resorption of the calcium deposits in 40% of cases and complete resorption in 31% of cases in group 1. In the control group no significant decrease of pain and no significant increase in shoulder function was seen. No modifications were observed by x ray examination. CONCLUSION: Because of its good tolerance, safety, and clinical radiological response, ESWT can be considered as an alternative treatment for chronic calcific tendinitis of the shoulder. Am J Sports Med. 2004 Apr-May;32(3):734-43. BACKGROUND: There is conflicting evidence regarding extracorporeal shock wave treatment for chronic tennis elbow. HYPOTHESIS: Treatment with repetitive low-energy extracorporeal shock wave treatment is superior to repetitive placebo extra-corporeal shock wave treatment. METHODS: Seventy-eight patients enrolled in a placebo-controlled trial. All patients were tennis players with recalcitrant MRI-confirmed tennis elbow of at least 12 months' duration. Patients were randomly assigned to receive either active low-energy extracorporeal shock wave treatment given weekly for 3 weeks (treatment group 1) or an identical placebo extracorporeal shock wave treatment (sham group 2). Main outcome measure was pain during resisted wrist extension at 3 months; secondary measures were >50% reduction of pain and the Upper Extremity Function Scale. RESULTS: At 3 months, there was a significantly higher improvement in pain

during resisted wrist extension in group 1 than in group 2 (mean [SD] improvement, 3.5 [2.0] and 2.0 [1.9]; P =.001 for between-group difference of improvement) and in the Upper Extremity Function Scale (mean [SD] improvement, 23.4 [14.8] and 10.9 [14.9]; P <.001 for between-group difference of improvement). In the treatment group, 65% of patients achieved at least a 50% reduction of pain, compared with 28% of patients in the sham group (P =.001 for between-group difference). CONCLUSION: Low-energy extracorporeal shock wave treatment as applied is superior to sham treatment for tennis elbow. Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard CH. J Bone Joint Surg Br. 1992 Sep;74(5):646-51. Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. We have reviewed 185 articles published since 1966 to assess the scientific evidence for methods of treatment for lateral epicondylitis of the elbow. Of the 185 articles, 78 discussed treatment, but since the natural history of the syndrome is uncertain we considered only those series with concurrent control groups. Only 18 of these were randomised and controlled studies. We then graded these papers for scientific validity, using the methods of Chalmers et al (1981). The mean score of the 18 articles was only 33%, with a range from 6% to 73%. A minimum of 70% is required for a valid clinical trial, and we therefore concluded that there was insufficient scientific evidence to support any of the current methods of treatment. There were too many methodological differences to allow a quantitative meta-analysis, but our qualitative review established the importance of the natural evolution of the syndrome and of the placebo effect of all treatments. Properly designed, controlled trials are needed. Hudak PL, Cole DC, Haines AT. Arch Phys Med Rehabil. 1996 Jun;77(6):586-93. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. OBJECTIVE: A systematic overview of evidence aimed at determining the clinical course of lateral elbow pain and prognostic factors that affect elbow pain duration and outcomes. DATA SOURCES: Online bibliographic database searches from 1983 to 1994; information requests from selected authors and bibliography screenings. STUDY SELECTION: One author reviewed 424 articles; 40 met the following eligibility criteria: any study with primary data on soft tissue injuries specific to the elbow which referred to prognosis or reported use of any outcome measure. DATA ABSTRACTION: Strength of evidence grade based on clinical epidemiological validity assessment. Criteria included in the validity assessment included case definition, patient selection, follow-up, outcome, prognostic factors, and analysis. All eligible studies were independently assessed by two investigators. DATA SYNTHESIS: Four studies (10%) were judged to provide moderate strength of evidence; no studies were graded as providing strong evidence on

prognosis. All four moderate-quality studies were clinical trials of short duration. One study indicated that site of lesion and prior occurrence may be predictive of poorer outcome in patients with lateral epicondylitis. CONCLUSION: The majority of studies on lateral elbow pain were limited by methodological weaknesses in selection and definition of the study population, length of follow-up, and analysis of prognostic factors. Estimates of duration were only available from weaker studies with longer follow-up times; significant subject heterogeneity in the weaker studies prevented a determination of usual clinical course. More methodologically rigorous research on prognosis could assist clinicians in patient care and evaluation of interventions. Boddeker I, Haake M. Orthopade. [Extracorporeal shockwave therapy in treatment of epicondylitis humeri radialis. 2000 May;29(5):463-9 A current overview] In the past, extracorporeal shock-wave therapy (ESWT) has been used increasingly as a treatment for conservatively unsuccessfully treated radiohumeral epicondylitis. However, published reviews of clinical trials on the efficacy of ESWT have led to inconsistent results and are outdated or methodologically inadequate. As a consequence, a systematic literature search was conducted which yielded 20 relevant papers that described trials on the efficacy of ESWT in the treatment of radiohumeral epicondylitis. These were rated according to biometrical criteria for the conduct of therapeutic trials. None of the rated trials fulfilled all of the criteria, and it is concluded that the efficacy of ESWT in the treatment of epidondylitis can presently be neither confirmed nor excluded.

CONCLUSO Foram selecionadas 20 publicaes: duas referncias conceituais, doze ensaios controlados, um guideline e cinco revises, duas tradicionais e trs sistemticas. Trs revises sistemticas analisando vrios procedimentos teraputicos para a dor lateral do cotovelo foram realizadas at o ano de 2000, duas delas (2,3) concluram pela ausncia de eficcia das ondas de choque e a terceira (4) reuniu 20 ensaios clnicos, mas apenas um controlado e a concluso dos autores foram pela ausncia de evidncias que suportassem o emprego das ondas de choque no tratamento do cotovelo do tenista. A ltima reviso sistemtica encontrada foi publicada pela Cochrane e atualizada pela ltima vez em novembro de 2001 (5). O objetivo foi revisar a efetividade do tratamento com ondas de choque na reduo da dor e na melhora da funo em adultos com dor lateral do cotovelo. Dois ensaios randomizados foram encontrados com parando o procedimento com placebo (6,7), o primeiro mostrando benefcios do procedimento quando comparado com placebo e o segundo no. Quando os dados foram agrupados na metanlise o resultado para o desfecho falha no tratamento no mostrou diferena significante entre os dois grupos (risco relativo 0.40 IC95% 0.08 a 1.91 em seis semanas; 0.44 IC95% 0.09

a 2.17 em um ano), para o desfecho dor tambm no houve diferena entre os procedimentos estudados (seis meses - diferena mdia ponderada - 11.40 IC95% -26.10 a 3.30). Os revisores concluram que mais estudos deveriam ser realizados para que se pudesse concluir sobre as vantagens do tratamento com esta indicao. O rgo do governo americano FDA aprovou o emprego do equipamento para o tratamento (Extracorporeal Shock Wave Therapy ESWT system) para a seguinte indicao: tratamento no cirrgico da epicondilite crnica lateral (cotovelo de tenista) com histria superior a seis meses e sem sucesso com tratamento conservador (8) e para a fascite proximal crnica (calcneo doloroso) que no tenham respondido a tratamento conservador (9). Guidelines publicados em 2002 (10) sobre calcanhar doloroso indicam cirurgia ou ondas de choque para esta afeco caso no tenha havido melhora da sintomatologia aps dois ou trs meses de tratamento, incluindo imobilizao. Aps a metanlise da Cochrane (5) outros dez ensaios controlados foram selecionados com resultados nem sempre semelhantes para as vrias indicaes: Epicondilite lateral (cotovelo do tenista) Resultado semelhante ao do grupo controle Haake M, Konig IR, Decker T, Riedel C, Buch M, Muller HH; Extracorporeal Shock Wave Therapy Clinical Trial Group. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial. Bone Joint Surg Am. 2002 Nov;84-A(11):1982-91. Melikyan EY, Shahin E, Miles J, Bainbridge LC.J Extracorporeal shock-wave treatment for tennis elbow. A randomised double-blind study.Bone Joint Surg Br. 2003 Aug;85(6):852-5. Resultado favorvel ao tratamento com ondas de choque Rompe JD, Decking J, Schoellner C, Theis C. Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med. 2004 Apr-May;32(3):734-43. Fascite plantar (calcneo doloroso) Resultado semelhante ao do grupo controle Hammer DS, Adam F, Kreutz A, Kohn D, Seil R. Extracorporeal shock wave therapy (ESWT) in patients with chronic proximal plantar fasciitis: a 2-year follow-up. Foot Ankle Int. 2003 Nov;24(11):823-8. Speed CA, Nichols D, Wies J, Humphreys H, Richards C, Burnet S, Hazleman BL. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial. J Orthop Res. 2003 Sep;21(5):937-40. Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, Hausdorf J, Zamzow K, Schade-Brittinger C, Mueller HH. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ. 2003 Jul 12;327(7406):75.

Resultado favorvel ao tratamento com ondas de choque Theodore GH, Buch M, Amendola A, Bachmann C, Fleming LL, Zingas C. Extracorporeal shock wave therapy for the treatment of plantar fasciitis. Foot Ankle Int. 2004 May;25(5):290-7. Tendinite calcificante crnica de ombro Resultado favorvel ao tratamento com ondas de choque Gerdesmeyer L, Wagenpfeil S, Haake M, Maier M, Loew M, Wortler K, Lampe R, Seil R, Handle G, Gassel S, Rompe JD. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA. 2003 Nov 19;290(19):2573-80. Pan PJ, Chou CL, Chiou HJ, Ma HL, Lee HC, Chan RC. Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: a functional and sonographic study. Arch Phys Med Rehabil. 2003 Jul;84(7):988-93. Cosentino R, De Stefano R, Selvi E, Frati E, Manca S, Frediani B, Marcolongo R. Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulder: single blind study. Ann Rheum Dis. 2003 Mar;62(3):248-50. Os resultados das metanlises e ensaios randomizados mostram resultados heterogneos quando eficcia do tratamento com ondas de choque nas doenas msculo-esquelticas estudadas (epicondilite lateral, fascite plantar e tendinite crnica de ombro). Frente s evidncias encontradas, a conduta adotada pelo FDA parece ser a mais adequada, ou seja, autorizar o emprego do tratamento nas referidas doenas desde que o paciente j tenha se submetido a tratamento conservador anteriormente durante alguns meses e no tenha obtido resultado satisfatrio. Convm observar com ateno as recomendaes quanto aos cuidados especiais e segurana emitidos pelo FDA e que se acham descritos a seguir. Cuidados especiais / Segurana As recomendaes do FDA especificamente sobre o uso do equipamento SONOCUR (Siemens) no tratamento do cotovelo do tenista so: Os operadores do equipamento devem ser treinados quanto freqncia a ser usada e ao direcionamento leso; Usar o equipamento sob superviso mdica; Manter sempre correto o posicionamento do aparelho para evitar danos a vasos e tecido nervoso adjacente; Em caso de muita dor durante o procedimento, interrompe-lo e adequar a profundidade de penetrao das ondas; Se houver reao vaso-vagal durante o procedimento, reclinar o paciente em posio supina at os sintomas desaparecerem;

Pacientes sob anticoagulao devem consultar seus mdicos antes do procedimento para evitar o risco de equimoses; se em uso de aspirina, interromper a medicao uma semana antes do tratamento. No foi ainda demonstrada segurana do uso do equipamento para: Gestantes, Menores de 18 anos de idade; Pacientes com doenas hemorrgicas, infeces, tumor, sndrome da compresso cervical, artrite cervical ou de membros superiores, artrose localizada, anormalidades neurolgicas, Pacientes com cirurgia prvia para epicondilite lateral; Pacientes com doenas sistmicas graves que possam levar a distrbios sensoriais ou dor neuroptica (p. ex. diabetes e artrite reumatide); Portadores de marca-passo cardaco; Pacientes submetidos fisioterapia ou terapia ocupacional < quatro semanas; Pacientes medicados com esterides injetveis < seis semanas. (9)

REFERNCIAS BIBLIOGRFICAS (1) Hurt G, Baker CL Jr. Calcific tendinitis of the shoulder. Orthop Clin North Am. 2003 Oct;34(4):567-75. (2) Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard CH. Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. J Bone Joint Surg Br. 1992 Sep;74(5):646-51. (3) Hudak PL, Cole DC, Haines AT. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. Arch Phys Med Rehabil. 1996 Jun;77(6):586-93. (4) Boddeker I, Haake M. [Extracorporeal shockwave therapy in treatment of epicondylitis humeri radialis. A current overview]. Orthopade. 2000 May;29(5):4639. (5) Buchbinder R, Green S, White M, Barnsley L, Smidt N, Assendelft WJJ.. Shock wave therapy for lateral elbow pain (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Oxford: Update Software. (6) Rompe J, Hopf C, Kullmer K, Heine J, Burger R, Nafe B. Low-energy extracorporal shock-wave therapy for persistent tennis elbow. International Orthopaedics 1996;20:23-27. (7) Haake M, Boddeker IR, Decker T, Buch M, Vogel M, Labek G, Maier M, Loew M, Maier-Boerries O, Fischer J, Betthauser A, Rehack HC, Kanovsky W, Muller I,

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