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Extracorporeal shockwave: mechanisms of action and physiological aspects for cellulite, body shaping, and localized fat—Systematic review

Authors:

Abstract

Extracorporeal Shockwave Therapy – ESWT has had a wide use in rehabilitation, and has presented positive effects in the treatment of unaesthetic affections. The objective of the present study was to search, in the literature, the mechanisms of action and the physiological aspects of shockwaves acting on the biological tissue to improve the condition of cellulite and localized fat. A systematic review of the literature was carried out in the period from September 2016 to February 2017 based on the bibliographic databases Lilacs, MedLine, PubMed and Scielo. Fifteen articles were identified in that systematic review, three of which were excluded because they did not make the complete access to the article available or the theme investigated did not encompass the objective of the study. The revision demonstrated that extracorporeal shockwaves present relevant effects on the biological tissue, which leads to the restructuring of skin properties and subcutaneous tissue, clinically improving the aspects of cellulite and localized fat.
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E
xtracorporeal shockwave: mechanisms of action and
physiological aspects for cellulite, body shaping and
localized fat – systematic review.
Journal:
Journal of Cosmetic and Laser Therapy
Manuscript ID
Draft
Manuscript Categories:
Reviews of Treatment Studies
Date Submitted by the Author:
n/a
Complete List of Authors:
Modena, Débora; Universidade Estadual de Campinas, Surgery
Department; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil
Silva, Caroline; Universidade Estadual Paulista Julio de Mesquita Filho -
Campus de Marilia, Human Development and Technologies; Ibramed
Research Institute, Study Group in Technology Applied to Health, Brazil
Grecco, Clovis; Ibramed Research Institute, Research Development and
Innovation
Guidi, Renata; Universidade Estadual de Campinas, Biomedical Engineering
Department; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil.
Moreira, Renata; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil
Coelho, Andresa; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil
Sant'Ana, Estela; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil.
Souza, José; Ibramed Research Institute, Study Group in Technology
Applied to Health, Brazil.
Keyword:
Cellulite, acoustic wave therapy, extracorporeal shockwaves, shockwaves
cellulite
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Journal of Cosmetic and Laser Therapy
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Title Page
Extracorporeal shockwave: mechanisms of action and physiological aspects for
cellulite, body shaping and localized fat – systematic review.
Physiology extracorporeal shock waves
MSc. Débora A Oliveira Modena
a,c
, PT. Caroline Nogueira da Silva
b,c
, PhD. Clovis
Grecco
c
, PT. Renata Michelini Guidi
c,d,e
, PT. Renata Gomes Moreira
c
, Andresa A
Coelho
c
, PhD. Estela Sant’Ana
c
, José Ricardo de Souza
c,e
.
a
Of Surgery Department, Faculty of Medical Sciences, University of Campinas
(Unicamp), Brazil.
b
Human Development and Technologies, Universidade Estadual Paulista (UNESP),
Brazil.
c
Ibramed Research Institute: Study Group in Technology Applied to Health, Brazil.
d
Biomedical Engineering Department, Faculty of Electrical Engineering and
Computing, University of Campinas (Unicamp), Brazil.
e
Centro de Estudos e Formação Avançada Ibramed (CEFAI), Brazil.
Corresponding Author: MSc. Débora A Oliveira Modena
de.modena@ibramed.com.br
Av. Dr. Carlos Burgos, 2800 - Jardim Itália, Amparo - SP, 13901-080
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Contributions of all authors
MSc. Débora A Oliveira Modena
a,c
, search for articles in the database, articles analysis,
manuscript writing.
PT. Caroline Nogueira da Silva
b,c
, search of articles in the database, articles analysis,
manuscript revision, contributions in writing the manuscript.
PhD. Clovis Grecco
c
, manuscript revision, contributions in writing the manuscript.
PT. Renata Michelini Guidi
c,d,e
manuscript revision, contributions in writing the
manuscript.
PT. Renata Gomes Moreira
c
, manuscript revision, contributions in writing the
manuscript.
Andresa A Coelho
c
, manuscript revision, contributions in writing the manuscript.
PhD. Estela Sant’Ana
c
, manuscript revision, contributions in writing the manuscript.
José Ricardo de Souza
c,e
.
manuscript revision, contributions in writing the manuscript.
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Extracorporeal shockwave: mechanisms of action and physiological aspects for
cellulite, body shaping and localized fat – systematic review.
Abstract: Extracorporeal Shockwave Therapy ESWT has had a wide use in
rehabilitation, and has presented positive effects in the treatment of unaesthetic
affections. The objective of the present study was to search, in the literature, the
mechanisms of action and the physiological aspects of shockwaves acting on the
biological tissue to improve the condition of cellulite and localized fat. A systematic
review of the literature was carried out in the period from September 2016 to February
2017 based on the bibliographic databases Lilacs, MedLine, PubMed and Scielo.
Fifteen articles were identified in that systematic review, three of which were excluded
because they did not make the complete access to the article available or the theme
investigated did not encompass the objective of the study. The revision demonstrated
that extracorporeal shockwaves present relevant effects on the biological tissue, which
leads to the restructuring of skin properties and subcutaneous tissue, clinically
improving the aspects of cellulite and localized fat.
Keywords: cellulite, acoustic wave therapy, extracorporeal shockwaves, shockwaves
cellulite, shockwaves subcutaneous fat.
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Introduction
Growing technological advances in technology have promoted the
development of new electromedical devices that can stimulate new therapeutic
modalities. The Extracorporeal Shock Wave Therapy - ESWT is an example of
technological evolution that opens the possibility for a non-invasive therapeutic
modality, validated for use in the healthcare sector, indicated for the treatment of
musculoskeletal disorders and which has recently been explored in the scope of
aesthetic affections. Even with the growing use of this technology, its mechanisms of
action have not yet been clearly established (1,2).
The use of ESWT had its beginnings in the early 70s in Extracorporeal
Lithotripsy, then becoming a golden standard for the treatment of gallstone, renal
calculi, ureteral calculi and vesical calculi [3,4]. During Lithotripsy treatment for lower
ureteral calculi, physicians observed that some patients presented increase in bone
density in the pelvic region. Based on this observation, they began to use equipment
designed for Lithotripsy for the treatment of orthopedic dysfunctions, originating a new
technology that allowed the grading of depth and intensity with which shockwaves
penetrate biological tissues (4,5).
In 1997 in Vienna, Austria, the European Society for Musculoskeletal
Shockwave (ESMST) was founded, with the objective of promoting the research and
development of therapy in Europe. In Brazil, the use of shockwaves as an orthopedic
therapy started in 1998. In 2001, ESWT was approved by the Federal Drug
Administration (FDA), for the treatment of chronic plantar fasciitis in the United States
(EUA) (5,6).
The possibility of the use of ESWT in aesthetic treatments emerged from
the observations of surgical results, when women suffering from muscle disorders, after
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receiving hip prosthesis, reported an enhancement in mobility and pain, an improvement
in the aspect of the skin and body contour, suggesting that there was a decrease in the
body circumference in the treated area (4,7,8).
The ESWT technology appeared during World War II when submarines
were attacked by bombs and remained intact, and the sailors on board presented serious
trauma with visceral and pulmonary lesions without external lesions. These lesions were
attributed to the shockwaves, which went through the submarine walls and propagated
amongst the sailors. In everyday life, shockwaves can be perceived when there is
thunder, which occurs due to the intense heating and the rapid expansion of the air
surrounding the lightning (4,9).
ESWT is characterized by a high pressure pulse (80 MPa) in a time interval
of extremely short duration (in the order of nanoseconds), which produces mechanical
pressure waves that promote cavitation in liquid medium (gas bubbles in fluid medium)
and increase in local temperature. These shockwaves propagate in the target tissue,
generating essential mechanisms of action such as the mechanical impact in the tissues
and formation of microbubbles, which favors the achievement of the therapeutic
objective (4).
For therapeutic purposes, there are four types of shockwave generators: The
electro-hydraulic system, the piezoelectric system, the electromagnetic system and the
pneumatic system, the latter two being the most frequently used in rehabilitation and
aesthetics (6,10). The electromagnetic generator presents two coils inside that generate a
magnetic field when run through by electricity – the action of the field causes the
projectile, situated inside the applicator, to move quickly and collide with the tip of the
applicator. In the collision of the bullet, there is the transfer of energy from the
projectile to the tip of the applicator, which then transfers the energy received in the
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form of mechanical waves to the treatment area. In the pneumatic generator, differently,
the projectile is displaced towards the tip by the pressure exerted by the compressed air
(5,6,10) (Figure 1).
ESWT equipment can be built in such a manner that it emits two types of
waves, classified as focal waves (more intense and profound), directed at the target
tissue, or radial waves (less intense and more superficial) diverge over the treatment
area (5,11). There is equipment which offer the two types of wave and other that use
only one which is adequate to the therapeutic objective. The ESWT energy can also be
classified as low, medium and high, and that favors the field of action because each
energy reaches structures like muscles, tendon and bones in different depths and forms
(7,8,12).
Considering that this technology is relatively new in the aesthetic area, there
are few studies that discuss the interaction between ESWT and the biological tissues for
this purpose, which makes decision-making about the use of this technology difficult
based on evidence. Therefore, the objective of this study was to present a revision of the
literature about the technical aspects, mechanisms of action and physiological effects
that involve the use of extracorporeal shockwave therapy in aesthetic alterations.
Material and Methods
This is a revision of the literature carried out from September 2016 to February based
on bibliographic databases Lilacs, MedLine, PubMed and Scielo. As the theme is
relatively recent, there is difference in the indexing processes in the bibliographic
databases; therefore, the search for free themes, without the use of the controlled
vocabulary (descriptors) was the option chosen. Using this strategy, there was an upturn
of a greater number of references, guaranteeing the detection of most of the published
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studies within pre-established criteria. Terms such as cellulite, acoustic wave therapy,
extracorporeal shockwaves, shockwaves cellulite, shockwaves subcutaneous fat were
combined. The selected studies included the extracorporeal shockwave theme and the
discussion of the mechanisms of action and physiological effects in the treatment of
aesthetic alterations.
All of the original articles indexed about the action of ESWT on cellulite
and localized fat written in English published between 2005 and 2017 with
experimental (clinical trials, randomized or not) or observational (case studies, case-
control, cross-sectional studies and before-and-after treatment studies) approaches
carried out in humans were included. Experimental studies were excluded.
After checking titles, authors and abstracts, with the objective of avoiding
the repetition of publications, the availability of complete access and the theme were
investigated, and an evaluation of articles by peers, specialists in the investigated area,
was carried out.
After the inclusion of the articles, an analytical reading of each study was
performed, as well as a record of concept, method used for evaluation, classification of
ESWT use in the pre-established area, in the mechanisms of action, the physiological
effects and last but not least, a comparative analysis between the findings and the
theoretical discussion.
Results
In the systematic review, 15 papers were identified, three of them were excluded
because not providing complete access availability, or they were animal studies or the
theme investigated did not encompass the objective of the study. The selected papers
are presented according to Table 1.
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Table 1. Published studies about the action of ESWT on cellulite and localized fat.
ESWT: Extracorporeal Shockwave Therapy
Discussion
The objective of the present study was to search for literary evidence about
the physiological effects of ESWT in biological tissues in aesthetic disorders. ESWT
has continuously been indicated for the treatment of cellulite, also known as Gynoid
Lipodystrophy (12-14). Cellulite is an aesthetic alteration which attacks the thighs,
gluteus, abdomen and upper region of the arms. It is a multifactor disorder with increase
of adipose tissue that causes cellular dystrophy, dysfunctions of the hydraulic
metabolism with blood congestion, tissue fibrosis and proliferation of fibroblasts around
the adipose cells (1,12,14). Cellulite is more common in women, because they present
about 21 to 22 billion adipose cells, whereas men present about 17 to 18 million. This
difference in the quantity of adipocytes causes men to have a smaller ability to store fat
in relation to the female sex. Besides, the subcutaneous conjunctive tissue of women
presents some particularities such as the fine fibrous septum, directed vertically in the
cutaneous surface, causing the adipose cells to present a regular form and the projection
of these structures become superficial reaching the dermis, giving the skin the “orange
peel” appearance (9,15-17).
Several treatments for cellulite have been developed in the last decades,
with the objective of promoting the improvement of blood and lymphatic circulation
using physical treatments, pharmacotherapy and treatments in association with
electromedical equipment. However, there is not any one treatment that is completely
effective (16–20).
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The first ESWT study for the treatment of cellulite was carried out in 2005,
in a clinical study with 26 women with average age of 45 years, which compared the
independent application of ESWT and in combination with decongestive therapy for
two weeks. Six sessions of ESWT were performed with 1.000 shots in only one thigh
and the decongestive therapy was performed in both thighs. The authors concluded that
one single application of ESWT can significantly decrease the levels of Plasma
Malondialdehyde (MDA), a biomarker of the level of oxidative stress, which would
cause improvement of the biomechanical properties of the skin (19). Oxidative stress is
generated when there is imbalance in the production and tamponade of free radicals,
biochemical physiological alterations during metabolic processes or due to external
factors such as poor nutrition, exhausting exercise, psychological stress, and tobacco
use, among others. As we suffer the influence of these factors, the cell walls and their
molecules are attacked, causing a continuous and aggressive imbalance, which
unleashes a cascade of events that induce the cellular aging. When the oxidative stress
reaches high levels in the body it causes inflammation and cytotoxicity and it plays an
important part in fibrotic degeneration, which can contribute to the formation of
cellulite (7,19-21).
According to Wang (2003), the use of ESWT promotes a cascade of
physiological events, which have not yet been entirely elucidated. What is known is that
after the application there is improvement in the metabolism with subsequent stimulus
of microcirculation by the liberation of nitrous acid and improvement in cell
permeability, which favors the exchange of substances and the reorganization of the
cellular matrix. This leads to the rebalance of the production and tamponade of free
radicals. This data was reaffirmed by the findings of Siems et al. (2005), where there
was improvement of the aspect of the skin after six sessions of ESWT (9,19,21–23).
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Angehrn et al. (2007) evaluated the effects of ESWT in the treatment of
cellulite in 21 women aged between 20 and 60 years. 40 thousand shots were applied in
the lateral area of the thigh, twice a week, during six weeks of treatment. The authors
used diagnostic ultrasound as evaluation method (Collagenoson®), which evaluated the
distribution of the epidermis, dermis and subcutaneous tissue. The results showed that
ESWT was effective for the treatment of cellulite, because it promoted the remodeling
of the collagen by realigning the dermal fibers and the improvement in the aspect of the
skin, which remained latent after six months (8).
Corroborating the findings of Angehrn et al. (2007), in 2008 two studies
evaluated the effects of ESWT in cellulite and body contour. First Kuhn et al. (2008)
presented a case study with a 60-year-old woman with cellulite degree three in the
gluteus and thighs, where four sessions of ESWT were applied only in the left thigh;
after the end of the application the patient underwent orthopedic surgery in the region of
the hip in which a sample of tissue of the treated and of the non-treated regions were
removed. The authors concluded that there was histological improvement of the dermis
with increase of the thickness of the extracellular matrix of the dermis, by means of
induction of neocollagen and neo-elastin (8,24).
The second study was developed by Christ et al. (2008), who evaluated 59
women with cellulite, subdivided in two groups in which: the first received six sessions
of ESWT for three weeks and the seconds eight sessions in four weeks of treatment.
The results presented were considered excellent, because there was an increase in the
elasticity and firmness of the skin in both groups after three and six months of therapy
of 95 to 105%, respectively (15).
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Angehrn et al. (2007); Kuhn et al. and Christ et al. (2008) found in their
studies similar results which involve induction of formation of collagen, neo-elastin,
improvement of the aspect and elasticity of skin and remodeling of collagen (8,15,24).
Collagen is a protein synthesized by the fibroblast, fundamental in the
constitution of the extracellular matrix and of the conjunctive tissue, and its main
objective is to structure and protect the properties of the skin. In cellulite, there are
structural alterations in the intracellular and extracellular matrix, degradation of
collagen and of fibroblasts. One of the objectives to be achieved is to stimulate the
fibroblasts to induce the synthesis of new collagen fibers (neocollagen) and elastin (neo-
elastin) with subsequent restructuring of the properties of the tissue, which we call
collagen remodeling (14-16,25,26). The cells in our body recognize mechanical stimuli,
due to this the fibroblasts are activated and start a cascade of formation of neocollagen
and neo-elastin and the restructuring of the tissue. This mechanism is called
mechanotransduction of signal, when the cell responds to a mechanical stimulus with
biochemical reactions in cascade and act on the cellular level transmitting the energy to
the extracellular matrix (27).
The first stimulus of ESWT is mechanical, characterized by the peak of
pressure, short duration, with high density of energy and low frequency; when in
contact with the treatment area this mechanical energy leads to the activation of
mechanotransduction of signal and the extracellular matrix mobilizes the cells. These
cells, respond to the indirect effect of shock wave cavitation, bringing forth alterations
beneficial for the treatment of cellulite such as the increase of local circulation and
stimulus to the production of collagen, leading to the restructuring of the dermis and
epidermis, thus restoring the elasticity of the conjunctive tissue and improving skin
texture (2,28).
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Adatto et al. (2010) and Adatto et al. (2011) evaluated the effects of ESWT
in cellulite and the improvement of body contour, and in their last study the objective
was to evaluate ESWT in localized fat (29,30).
For the treatment of cellulite, 25 women who received 3000 shots in an area
of 10x15cm² in the lateral region of the thigh were evaluated and six sessions twice a
week were performed. The results demonstrated reduction of the appearance of cellulitis
after three months of the last treatment. The authors concluded that the shockwave
therapy can stimulate lymphatic drainage and microcirculation. In the study about
improvement of the body contour, 14 women were evaluated after eight sessions in the
lateral region of the thigh, with the application of 4500 shots. There was temporary
improvement in the texture and elasticity of skin, and a reduction? of the adipose tissue
(29,30).
Besides the mechanical effects, ESWT has the effects of unstable cavitation,
which is the formation of gas microbubbles in the biological liquids, which implode
causing physiological effects (3-6). According to Steinbach et al. (1993) and Kuhn et al.
(2008), the effects caused by cavitation are related with the dose of energy used to
achieve the therapeutic objective. When high doses of energy are used, the damages are
the increase of cellular diffusion with improvement in the permeability of the cellular
membrane, lesions in the endoplasmic reticulum in the cytoskeleton that gives form to
the cell and in the cellular junctions. All these factors may lead to apoptosis. There is
still the liberation of endothelial growth factor, synthesis of eNOS enzyme, which
induces the production of endothelial nitric oxide (NO) (24,31). For smaller doses of
energy, the principle of action of ESWT is the stimulus to the self-regeneration of the
tissue; therefore, smaller doses are indicated for the treatment of different types of
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musculoskeletal diseases. However, both doses stimulate the local blood circulation and
the metabolism (31).
During the bibliographic revision carried out in the present study, out of the
12 articles evaluated, most of them used high doses between 3 and 4 bar for devices
with pneumatic shockwave energy generators. Therefore, we can suggest that, by the
findings in this study, that high energy is efficient in the treatment of localized fat,
because the effects of ESWT can lead to cellular apoptosis (28,32,33).
Another Ferraro et al. (2012) study, also demonstrated decrease in thickness
of the layer of localized fat and of the circumference of the treated area and
improvement in the aspect of the skin after 12 months of the end of treatment. However,
the study protocol evaluated the combination of ESWT with cryolipolysis sliding mode,
using the device that presents both these therapies, but it was not possible to evaluate if
the results could be attributed solely to the use of ESWT, because cryolipolysis also
presents significant results for the reduction of localized fat. It is worth mentioning that
the technique of cryolipolysis sliding mode differs from conventional cryolipolysis
usually mentioned in literature [33].
Knobloch et al. (2013) compared two groups, application of ESWT
(0,25mJ/mm²) in gluteus and thighs, followed by thigh strengthening training and the
second control group with application of ESWT (0,01mJ/mm²) in gluteus and thigh,
followed by thigh and gluteus strengthening training. In both groups, six sessions were
applied for two weeks. The objective was to evaluate if the muscle strength training
would lead to additional effects to the ESWT therapy in the improvement of cellulite.
The results obtained demonstrated that the combination of therapies presented superior
results in relation to the control group, with significant alterations of 24% in the
improvement of the aspect of cellulite. The authors suggest that this improvement
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occurred through the mechanical energy of ESWT, which acts on the fibrous septum
and induces their reorganization, making the skin smoother (34).
Proving the previous results, Russe-Wilflingseder et al. (2013) evaluated, in
their double blind randomized clinical trial, the effects of ESWT in the treatment of
cellulite. A placebo group was evaluated, where the transfer of energy was blocked and
for a second group that effectively received intervention were performed weekly
sessions for seven weeks. The treated group presented improvement in the aspect of
skin, in the appearance of cellulitis with decrease of undulations and depth and
reduction in the circumference of thighs after three months of treatment; however, the
researchers suggested that these results can be temporary (28).
The findings corroborate the effects of ESWT in the remodeling of collagen,
formation of neocollagen and neo-elastin, acting in the improvement of tissue firmness
and preventing that the irregularities present in the subcutaneous tissue project onto the
dermis, decreasing the aspect of “orange peel” skin (8,15,30,35).
In 2014, Schlaudraff and collaborators evaluated the individual clinical
result of the treatment of cellulitis with ESWT in 14 women who received 7500 shots in
unilateral thigh and gluteus in two sessions per week in four weeks, totalizing eight
treatments. The authors concluded that there was improvement and decrease in the
degrees of cellulite, but that this result cannot be correlated with individual variables
such as body mass index (BMI), weight, height or age (28).
Nassar et al. (2015) evaluated the efficacy of lipolysis induced by ESWT, in
15 individuals; eight sessions during four weeks were carried out, and 4000 shots were
applied. The authors concluded that ESWT was efficient in the improvement of body
contour, with reduction of the circumference and the fat layer and improvement of the
appearance of cellulite after three months of the end of the treatment (36).
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The most recent study published, Hexsel et al. (2016), is in accordance with
the previous findings. This study evaluated the efficiency of ESWT in the treatment of
cellulite and body contour with 5000 shots in the region of gluteus and posterior region
of thigh for 12 sessions. The authors concluded that there was decrease in the
circumference of the treated area, measured in the magnetic resonance exam, with
improvement of the severity of the degrees of cellulite (37).
The systematic review carried out in the present study shows that the use of
ESWT in the treatment of cellulite and localized fat seems to be a tool with efficient
results, provided that the parameters used are observed. The main effects reported in
these studies are related with the activation of the mechanisms of action and the
physiological effects as a result of the stimulus by mechanical shockwaves and effects
of cavitation promoted by the shockwave therapy.
The main effects observed in the biological tissue are: damage to the
extracellular matrix which promotes a cascade of physiological reactions that favor the
reorganization of the extracellular medium, increase of blood and lymphatic circulation,
alterations in the permeability of the cellular membrane, liberation of nitric oxide,
balance of free radicals, drainage of molecular proteins, stimulus for fibroblast
activation by mechanotransduction, formation of neocollagen, neo-elastin and
remodeling of collagen. Other results of the action of ESWT in the biological tissues
were described by Kuhn et al., (2008) and Nassar et al., (2015), the authors suggest that
ESWT can induce lipolysis and/or apoptosis of the adipose cell (8,24,36).
The few studies about ESWT in aesthetic affections show that the
mechanisms of action and physiological effects of this technique are beneficial and
promising for the treatment of cellulite, body contour and localized fat, particularly
because they represent a safe and non-invasive therapeutic mode. There are no reports
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of adverse reactions of ESWT in the treatment; only the discomfort reported by the
therapist due to the noise emitted by the shock of the projectile colliding with the tip of
the applicator; to minimize this discomfort, the use of an auricular protector is
suggested.
Conclusion
The results presented in this study show the efficacy of the ESWT technique
as a safe and non-invasive method. Its mode of action in the biological tissue benefits
the treatment of cellulite, body contour and localized fat. Because it is a relatively new
therapy in the aesthetic area, ESWT is a promising field for studies and application, but
it still requires investigation as to the mechanisms of action and their interaction with
the adipose tissue, which demands further experimental studies with ESWT in aesthetic
affections.
Conflicts of Interest
The authors declare that there are no conflicts of interest regarding the
publication of this paper.
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Figure 1. Electromagnetic System (a): (A) coils, (B) projectile, (C) tip of the applicator.
Pneumatic System (b): (B) projectile; (C) tip of the applicator, (D) compressed air inlet.
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Table 1. Published studies about the action of ESWT on cellulite, body contour and
localized fat.
Author Year Protocol
Treatment
Area Conclusion
Siems et al. 2005
ESWT +
Decongestive
therapy Thigh
Decrease of oxidative stress and
improvement of skin properties.
Angehrn et
al. 2007
ESWT
Lateral
region of
thigh
Remodeling of collagen and
improvement of the aspect of
skin.
Kuhn et al. 2008
ESWT
Thigh and
gluteus
Histological improvement of
epidermis and of the extracellular
matrix of the dermis.
Christ et al. 2008
ESWT
Thigh and
gluteus
Improvement of elasticity and
tightness of skin.
Adatto et al.
2010
ESWT Lateral
region of
the thigh
Improvement in skin texture and
elasticity, number of depression
and decrease of thickness of the
subcutaneous tissue. 2011
Ferraro et al. 2012
ESWT+
Cryolipolysis
Abdomen,
arms,
gluteus and
thigh.
Decrease of the thickness of the
adipose tissue, circumference of
the treated area and improvement
of the aspect of the skin.
Knoblock et
al. 2013
ESWT+
Muscle
strengthening.
Thigh and
gluteus
Improvement of the aspect of
cellulite.
-
wilflingseder
et al. 2013
ESWT Thigh
Temporary improvement of the
aspect of the skin and reduction in
the circumference of the thigh.
Schlaudraff
et al. 2014
ESWT
Thigh and
gluteus
Decrease in the degree of
cellulitis.
Nassar et al. 2015
ESWT Thigh
Reduction of the circumference of
the treated area, thickness of the
fat layer and appearance of
cellulite.
Hexsel et al. 2016
ESWT
Thigh and
gluteus
Decrease of the circumference of
the treated area and severity of
the degrees of cellulite.
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... Esses recursos auxiliariam no processo de perda de peso de forma a contribuir para uma possível diminuição nos fatores de risco ao desenvolvimento das comorbidades associadas à obesidade simultaneamente aos tratamentos atuais não invasivos e com o mínimo de efeitos adversos. 7,8 A terapia de ondas de choque extracorpóreas (ESWT) é um desses recursos. A tecnologia foi desenvolvida com base no equipamento de litotripsia extracorpórea utilizado até os dias atuais no tratamento de cálculos renais e uretrais. ...
... Algumas investigações clínicas vêm mostrando que o recurso também pode atuar no estímulo metabólico da célula adiposa. [7][8][9][10][11] Com base nesses estudos sobre a ESWT e na dificuldade da perda de peso e do combate às comorbidades associadas à obesidade, esse estudo tem o objetivo de avaliar se a ESWT pode atuar no estímulo da lipólise e/ou apoptose da célula adiposa e, desta forma, contribuir para a redução dos fatores de risco no desenvolvimento das comorbidades associadas à obesidade, validando sua possível utilização no tratamento conservador da obesidade. ...
... No presente estudo, demonstramos que seu estímulo fisiológico pode ocorrer por meio do processo biológico da lipólise por via apoptótica. 7,[24][25][26] Demonstramos que o tecido tratado com ESWT apresentou um aumento significativo de células adiposas positivas para Caspase-3 e para Caspase-3 clivada. A Caspase-3 é ativada na célula apoptótica tanto por vias extrínsecas (mediada por receptores celulares) quanto intrínsecas (mitocondriais). ...
Article
Full-text available
Introdução: a obesidade é uma doença que afeta a saúde pública em nível mundial devido a suas comorbidades e ao risco de morte prematura. Diante disso, a tecnologia de terapia de ondas de choque extracorpóreas (ESWT) pode ser útil em seu tratamento e na prevenção de suas comorbidades. Objetivos: o objetivo foi avaliar se a ESWT é capaz de estimular a lipólise e/ou apoptose da célula adiposa de indivíduos obesos. Métodos: trata-se de um estudo comparativo de intervenção baseado em análises imuno-histoquímicas de um conjunto de amostras de tecido subcutâneo de mulheres com obesidade, submetidas ao tratamento ESWT. O material biológico foi coletado no momento da cirurgia bariátrica. Resultados: 14 mulheres obesas foram incluídas na pesquisa. Foi evidenciada positividade na expressão de Casp3 (p
... We chose individuals with obesity since the condition of their skin is often little explored by healthcare professionals. Assuming that excess weight interferes with homeostasis, generating risk for skin diseases and skin flaccidity, this should also be one of the key points for the treatment of the disease considering its clinical aspect and its ability to interfere in the quality of life of the individual during the obesity process or during weight loss [5][6][7]. ...
... However, the process of tissue repair and regeneration in the individual with obesity is compromised, and the endogenous inflammatory response may not be successful, because the excess of subcutaneous adipose tissue causes tissue hypoperfusion; that is, the tissue is less vascularized, less oxygenated, and malnourished, consequently causing an imbalance of demand with the supply of oxygen that can compromise the process of tissue regeneration, particularly in the skin [5,7]. Shock waves stimulate the sub-clinical inflammatory process extracorporeally. ...
... Such action is also observed in clinical investigations that use ESWT at similar doses in the treatment of aesthetic disorders. Modena et al. (2017) carried out a study to review the performance of ESWT in localized fat, cellulite, and skin flaccidity. Of the 11 studies included in the research, it was observed that in 7 of them, they indicated the improvement in the viscoelastic properties of the skin proven in clinical and histological studies [6]. ...
Article
Full-text available
The technology of extracorporeal shock wave therapy (ESWT) has been studied around the world for its possible benefits in the treatment and rehabilitation of aesthetic disorders. To better elucidate its real physiological effect on the integumentary tissue, this study was proposed aimed at evaluating whether ESWT can act to stimulate the inflammatory process and angiogenesis in the dermis and epidermis of obese individuals. This is an immunohistological study that evaluated a set of samples of the integumentary tissue of women with grade II obesity with weight loss of 10% of the initial weight undergoing ESWT treatment; the collection of biological material was performed at the time of surgery of bariatric surgery. For immunohistochemical evaluation, the markers to assess the presence and distribution of inflammatory cells, anti-COX-2, CD3, CD20, CD163, and NK were used. For physiological stimulus pathways for blood vessel angiogenesis, markers CD 34, CD 105 and VEGF were used. Fourteen obese women were included in the study. Positivity was evidenced in the epidermal expression of markers of the inflammatory process COX-2, CD3, CD20, NK cells, CD68, and CD163 (p < 0.0001) in the intervention sample when compared to controls. There was a positive expression for the angiogenesis markers CD105 and VEGF (p < 0.0001) when comparing the intervention group with the control group. It was concluded that ESWT can stimulate a local inflammatory process, mediating and modulating important growth factors to act in the repair process and skin tissue regeneration, being considered a promising treatment for skin diseases related to weight gain or loss.
... 2,4,6 According to the hormonal theory, women have about 20% more adipocytes, which is thought to be estrogen-related, a fact that may contribute to the severity of cellulite. 5,7 The morphological characteristics of these cells predispose them to herniation, also described in the theory of morphological alterations of the subcutaneous adipose tissue. ...
... This leads to increased cell diffusion, increased membrane permeability, and cytoskeletal lesions which lead to adipocyte lipolysis and/ or apoptosis. 7,11,12 In addition, it promotes increased blood flow in the region and cellular metabolism, as well as stimulation of lymphatic drainage and self-regeneration processes. 3,7,11-13 Also, SWT promotes skin elasticity, as it enhances neocollagen and elastin production by the stimulation of fibroblastos. ...
... 3,7,11-13 Also, SWT promotes skin elasticity, as it enhances neocollagen and elastin production by the stimulation of fibroblastos. 4,7,10,11,13,14 Several studies have verified the isolated effectiveness of SWT in reducing the severity of cellulite. Knobloch et al. associated this with an exercise program. ...
Article
Background Cellulite is a multifactor and controversial condition. Several methods have been explored to reduce it, not always with favorable results. Shock Wave Therapy has been shown to be effective, but the results of its association with an Aerobic Exercise Program are unknown. Aims To verify whether Shock Wave Therapy in association with an Aerobic Exercise Program reduces the degree of severity of Cellulite in the gluteal region and in the ⅓ of the proximal posterior of the thigh. Methods Forty‐five healthy women, aged from 18 to 32, randomly assigned, considering the severity degree in the Cellulite Severity Scale and the level of physical activity, in three groups: two experimental and one control group. The control group performed the evaluations. The experimental group 1 performed an Aerobic Exercise Program, and the experimental group 2 associated this program with a Radial Shock Wave Therapy protocol. The experimental groups completed six interventions within 3 weeks. In addition, the degree of severity in the Cellulite Severity Scale, height, body composition, skin temperature, and subcutaneous adipose tissue thickness were assessed. One‐way ANOVA test and Kruskal‐Wallis were used to obtain the results, with level of significance of 0.05. Results Forty‐two women completed the study. There was a significant reduction in the severity of Cellulite between experimental group 2 and group 1 (P = 0.032), and from group 2 to the control group (P = 0.042). Conclusion The association of Shock Wave Therapy and Aerobic Exercise was shown to be effective in reducing the severity of cellulite.
... Some studies show that the ESWT has the ability to improve the metabolism and activity of several types of cells, including dermal and epidermal, and thus modulate the repair and tissue regeneration process. [5][6][7] To date, there is no clear evidence that substantiates the real physiological e ect of ESWT in the skin tissue, and therefore in this study we aimed to evaluate the e cacy and safety of the ESWT therapy in stimulating the broblast cells of the dermis in individuals with obesity aiming to favor neocollagenesis through a histological and immunohistochemical analysis. ...
... In our study, we used electromagnetic ESWT therapy, which provides energy propagation coming from the generation of a magnetic eld run by electricity displaces a projectile inside the applicator and from that moment on, there is a transfer of energy from the projectile to the tip of the applicator, and this energy is then transformed in mechanical waves, which favor cavitation and the physiological e ects in the target tissue. 5,13 As we see in our study, ESWT was able to stimulate the proliferation of broblast cells in the dermis and in ammatory cells in the epidermis and dermis of obese individuals. Also, the skin treated with EWST demonstrates a greater quantity of collagen bers, better organization and disposition of epidermal cells, of the dermis-epidermis junction and papillary dermis. ...
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BACKGROUND: Obesity became a worldwide public health problem and its treatment presents a strict relationship with skin accidity, for which the development of non-invasive therapies is an emerging eld. OBJECTIVE: This study aims to evaluate the physiological response of the skin tissue of individuals with obesity with accidity to the physiological stimulus of shockwave therapy (ESWT). METHODS: This is a comparative intervention study based on histological and immunohistochemical analyses of a set of samples of skin tissue of women with Grade II obesity who achieved a 10 percent preoperative weight loss before bariatric surgery and complaints of skin accidity, subjected to the ESWT treatment. A total of seven sessions were carried out in the abdominal region on the left side, and the collateral side was used as control; the biological material was collected at the moment of the bariatric surgery. Hematoxylin and Eosin, Masson’s trichrome, Picrosirius Red and the markers for immunohistochemical were used for the morphological evaluation. RESULTS: Fourteen women were included in the research. The results demonstrated that the tissue which underwent the ESWT intervention presented signi cant increases of broblast cells (p<0.0001) and collagen bers Type I and II (p<0.0002). In the signi cant expressions of the markers FGF1, FGF2, FGFR1 were identi ed in the exposed side (p<0.0002, 0.0017, <0.0001, respectively) as well as a signi cantly higher expression of Ki67 marker of cell proliferation (p<0.0002). CONCLUSION: ESWT was associated with a signi cant increase of cell proliferation and collagen expression in accid skin of individuals who achieved weight loss before bariatric surgery. KEYWORDS: Dermatology, obesity, skin accidity, shockwave, quality of life
... Energy shock wave (ESW) is a type of stress wave that can carry energy and propagate through a medium [29]. Previous studies have revealed that using low ESW (LESW) in a chronically-injured tissue can promote neovascularization, regeneration, and reduce inflammation [30]. ...
... Previous studies have revealed that using low ESW (LESW) in a chronically-injured tissue can promote neovascularization, regeneration, and reduce inflammation [30]. LESW is now widely used in treating patients with chronic joint pain, inflammation, and adhesion [29,31]. A previous animal study showed that LESW can reduce bladder pain, urinary frequency, and inflammation in rats with cyclophosphamideinduced bladder inflammation [32]. ...
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Although intravesical botulinum toxin type A (BoNT-A) injection for functional bladder disorders is effective, the injection-related problems—such as bladder pain and urinary tract infection—make the procedure invasive and inconvenient. Several vehicles have recently been developed to deliver BoNT-A without injection, thereby making the treatment less or non-invasive. Laboratory evidence revealed that liposome can carry BoNT-A across the uroepithelium and act on sub-urothelial nerve endings. A randomized placebo controlled study revealed that intravesical administration of liposome-encapsulated BoNT-A and TC-3 hydrogel embedded BoNT-A can improve urinary frequency, urgency, and reduce incontinence in patients with overactive bladders. A single-arm prospective study also revealed that intravesical administration of TC-3 hydrogel embedded BoNT-A can relieve bladder pain in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). We recently administered suprapubic energy shock wave (ESW) after BoNT-A intravesical administration in six patients with IC/BPS. Although pain reduction and symptom improvement were not significant, immunochemical staining showed cleaved synaptosome-associated protein 25 in the bladder after the procedure. This suggests that ESW can promote passage of BoNT-A across the uroepithelium. In conclusion, using vehicles to intra-vesically deliver BoNT-A for functional bladder disorders is promising. Further studies are necessary to confirm the efficacy and explore novel applications.
... LESW is a kind of stress wave that carries energy and propagates through a medium to achieve desired biological effects [74]. A previous study revealed that the use of LESW in chronic injured tissue could reduce inflammation, promote neovascularization, and facilitate tissue regeneration [75]. ...
Article
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Low-energy shock wave (LESW) therapy is known to facilitate tissue regeneration with analgesic and anti-inflammatory effects. LESW treatment has been demonstrated to be effective in treating chronic prostatitis and pelvic pain syndrome as well as overactive bladder, and it has a potential effect on interstitial cystitis/bladder pain syndrome (IC/BPS) in humans. LESW reduces pain behavior, downregulates nerve growth factor expression, and suppresses bladder overactivity by decreasing the expression of inflammatory proteins. Previous rat IC models have shown that LESW can increase urothelial permeability, facilitate intravesical delivery of botulinum toxin A (BoNT-A), and block acetic acid-induced hyperactive bladder, suggesting that LESW might be a potential therapeutic module for relieving bladder inflammatory conditions, such as bladder oversensitivity, IC/BPS, and overactive bladder. A recent clinical trial showed that LESW monotherapy was associated with a significant reduction in pain scores and IC symptoms. BoNT-A detrusor injection or liposome-encapsulated BoNT-A instillation could also inhibit inflammation and improve IC symptoms. However, BoNT-A injection requires anesthesia and certain complications might occur. Our preliminary study using LESW plus intravesical BoNT-A instillation every week demonstrated an improvement in global response assessment without any adverse events. Moreover, an immunohistochemistry study revealed the presence of cleaved SNAP25 protein in the suburothelium of IC bladder tissue, indicating that BoNT-A could penetrate across the urothelial barrier after application of LESW. These results provide evidence for the efficacy and safety of this novel IC/BPS treatment by LESW plus BoNT-A instillation, without anesthesia, and no bladder injection. This article reviews the current evidence on LESW and LESW plus intravesical therapeutic agents on bladder disorders and the pathophysiology and pharmacological mechanism of this novel, minimally invasive treatment model for IC/BPS.
... 32 Initial mechanical stimulus by the pressure peak, leads to matrix mobilization of cells by mechanotransduction of the signal. The shock wave cavitation following this causes mechanical disruption of cellulite and localized adiposities, helps restructure the skin, 33,34 and improves the cellulite outcome by inducing collagen remodeling. ...
Article
Background: Cellulite is a common dermatological condition with a female preponderance, affecting up to 90% post-pubertal females. It is characterized with dimpling and denting of the skin surface, giving it a Peau d'orange appearance. Once considered to be a benign physiological isolated skin condition of only an esthetic concern, cellulite is now considered a pathological entity with systemic associations and a negative psychological impact on patients. Aims: The objective of this article was to discuss etiology, pathophysiology, and treatment of cellulite. Materials and methods: Literature was screened to retrieve articles from PubMed/Medline and Google Scholar and related websites. Cross-references from the relevant articles were also considered for review. Review articles, clinical studies, systematic reviews, meta-analysis, and relevant information from selected websites were included. Results: Several treatment options from lifestyle modifications and topical cosmetic therapies to energy-based devices have been studied for its treatment. However, treatment remains a challenge despite many new modalities in the armamentarium. Laser and light therapies along with radiofrequency are useful treatment options with good safety profile. Acoustic wave therapy, subcision, and 1440-nm Nd:YAG minimally invasive laser are beneficial in cellulite reduction. Discussion: Methodological differences in the trials conducted make it difficult to compare different treatment modalities. Conclusion: Overall, treatment needs to be individualized based on the patient characteristics and severity of the condition. A combination of treatments is often required in most patients for reducing cellulite.
... A shock wave (SW) is a mechanical energy wave generated by the medium's highly rapid compression and accumulation through vibration or high-speed motion (161,162). The mechanical stress generated by the extracorporeal shock wave stimulates the cells to make the cell membrane structure elastically deform, activate the mechanosensitive ion channel protein on the cell membrane, and produce a series of biological effects (163,164). Electricity plays a vital role in wound healing by activating Piezo1 channels and Ca 2+ influx (154). Knockdown of Piezo1 partially reversed radiation-induced in vitro epithelial-mesenchymal transition and played a therapeutic role in bleomycin-induced pulmonary fibrosis in rats (155). ...
Article
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Mechanical damage is one of the predisposing factors of inflammation, and it runs through the entire inflammatory pathological process. Repeated or persistent damaging mechanical irritation leads to chronic inflammatory diseases. The mechanism of how mechanical forces induce inflammation is not fully understood. Piezo1 is a newly discovered mechanically sensitive ion channel. The Piezo1 channel opens in response to mechanical stimuli, transducing mechanical signals into an inflammatory cascade in the cell leading to tissue inflammation. A large amount of evidence shows that Piezo1 plays a vital role in the occurrence and progression of chronic inflammatory diseases. This mini-review briefly presents new evidence that Piezo1 responds to different mechanical stresses to trigger inflammation in various tissues. The discovery of Piezo1 provides new insights for the treatment of chronic inflammatory diseases related to mechanical stress. Inhibiting the transduction of damaging mechanical signals into inflammatory signals can inhibit inflammation and improve the outcome of inflammation at an early stage. The pharmacology of Piezo1 has shown bright prospects. The development of tissue-specific Piezo1 drugs for clinical use may be a new target for treating chronic inflammation.
Article
Background: Extracorporeal shockwave therapy (ESWT) represents a promising, non-invasive management strategy supporting the treatment of a variety of conditions related to plastic surgery. Objectives: This literature review aims to give a systematic overview of current applications, its mechanism of action, and its potential to provide tangible therapies in plastic surgery. Methods: The databases PubMed (National Institute of Health, Bethesda, MD), Embase (via Ovid [Elsevier, Amsterdam, the Netherlands]) and the Cochrane Library (Cochrane, London, United Kingdom) were searched for articles published up to June 1, 2021. Clinical studies of any design, including ESWT in the context of plastic surgery, were included. Two reviewers extracted data and 46 articles were analyzed after application of the inclusion and exclusion criteria. Results: Forty-six included studies (n = 1496) were categorized into the following broad themes; Cellulite/Body Contouring/Skin rejuvenation, Burns/Scar treatment, Diabetic Foot Ulcers/Chronic Wound and Future perspectives of ESWT. Overall, applications of ESWT were heterogenous and the majority of studies reported effectiveness of ESWT as alternative treatment technique. Flawed methodology and differences in technical standards limit outcome and conclusion of this review. Conclusions: There is yet insufficient evidence to support the effectiveness of any specific intervention included in this review, however, all included studies report improvements in key outcomes. Where reported, ESWT displays a good safety profile with no serious adverse events. Further research is needed to provide more evidence in order to delineate the indications of ESWT in plastic surgery.
Article
Background: High levels of abdominal adiposity mean higher risk of developing cardiovascular diseases. Aerobic exercise per si reduces the risk of developing this type of diseases. Radiofrequency and shockwave therapy showed to be effective in the reduction of localized abdominal fat. Aim (s): To compare the effects of prescribed moderate aerobic exercise associated with 6 sessions of shockwave therapy or radiofrequency, in the subcutaneous abdominal adipose tissue, in overweight female individuals in fertile age. Methods: Randomized clinical trial, with 30 volunteers in fertile age with overweight and/or obese, randomly and equitably allocated in two experimental groups (1-shockwave therapy and 2-radiofrequency) and one control group. Aerobic physical exercise was prescribed to all groups. The values of anthropometric measurements were measured in two moments. The intervention protocol was performed in a clinic for six weeks, with one session per week. The ANOVA test, paired samples t test, Kruskal-Wallis test, and Wilcoxon test were used to compare the results, for a significance level of 0.05. Results: Of 28 participants completed the study. There were significant differences in waist circumference reduction between the experimental group 1 and 2 when compared to the control group (p = 0.005 and p = 0.014, respectively). There was a statistically significant reduction in navel level circumference in experimental group 1 when compared to experimental group 2 (p = 0.024) and with the control group (p = 0.016). Conclusion: Both resources were effective in reducing abdominal measurements when compared to the control group. However, SWT was superior in reducing the navel level circumference.
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Background and Aims. The exploration of an individualised protocol of radial extracorporeal shock wave therapy (rESWT) for plantar fasciopathy, assessing success rates and the recurrence rate over a 1-year period after treatment, is not yet identified in literature. Methods and Results. Between 2006 and 2013, 68 patients (78 heels) were assessed for plantar fasciopathy. An individualised rESWT treatment protocol was applied and retrospectively analysed. Heels were analysed for mean number of shock wave impulses, mean pressure, and mean frequency applied. Significant mean pain reductions were assessed through Visual Analogue Scale (VAS) after 1-month, 3-month, and 1-year follow-up. Success rates were estimated as the percentage of patients having more than 60% VAS pain decrease at each follow-up. 1-year recurrence rate was estimated. The mean VAS score before treatment at 6.9 reduced to 3.6, 1 month after the last session, and to 2.2 and 0.9, after 3 months and 1 year, respectively. Success rates were estimated at 19% (1 month), 70% (3 months), and 98% (1 year). The 1-year recurrence rate was 8%. Moderate positive Spearman’s rho correlation ( r = 0.462 , p < 0.001 ) was found between pretreatment pain duration and the total number of rESWT sessions applied. Conclusions. Individualised rESWT protocol constitutes a suitable treatment for patients undergoing rESWT for plantar fasciitis.
Article
Background: Cellulite is a common aesthetic condition that affects almost every woman. Objective: To evaluate the efficacy of acoustic wave therapy (AWT) for cellulite and body shaping. Methods: In this open-label, single-center trial, 30 women presenting moderate or severe cellulite underwent 12 sessions of AWT on the gluteus and back of the thighs, over 6 weeks. The following assessments were performed at baseline, and up to 12 weeks after treatment: Cellulite Severity Scale (CSS), body circumference measurements, subcutaneous fat thickness by magnetic resonance imaging (MRI), quality of life related by Celluqol®, and a satisfaction questionnaire. Results: The treatment presented positive effect in the cellulite severity. A considerable percentage of subjects shifted the cellulite severity to moderate or mild. The average CSS grading significantly reduced from 11.1 to 9.5 from baseline to follow up visits (p<0.001). The significant reduction in body circumference was corroborated by the significant reduction in the subcutaneous fat thickness assessed by MRI. The treatment resulted also in a remarkable improvement in quality of life and high satisfaction. No serious adverse events were reported. Conclusions: AWT is a safe treatment to improve cellulite appearance and reduce body circumferences.
Article
In this case study of an unique instance, effects of medium-energy, high-focused extracorporeal generated shock waves (ESW) onto the skin and the underlying fat tissue of a cellulite afflicted, 50-year-old woman were investigated. The treatment consisted of four ESW applications within 21 days. Diagnostic high-resolution ultrasound (Collagenoson) was performed before and after treatment. Directly after the last ESW application, skin samples were taken for histopathological analysis from the treated and from the contra-lateral untreated area of skin with cellulite. No damage to the treated skin tissue, in particular no mechanical destruction to the subcutaneous fat, could be demonstrated by histopathological analysis. However an astounding induction of neocollageno- and neoelastino-genesis within the scaffolding fabric of the dermis and subcutis was observed. The dermis increased in thickness as well as the scaffolding within the subcutaneous fat-tissue. Optimization of critical application parameters may turn ESW into a noninvasive cellulite therapy.
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Although the term cellulite is inadequate, since it does not refer to cellular subcutaneous tissue inflammations or infections, it is conventionally used to describe a female condition that is characterized by a wavy appearance of the skin's surface in some areas of the body. It constitutes a frequent complaint and an important concern for the majority of women and, due to its complex, multifactorial, and not completely known etiopathogenesis, there is still no effective and definitive treatment. Consequently, many therapeutic proposals, either based on poor quality publications or lacking sufficient scientific evidence, have been introduced. Topical treatments are not effective, though some can be indicated as adjuvant therapies. There is currently no technology able to correct the structural alterations of the female adipose tissue and deep dermis. That status clearly depends on the development of technologies based on the selective photothermolysis principle aimed at treating superficial hypodermal fat and the deep dermis. This article presents a review of the epidemiology, etiopathogeny, histology, clinical classification, and methods for the diagnosis, evaluation, and treatment of cellulite.
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The treatment of cellulite, a major cosmetic concern for many women, remains challenging. Although a number of studies have investigated the effects of a wide range of products/procedures on cellulite-related endpoints, most of these studies have important methodological flaws. At present, there is no clear clinical evidence that any evaluated treatments have good efficacy in reducing cellulite, with the most promising results shown with acoustic wave therapy.
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Oxidative stress is the resultant damage that arises due to redox imbalances, more specifically an increase in destructive free radicals and reduction in protection from antioxidants and the antioxidant defence pathways. Oxidation of lipids by reactive oxygen species (ROS) can damage cellular structures and result in premature cell death. At low levels, ROS-induced oxidative stress can be prevented through the action of antioxidants, however, when ROS are present in excess, inflammation and cytotoxicity eventually results leading to cellular oxidative stress damage. Increasing evidence for the role of oxidative stress in various diseases including neurological, dermatological, and cardiovascular diseases is now emerging. Mitochondria are the principal source (90%) of ROS in the cell, with superoxide radicals being generated when molecular oxygen is combined with free electrons. Given the key role of mitochondria in the generation of cellular oxidative stress it is worth considering this organelle and the process in more detail and to provide methods of intervention.
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The aim of this metaanalysis was to investigate the effectiveness of extracorporeal shock wave therapy (ESWT) in cellulite. Electronic databases (such as Ovid MEDLINE, Scopus and Ovid) as well as reference lists of the available studies were evaluated in June 2015 by two expert examiners. Assessment of each study's methodological quality was performed with the help of the published quality index tool by Downs and Black. This metanalysis included a total of eleven clinical trials on the effects of ESWT on cellulite with a total of 297 included females. Among the eleven clinical trials five randomized controlled trials on ESWT in cellulite with a total number of 123 females have been published so far. Both, focused as well as radial ESWT devices have been found effective in treating cellulite so far. Typically, one or two sessions per week and six to eight sessions overall were studied in the published clinical trials. Overall, outcome parameters mainly focused on digital standardized photographs, circumference measurements and specific ultrasound examinations. Reporting quality showed substantial heterogenity from 22 to 82 points with a mean of 57 points. This metanalysis identified eleven published clinical studies on ESWT in cellulite with five randomized-controlled trials among them. There is growing evidence that both, radial as well as focused ESWT and the combination of both are able to improve the degree of cellulite. Typically, six to eight treatments once or twice a week have been studied. Long-term follow-up data beyond one year are lacking as well as details on potential combination therapies in cellulite such as with low level laser therapy (LLLT), cryolipolysis and others. Copyright © 2015. Published by Elsevier Ltd.
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An effective and long-term treatment of cellulite has not been well established. To our knowledge, no review has analyzed the whole range of treatments for this condition. We conducted a review of in vivo studies on humans adopting the key words "cellulite" and "treatment." The studies were included according to eligibility criteria. We performed an analysis to estimate the overall effect of cellulite treatments from clinical studies. Medline library was screened up to December 2014 to identify eligible studies. We included 73 original studies in the present review. All of them were clinical studies, in most of them, only women were recruited. Above the studies searched up, 66 tested the effectiveness of an exclusive treatment performed without the association to other procedures: 11 topical agents, 10 shock-wave therapy, 10 radio frequency, eight laser therapy, five oral therapy, four manual massage therapy, three carbon dioxide therapy, two compressive therapy, two infrared therapy, one dermabrasion, and 11 devices that use an association of multiple treatments. Seven papers tested a combination of two or more treatments. The mean difference of clinical morphologic features and ultrastructural changes between the treated group and the controlled showed significant heterogeneity between studies. It is still difficult to indicate an exclusive and effective single treatment for this condition. Our analysis purposed to obtain a complete overview of the available treatments in cellulite reduction. © 2015 Wiley Periodicals, Inc.