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Focused extracorporeal shock waves improve pareses in 3 cases of myelomeningocele.
H. Lohse-Busch(1), C Fan (2)
(1)Clinic for Manual Medicine – Center for Movement Disorders
Rheintal Hospital Bad Krozingen, Germany
(2) Storz Medical, Tägerwilen, Switzerland
Abstract
Statement of problem: Can low-energy focused extracorporeal shock wave therapy (ESWT) improve
symptoms of a paraparesis?
Patients and Methods: 2 girls, 11, 12 years of age, suffering from paraparesis caused by
myelomeningocele, received ESWT (“Duolith” shock wave generator, Storz Medical) to the region of
the spinal cord lesion several times a week. This treatment was part of a complex therapy regime. The
courses of treatment were documented using surface EMG, manual muscle test (MMT), and functional
reach test (FR).
Results: Previously non-innervated muscles that were rated subsequently showed increasing EMG
activity and an average improvement in strength of about 3°- 4 ° in MMT. The patients improved their
FR when seated by 5 cm and 14 cm respectively. The degree of the American Spinal Injury
Association (ASIA) classification evolved from ASIA A to C and D. Superficial and deep sensibility
increased below the lesion level. There were no undesirable side effects.
Discussion: Suitable doses of ESWT stimulate muscles and nerves directly and may lead furthermore
to the release of neurotrophic substances.
Conclusions: ESWT enhance muscular function and superficial sensibility in the lower adjacent
region of the spinal cord lesion in children with myelomeningocele. The neurophysiological effects
need to be verified on larger numbers of patients.
Kex words: myelomeningocele, paraparesis, ESWT, motor function, sensibility
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Introduction
Focused extracorporeal shock wave therapy (ESWT) has a non-specific effect on soft tissue. What is
known to date is that this therapy promotes endothelial nitric oxide (eNO) production (17) as well as
stimulating angiogenesis (6) and neurogenesis (24) via the vascular endothelial growth factor (VEGF).
ESWT also promotes neurogenesis by stimulating FGF-2 (fibroblast growth factor) (10, 18).
Lymphatic drainage is positively influenced by the stimulation of the endothelial lymph vessel growth
factor (eLGF) (9). ESWT has an analgesic and anti-inflammatory effect (17).
After ESWT on hip necrosis (15), a systematic increase in the concentrations of eNO, VEGF and
FGF-2 in the serum was detected over a period of at least 4 weeks (27).
In recent years, the customary ESWT for various tendinopathies (22) and pseudarthrosis (30) has been
extended to different indications, including diabetic angiopathy, angina pectoris, revascularization of
infarcted areas of the heart (25), wound healing disorders (26, 20), growth stimulation of cardiac
progenitor cells (19), and lymphangiogenesis (23). ESWT is also known to have a tonus-lowering
effect on spasticity in children (1, 13, 14) and adults (16) with movement disorders, thus enabling a
better quality of movement.
Hypothesis
When using focused ESWT to treat spastic movement disorders in paraplegic patients, we observed an
increase in muscle motor activity that seemed to be achieved by motor efferences in the border area of
the spinal cord lesion.
These observations raised the question of whether additional treatment of the damaged spinal cord and
spinal nerve roots with focused ESWT might improve the qualities of the motor activity and the
sensibility below the lesion.
Ethics Commission
The Ethics Commission of Freiburg University Medical Center informed us that they had no
reservations about these therapy sessions being carried out.
Patients
We examined 3 with myelomeningocele – two girls and a boy aged 9, 11 and 12, respectively.
Treatment concept
Thel patients received 3 weeks of complex therapy twice or three times a year. The complex therapy
regimen consisted of daily manual medicine, massages to stimulate proprioception, neurophysiology-
based physiotherapy, ergotherapy and, whenever indicated, medical mechanical therapy with a therapy
swing, the Giger MD® treadmill, the Galileo® vibration system and a motor-driven treadmill
(Woodway®).
The patients received 2000 focused ESW with an energy flux density from 0.1 to 0.2 mJ/mm² at
individually scheduled intervals 2-4 times a week to the region of the spinal cord lesion as well as to
2-3 segments extending cranially and caudally from it.
Storz Medical’s Duolith® was used to administer the ESWT. To minimize treatment risks, the energy
source was moved constantly during treatment.
Measurement methods
Surface electromyography
We used the surface EMG Synergy 3-D® (Prometheus) to view muscle activity prior to and after
treatment of the spinal cord and spinal nerve roots.
Functional Reach (3)
This test was designed for upright standing patients, but nevertheless appears suited to assessing
stability in a seated position. How far a seated patient is able to bend the trunk of the body forward and
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then return to the original upright position is measured from the fingertips of the patient’s outstretched
hands.
We also classified the degree of the paraparesis according to American Spinal Injury Association
(ASIA) standards, revised 2003 (21) and tested the muscular strength by the manual test of muscle
strength (MMT) (2)
ASIA A
Complete
No motor or sensory function below level of lesion
ASIA B
Incomplete
Sensibility preserved below level of lesion
ASIA C
Incomplete
Motor function with muscle strength (MMT) of < 3° preserved below
lesion level or in 3 segments below the lesion despite S4/5 deficit
ASIA D
Incomplete
Motor function with muscle strength (MMT) of > 3° below lesion level
ASIA E
Normal
No neurological deficits
Tab 1 Classification of spinal injury symptoms
0°
No muscle contraction
1°
Visible/palpable contraction
2°
Movement possible with full range of motion, but not against gravity
3°
Movement possible against gravity with full range of motion, but not
against resistance by the examiner
4°
Movement possible with full range of motion against some resistance by the
examiner
5°
Normal muscle strength
Tab 2 Manual test of muscle strength (MMT) (2)
“Full range of motion” is understood here as the extent of free movement of the joints up to the point
of soft contracture. The term “soft contracture” describes the constant, functional rigidity of a muscle
before the onset of the structural or “stiff” contractures seen in spastic movement disorders. The
assessments of all the patients in this study were carried out by the same physician.
Case histories
1. Tov Mar
This 11-year-old girl suffers from myelomeningocele with complete paraplegia, classified as ASIA A,
caudal L2.
Sitting unsupported was not possible. The knee extensors were not innervated. Superficial sensibility
was strictly limited to the L2 dermatome.
At the ages of 11 and 12, the patient received ESWT to the foot soles and the knee flexors during two
3-week-long sessions of complex therapy. This resulted in only about a 20° reduction of the knee
flexor contractures during passive movement.
Over a period of 22 months starting at age 13, the region around the spinal cord lesion was treated
with ESWT in addition to the complex therapy, which comprised five 3-week treatment sessions.
Subsequently, the patient was able while seated to actively stretch her dangling lower limbs by about
40° to 50° to the point of soft contracture. She was also able to sit without any support for several
seconds. She was able to sit up on her own when lying on her stomach and seat herself on a bench
without any help.
Functional reach improved from 0 to 5 cm. Her ASIA classification has improved from A to C.
Superficial sensibility is now limited to L4 on both sides.
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Fig. 1 M. rectus femoris of both sides recorded before starting ESWT to the region of the spinal cord
lesion.
Fig.2: Patient n° 1. Activity of the m. rectus femoris of right (black) and left (grey) side after 22
month (5 three week complex therapies including 45 ESWT)
Mar Tov
Before
After 22 weeks
number of treatment series
5
ESWT on spinal cord
45
MMT° knee extensors
0
3
Caudal m. erector spinae
0
3
Functional Reach
0
5
ASIA classification
A
C
Tab. 4 Development of motor function after five courses of complex therapy, including a total of 45
sessions of ESWT applied to the spinal cord lesion.
*C Number of treatment cycles, ** Number of sessions with ESWT
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2. Fur Ele
This 12-year-old girl suffered from myelomeningocele from Th10 to L2 with complete paraplegia
below Th10 and was classified as ASIA A. Superficial sensibility was strictly limited to the Th10
dermatome. Sitting was not possible.
At the age of 12, the girl received complex therapy with ESWT to the feet and lower leg muscles, and
there was no improvement in motor function. This was followed by six 3-week treatments over 22
months, supplemented by 54 ESWT applications to the region of the spinal cord lesion and to the
periphery musculature.
This brought about a constant improvement in the motor functions. In the end, she was able to sit
without support on a swing that moved up to 10° frontally and sagittally and catch and throw balloons.
Sitting at a table, she ate with both hands. She was able to move a treadmill against slight resistance,
using her hip muscles as well as the knee extensors and flexors.
Functional reach improved from 0 to 12 cm. The lower abdominal muscles and the lower erector
spinae system improved in strength from MMT 0° to MMT 3°-4°.Superficial sensibility improved
from Th 10 to Th 12. She now has to be classified to ASIA D.
Fig. 8 M. rectus femoris activity before application of ESW to the region of the spinal cord lesion.
Fig. 9 M. rectus femoris activity after a total of 54 sessions of ESWT to the region of the spinal cord
lesion. The patient is able to alternately stretch each knee joint against slight resistance when sitting on
a bench.
Fur Ele
Before
After 27 months
6
C n // ESWT n
6 // 54
MMT° knee extensors
0
3-4
MMT° abdominal muscles
0
4
MMT° lumbar m. erector spinae
0
4
Functional Reach
0
12
ASIA classification
A
D
Tab.5 Development of motor function after 6 courses of complex therapy, including a total of 54
sessions of ESWT applied to the spinal cord lesion and the periphery muscles.
Discussion
When any type of energy comes into contact with living tissue, the effect depends on the strength of
the energy and the exposure time to it. High-energy ESW can cause demyelination of the nerves (29)
and destroy brain tissue (8, 11). This would happen if very high energy were administered in a single
shot (8) or if several hundred shots were directed at the same treatment site (11, 29). To avoid any
potential damage to the nerve structures by an accumulation of ESW in a small area of tissue, we
never exceeded an energy flux density of 0.20 mJ/mm² in the focus area, and the energy source was
moved constantly. This prevented any undesired effects or painful irritations.
Low-energy ESW cause no damage to the spinal nociceptive system (4) and can contribute to the
repair of damage to the spinal cord structures (24, 28) by activating the neurotrophic system. This is
brought about by the systemic increase of the eNOs (17), the VEGF (6), and the FGF (5, 10) that is
induced by the shock waves. In rats the increase of VEGF facilitates recovery after the spinal cord has
been damaged (12) and stimulates neurite growth (7, 24).
Our patients benefited from the courses of treatment to the spinal cord within the limited scope of
what was feasible for them. They were able to use their newly acquired motor skills and sensibility to
an extent that impacted and improved their quality of life considerably.
As a rule, muscle innervation is plurisegmental. This is a factor that could be exploited by applying
ESWT to the areas bordering the spinal cord lesion. The ESWT causes an ad hoc stimulation of motor
units that are basically still able to work, but have not been used for a long time because they fail to
trigger any proprioceptively exploitable muscle contraction. The patients themselves notice this
stimulation to the musculature immediately after ESW treatment of the spinal cord. A similar line of
thought holds true for the different qualities of superficial and deep sensibility, both of which can also
improve.
The hypothesis of a stimulation limited to the duration of the treatment sessions fails to explain the
protracted course of the improvements, however. The process of recruiting an increasing number of
motor units continues for about 4 weeks even after a course of treatment has ended. Nevertheless, even
after several repetitions of complex therapy at intervals of several months and years, it is not clear why
the process of an expansion in motor and sensory skills should begin all over again. This could have to
do with a thinkable recovery process.
It appears conceivable that pathways, from which some threads perhaps pass through the spinal cord
lesion, experience a period of useable repair. An explanation for this phenomenon might be found in
the fact that the local and systemic increase in the concentrations of NO, VEGF, and FGF is verifiable
for about four weeks (27) and then gradually drops off again. Some of our patients noticed an increase
in muscular function during precisely this period. Subsequent studies need to clarify this by means of
electrophysiological investigations.
The increase in the different qualities of sensibility and their topical expansion appear to take far
longer than the recovery of motor function. Most patients only become aware of the improvement in
sensibility several weeks after the end of a three-week course of treatment.
After the potential verification elsewhere of the results presented in this paper, it is essential to work
on and determine – simultaneously – both the optimal dose of ESW energy flux density and the
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number of shots per region and session, as well as treatment frequency during any one course of
treatment and the intervals of time between each course of treatment. This will result in the needed
formulation of the therapy objective over time. These practical issues aside, this paper would like to
stimulate investigation into the neurophysiological and molecular-biological phenomena that arise
when nerve structures are treated with ESWT.
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The first author has an consulting contract with Storz Medical AG
