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Gaceta Médica Espirituana

On-line version ISSN 1608-8921

Gac Méd Espirit vol.22 no.3 Sancti Spíritus Sept.-Dec. 2020  Epub Dec 03, 2020

 

Editorial

Extracorporeal shockwave treatment in diabetic foot ulcers

Sandra Martínez-Pizarro1  * 
http://orcid.org/0000-0003-3070-8299

1Hospital comarcal de Huércal Overa, España.

Diabetic foot ulcers (DFU) occur in over 10 % of diabetic patients and are associated with high morbidity. Extracorporeal shockwave therapy (ESWT) has recently been suggested as a new adjuvant therapy that has demonstrated a potential ability to promote ulcer healing. 1

The 2019 review by Huang Q, et al. in China evaluated the efficacy of extracorporeal shockwave therapy in the healing of DFU; it found that extracorporeal shockwave therapy was associated with a greater reduction of ulcer area by 1.54 cm2 also an increase in re-epithelialization by 26.31 % than standard treatment. In addition, extracorporeal shockwave therapy also showed superiority to hyperbaric oxygen therapy in healing ulcers. This therapy is an effective adjuvant treatment that can improve the healing rate and shorten the healing period in intractable and recurrent diabetic foot ulcers. 1

in a review made about the efficacy of extracorporeal shockwave therapy in diabetic foot ulcers, this therapy shows positive short and long-term results as it improves blood flow perfusion rates in the ulcer, promotes and accelerates healing significantly compared to standard treatment; also, it is more effective than hyperbaric oxygen therapy in healing diabetic foot ulcers. This therapy appears to be effective, easy to apply, virtually without side effects and cost-effective compared to other treatments. 2

The 2018 U.S. study examines the effectiveness of extracorporeal shockwave therapy on neuropathic diabetic foot ulcers; 336 patients were randomly assigned to receive either standard care and extracorporeal shockwave therapy (n=172), or standard care and simulation (n=164); both therapies were administered 4 times during 2 weeks (study 1) and 8 times during 12 weeks (study 2); results showed that ulcers from the group receiving extracorporeal shockwave therapy healed more. At 20 weeks, 35.5 % vs. 24.4 %, and at 24 weeks, 37.8 % vs. 26.2 % in the extracorporeal shockwave therapy group compared to the simulation group. Extracorporeal shockwave therapy is an effective treatment in combination with standard care for neuropathic ulcers that do not respond to standard care itself. 3

The 2019 UK review by Hitchman LH, et al. included five trials of 255 patients; three of these compared extracorporeal shockwave therapy with standard care and two compared extracorporeal shockwave therapy with hyperbaric oxygen therapy, with the result that extracorporeal shockwave therapy was superior to standard care in complete healing of the ulcer, in healing time, and more effective than hyperbaric oxygen therapy. 4

A study conducted in 2016 in Denmark 23 patients with diabetic foot ulcers were randomly assigned to receive 6 extracorporeal shockwave therapy treatments during 3 weeks with standard care or standard care itself; this therapy was performed using 250 shocks/cm2 and 500 shocks in the ulcer´s arterial beddings; transcutaneous oxygen tension was significantly increased in patients treated with extracorporeal shockwave therapy compared to the control group at 3 weeks. The reduction in ulcer area was 34.5 % in the intervention group versus 5.6 % in the control group at 7 weeks; the study indicates a possible beneficial effect of extracorporeal shockwave therapy on ulcer healing as well as on tissue oxygenation. 5

By analyzing the studies presented in recent years conducted in various countries (China, Taiwan, Austria, United States, United Kingdom, Denmark), the potential of extracorporeal shockwave therapy to accelerate the healing of diabetic foot ulcers of grade 1A or 2A (Texas classification) can be proven; furthermore, taking into account that it increases healing it would allow to improve the quality of life of diabetics and reduce costs for diabetic foot ulcers. However, although the evidence reviewed seems to indicate that positive results can be expected from this treatment, the small amount of studies conducted in humans and the small number of samples included, is not sufficient to establish a general recommendation.

It is necessary to make this therapy known by health professionals, so that research in this area can be increased. The efficacy of extracorporeal shockwave therapy should be evaluated in larger samples of patients, examine its effect on various types of ulcers and analyze its synergistic effect with other treatments. This way patients can be offered the best care based on the latest evidence.

REFERENCIAS BIBLIOGRÁFICAS

1. Huang Q, Yan P, Xiong H, Shuai T, Liu J, Zhu L, et al. Extracorporeal shock wave therapy for treating foot ulcers in adults with type 1 and type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Can J Diabetes [Internet]. 2020 [cited 2020 Jul 20];44(2):196-204. Available from: Available from: https://pubmed.ncbi.nlm.nih.gov/31515158/Links ]

2. Wang CJ, Cheng JH, Kuo YR, Schaden W, Mittermayr R. Extracorporeal shockwave therapy in diabetic foot ulcers. Int J Surg [Internet]. 2015 [cited 2020 Jul 20];24(PtB):207-9. Available from: Available from: https://fyzzio.nl/assets/blogfiles/Extracorporeal-shockwave-therapy-in-diabetic-foot-ulcers.-Wang-et-al-2015.pdfLinks ]

3. Snyder R, Galiano R, Mayer P, Rogers LC, Alvarez O. Diabetic foot ulcer treatment with focused shockwave therapy: two multicentre, prospective, controlled, double-blinded, randomised phase III clinical trials. J Wound Care [Internet]. 2018 [cited 2020 Jul 21];27(12):822-36. Available from: https://www.magonlinelibrary.com/doi/abs/10.12968/jowc.2018.27.12.822Links ]

4. Hitchman LH, Totty JP, Raza A, Cai P, Smith GE, Carradice D, et al. Extracorporeal shockwave therapy for diabetic foot ulcers: A systematic review and meta-analysis. Ann Vasc Surg [Internet]. 2019 [cited 2020 Sep 21];56:330-9. Available from: Available from: https://www.clinicalkey.es/service/content/pdf/watermarked/1-s2.0-S0890509618308756.pdf?locale=es_ES&searchIndex=Links ]

5. Jeppesen SM, Yderstraede KB, Rasmussen BSB, Hanna M, Lund L. Extracorporeal shockwave therapy in the treatment of chronic diabetic foot ulcers: a prospective randomised trial. J Wound Care [Internet]. 2016 [cited 2020 Sep 21];25(11):641-9. Available from: Available from: https://www.magonlinelibrary.com/doi/abs/10.12968/jowc.2016.25.11.641?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.orgLinks ]

Received: March 26, 2020; Accepted: August 19, 2020

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