Effectiveness of Wave of Shock Extracorporeal in Patients with Hallux Rigidus in the CCOI Frank País

To evaluate the effectiveness of therapy with waves of shock in the treatment of hallux rigidus...


Introduction
Hallux rigidus is a deformity in the joint located in the base of the first finger. "Hallux" it refers to the first toe of the foot, while that "Rigidus" indicates a stiffness in the finger that prevents the movement. Hallux rigidus is the, in reality, a form of arthritis degenerative [1]. It was described for the first time by Davies-Colley in 1887, [2] who 's named as Hallux Flexus, and more later Coterill Pain continued in the hip, the knee or hand down the back due to changes in the mode of walking H. In severe cases, lameness [5] I. In its stage's primary, the mobility of the finger fat only find something limited; then it is called "Hallux Limitus ". But as the problem progresses, the range of movement of the finger decreases until reaching the state final "Rigidus" which is when the finger remains stiff or as " frozen " [4].

J.
In the literature is described four degrees as the classification of Coughlin: [6] K. Grade 0, the dorsiflexion of the first metatarsophalangeal is between 40 and 60 degrees (loss of 20% of normal mobility), without clinical or radiographic alterations.

L. Grade I, the dorsiflexion is located between 30 and 40
degrees and appreciate osteophytes lats, but with minimal narrowing joints.
M. Grade II, dorsiflexion is between 10  of the synovial swollen, and as the nerves digital and capsule [7].
The rays X can be entirely normal or show destruction articular severe. The changes radiological not necessarily correspond to the symptomatology. However, in the projection dorsoplantar is can observe reduction of the space and osteophytes lateral and medial, the injuries osteochondritis also be seen better in the projection anteroposterior. The projection side can see the osteophytes ridges and bodies free, as well as the decrease of the space joint [8].
At the present time they are have described various treatments, although the evidence scientific still is scarce [4,9] is recommended approximately of recovery six weeks [10]. However, before this method invasive, in the present it is recommended first to treat the lesion with waves of shock extracorporeal [11]. The application of this therapy has proven to be safe and effective; in other pathologies, surgical procedures have been avoided [12,13]. The goal of therapy by waves of shock extracorporeal, is relieve pain, improve the mobility and stability.
In the Complex Scientific Orthopedic International "Frank   The processing of information is performed in EXCEL and by the package statistical SSPS 11.5. Is performed the analysis of frequency of the variables referred to in the study and obtained the frequencies absolute and relative. Similarly, it made the Test Ji square of independence to determine the existence of differences statistically significant between the proportions obtained. Is indicated, in each case the value corresponding to the probability of occurrence p; an alpha error of 0.05 and a confidence of 95% were prefixed. It was determined, as region critical or rejection, when the value associated to p was less than 0.05 and, in such case, is rejected the hypothesis null of independence and concluded that the variables were dependent among themselves.

Ethical Considerations
The study was conducted following the principles ethical contained in the Declaration of Helsinki [14]. The Committee of

Ethics for research in human, of the Complex Scientific Orthopedic
International "Frank País", ensured by the fulfillment of these requirements and approved the research. The information obtained is handled on a confidential and only was used for purposes research. Not reveal the identity of people.

Results
As can be seen in the Table 1 in the sample there was a predominance of the sex female with 22 patients (84.6%) of the group age of 50-60 years (38.5%). With a femininity ratio of 5.5 in which there are around 5 sick women for every sick man in the place and period studied. In the Table 2 is analyzed the number of patients according to the classification of Coughlin, in which belonged to the grade I 65.3% of patients treated. Only he is found in the sample studied by 3.8 % in the grade 0, belonging to the sex male. In the grade III and IV with 7.7% each one, of both sexes.
As can observe in the Table 3, the totality of the patients he had pain before the application of the wave of shock, was indication principal for the realization of this technique not invasive. After of the treatment this situation is reversed favorably because 69.2% of the patients did not have pain. Only 7.7% presented pain in the march, coinciding also two patients (7.7%) with pain in the rest. It noted that were patients that were found in the degree III and IV on the scale of Coughlin. In the Table 4 can see the results with the scale of AOFS. They reached a qualitative interpretation of bad (<50 points) 53.8% of the patients studied, before starting the treatment.
After the performed five sessions of therapy with waves of shock, according to the procedure described, 53.8% and 30.8% of patients reached results of excellent and good, respectively. Only two cases (7.7%) remained with a regular score (51-70) and also two patients (7.7%) with a low score of 50 points. At the same time, it coincided that they belonged to grade III and IV on the Coughlin scale.    In the Table 5 shall appreciate the analysis of the criteria for evaluation of response to the treatment, in which the results good and regularly are considered satisfactory and bad, unsatisfactory.
There was a higher percentage of satisfactory results at the end (50%), when re-evaluating at three months there was an increase (69.2%). Only 15.4% of the evaluating to three months completed the therapy had one response bad, coinciding with that found in the grade III and IV according to the classification Coughlin, at which contributed to the therapy does not result, persisting pain and functional limitation.

Discussion
According to the literature reviewed, the Hallux rigidus is more common in the adults for over 50 years old of age, predominating in the sex feminine [4]. This coincided with the studio that presents. It is described that degenerative arthritic changes increase with age Coughlin and Shurnas indicate that, when are still to patients with hallux rigidus during one period of time long, more than 80% can develop plus one symptomatology bilateral [6]. There are multiple classifications described by Regnauld, [7] Hattrup and Johnson, [15] Núñez -Samper [5] with wide interobserver variability, but perhaps the most complete and applicable is the one developed by Coughlin and Shurnas in 2003, [6] coinciding with this study. According to Deland JT and others, pain is a symptom common in this condition and may be present in the totality of cases [16]. This result was able to corroborate in the research that shows. Pain referred by the   [11][12][13] due to their biological effects.
When it applies this treatment, it occurs at the point of application one increase of formation of vessels blood by micro rupture of capillaries of tendon and bone. The increase of traffic in the area will allow the arrival of factors of repair tissue and oxygen, which will favor one recover more quickly.
Ago so that restore the process of healing, which in many cases.
In the processes chronic, have been stopped or enlentecidos, causing, in addition, one response inflammatory initial, which gets one effect analgesic, accelerator of the metabolism and revascularization area [22]. The success of the treatment in this study in particular is achieved by the cooperation of patients, and it needs to locate the most painful point in the area treated. On the one hand, there is an individual tolerance to pain that is variable and individual to each person. This makes that the processes that for a patient are very painful, for others are not both. When the point of pain primary is eliminated by the effect analgesic of the wave of shock, appear other points that have been superimposed by the main pain. The more stitches disappear, the more effective the treatment, until their total remission. Such is the case that remained patients not improved after applying said therapy corroborating the literature reviewed; in which to patients who are in the grade III and IV is necessary realizable treatment surgical [10] (Annexure 1).

Conclusion
The therapy with waves of shock an important condition that can cause discomfort and even disability but is treated properly, with the team Well Wave, had one high effectiveness, which allowed one quick recovery of patients, their addition to the activities daily and improved their quality of life.

Contribution of the Authors
Marisel Ibarbia Carreras. General conception, research design and writing of the document, Ernesto W. Planas Montalvo.
Analysis and interpretation of the study data and Luis Oscar Marrero Riverón. Corrections to the document and execution of the statistical analysis.