Effectiveness of Shock Wave Therapy in Injuries of Tendons and Ligaments of the Osteomyoarticular System

Objective: To evaluate the effectiveness of the Well Wave equipment in treating patients with injuries to the tendons and ligaments of the osteomyoarticular system. Methods: A descriptive, cross-sectional study was carried out with 107 patients diagnosed with injuries to the tendons and ligaments of the osteomyoarticular system, which were treated with the Well Wave equipment (extracorporeal shock waves) at the International Orthopedic Scientific Complex “Frank Country ”, in the period between March 2019 and April 2020. The analysis of the variables (age, sex, pain and disability) was carried out. To determine the effectiveness (real benefit), the medical and physiological effects that occur when applying this therapy were analyzed. Results: Female sex predominated (71.9%) and 51-60 years (28%). 40.2% of the patients were treated for presenting supra spinous tendonitis. All patients had pain before the application of therapy. After treatment, 86.9% of the patients stopped feeling it and 58% presented absence of disability according to the DASH scale. According to the evaluation criteria of the response to treatment, the results were satisfactory (72.9%). Conclusions: The therapy with shock waves enabled a rapid recovery of the patients attended and their incorporation into daily activities. Tendons Ligaments of the Osteomyoarticular System.


Introduction
For more than 20 years, medical technology with great potential to improve or replace some invasive procedures has been successfully applied in the world, such is the case of Extracorporeal Shock Wave therapies. In 1997 the European Society for Muscleskeletal Shock Wave Therapy was established in Vienna, due to the rapid diffusion of the method, in 1999 it was renamed the depth of penetration of the shock wave focus into the tissues can be varied by modifying the thickness of the coupling pillow [1,2].
At present in Cuba the number of elderly people has increased, this brings a series of progressive physiological and functional deteriorations with the consequent acquisition of chronic degenerative diseases. Diseases that cause joint pain are chronic and often disabling. Between 50-80% of the population over 65 years of age present pain [3]. Medical care for osteomyoarticular conditions that end in a surgical procedure is high, every day the number of patients who need specialized medical assistance in search of a solution to their health problem is greater.
Thus, it is necessary to use a new technology that manages to improve, replace or replace some old invasive procedures compared to new technologies, such is the case of Extracorporeal Shock Wave therapies, with the aim of improving the quality of life of patients.
the Cuban population and treat conditions of the osteomyoarticular system. In Cuba, at the "Frank País" International Orthopedic Scientific Complex, it began to be applied in 2001. This therapy has been used until now as a method of treating chronic pain in patients who do not improve with other conservative treatments.
The use of this equipment in musculoskeletal conditions enables a wave disintegrating effect to treat calcifications, has analgesic effects and allows stimulation of the repair process in tendons, soft tissues and bones [4]. The treatment unit produces, by means of an external piezoelectric source, high-energy sound waves, which have a great depth of penetration. This maximum energy in the affected area allows exact location of the area to be treated, low risk of bruising and very little irritation to the skin. It facilitates the outpatient treatment of the patient, short sessions [3][4][5], without risk of allergy or the need for anesthesia [5].
The number of patients who have received physiotherapeutic treatment with shock waves for this cause has increased in recent years at our institution. The objective then of our research was to evaluate the effectiveness of extracorporeal shock wave therapy in patients with injuries to the tendons and ligaments of the osteomyoarticular system.     The information processing was carried out in EXCEL and using the statistical package SSPS 11.5. The frequency analysis of the variables contemplated in the study was carried out, the absolute and relative frequencies were obtained. In addition, measures of central tendency (mean, median) and dispersion (standard deviation) were used. Likewise, the Chi square test of independence was performed to determine the existence of statistically significant differences between the proportions obtained. 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 a critical or rejection region, when the value associated with p was less than 0.05 and, in this case, the null hypothesis of independence was rejected, and it was concluded that the variables were dependent on each other.

Ethical Considerations
The study was carried out following the ethical principles set out in the Declaration of Helsinki. The Ethics Committee for research in humans, of the International Orthopedic Scientific Complex "Frank País", ensured compliance with these requirements and approved the research. The information obtained was kept confidential and was only used for investigative purposes. Similarly, to obtain personal information from each patient, their consent was requested, and the reserved nature of the information provided and its scientific use was explained (Annex 3).

Results
As can be seen in Table 1, in the sample there was a predominance of females with 77 patients (71.9%) and the age group of 51-60 years (28%). The median age of the patients seen was 58 years of age. There were no significant differences in terms of age and sex distribution (p = 0.253).   AF: Absolute frequency p = 0.345 As can be seen in Table 3, all the patients had pain before the application of the shock wave, inclusive, it was the main indication for performing this non-invasive technique. After treatment, this situation was reversed, 78.5% of the patients were without pain. Only 8.4% had pain while walking and 7.5% at rest. These differences in pain before and after therapy were statistically significant (p = 0.0000). AF: Absolute frequency p = 0.0000 Table 4 shows the results obtained after applying the DASH Scale. 43% of the patients studied had total disability before starting treatment. Only 4.7% were found in the category of absence of disability. After five sessions of therapy, according to the procedure described, 71% had no disability and only 5.6% remained in the category of total disability. Significant results were obtained (p = 0.0000). AF: Absolute frequency p = 0.0000 Table 5 shows the analysis of the evaluation criteria for response to treatment, where good and fair results were considered satisfactory and bad, unsatisfactory. There was a higher percentage of satisfactory results (56% and 23.4%). Only 20.6% of the sample had a poor response, persisting symptoms of pain and functional limitation. The results were significant (p = 0.0000).

Discussion
According to the literature reviewed, tendinopathies of the shoulder injury to the supraspinatus, tennis elbow (epicondylitis) are common between 40 and 60 years of age. The literature states that 2 to 50% of the population have shoulder pain, accompanied by common symptoms such as atrophy of the muscles and limitation of movements. It is common in both sexes, with a 4: 1 ratio, in favor of women associated with jobs such as seamstresses, housewives, hard workers, athletes and musicians. In the case of Epicondylitis, its prevalence is 10% [6]. Calcaneal spur, plantar fasciitis and calcific achillean tenosynovitis are diseases that have a high prevalence that increases with age. It is of multifactorial origin, although a history of repetitive microtraumas is collected, being more common in runners, overweight people and tasks that require standing for long periods of time. It affects 10% of the population throughout their life between the fourth and sixth decade of life, also causing functional disability. The aforementioned diseases are common conditions in women, which coincided with our study, including age [7]. Age can be considered a risk factor in itself for the suffering of these conditions, since in the aging process itself changes occur in our body that favor the appearance of these diseases.
According to Mirallas Martínez, pain, limited movement and disability is a frequent symptom, characteristic of all these conditions and can be present in all cases [8]. This result could be The reversal of chronic inflammation is another advantage of the use of extracorporeal shock waves, since this persistent inflammation requires components (called mast cells), whose activity increases with acoustic waves, allowing the production of chemokines and cytokines that improve the inflammatory process [9]. Effectiveness was demonstrated in the treatment of supraspinatus tendonitis and epicondylitis [13]. The improvement is significant in pain intensity, with good or excellent functional gain in 56% of patients treated with extracorporeal shock wave therapy.
There are significant differences between patients in the treatment and placebo groups in pain and function, and it is concluded that treatment using this therapy is a pre-surgical alternative. The improvement in pain and function is good or excellent in 48% and acceptable in 42%, with a significant difference in favor of patients in the treated group compared to those in the placebo group. The improvement in pain and function is good or excellent in 52% of those treated compared to 6% of those in the placebo group [14].
Similar results to ours were observed.
In the case of plantar fasciitis and achillean tenosynovitis, Gollwitzer H, et al. [15] Conducted the study that used the largest sample size, with 250 subjects for the trial obtaining satisfactory results. This effectiveness or benefits are reflected in an improvement in the patient's symptoms, especially in the decrease in pain and improvement in functional capacity, and in a decrease in the thickness of the plantar fascia based on the studies reviewed, as these are the variables more measures together [15]. The main weakness of this study is the small sample size, but with results similar to those found in other studies where a similar response to both treatments could be observed, this fact supports the strength of our findings.

Conclusion
Some of the sociodemographic characteristics of the patients studied do not differ much from those indicated by other authors, such as: the predominance of female sex and age. Treatment with extracorporeal lithotripsy (shock wave therapy), with the Well Wave equipment, was an effective method. It is a modern and noninvasive technique, which has enabled a rapid recovery of patients, their incorporation into daily activities, promotes rehabilitation, early return to work activities and better use of the working day.