A comparison between extracorporeal shockwave therapy and dextrose prolotherapy on quadriceps muscle performance in knee osteoarthritis
DOI:
https://doi.org/10.47197/retos.v68.113579Keywords:
Dextrose Prolotherapy (DP), Extracorporeal Shockwave Therapy (ESWT), Osteoarthritis, Quadriceps Muscle, Vastus Medial Oblique (VMO), good health, well-beingAbstract
Introduction: The Quadriceps Femoris muscle group frequently exhibits weakness in individuals diagnosed with knee Osteoarthritis (OA). This weakness arises from muscle atrophy and mechanisms such as arthrogenic muscle inhibition. Emerging therapies such as hypertonic Dextrose Prolotherapy (DP) and Extracorporeal Shockwave Therapy (ESWT) offer promising intervention for knee OA, focusing on pain relief and functional improvement. This study aims to evaluate and compare the effects between ESWT and DP on pain, quadriceps femoris muscle thickness and the Vastus Medial Oblique (VMO) electromyography (EMG) activity in knee OA patients. Methods: Eighteen subjects with unilateral knee OA grade 2-3 (Kellgren-Lawrence) randomized into ESWT and DP group. The ESWT group received six sessions of focused-ESWT therapy, with 1-week interval. The dextrose prolotherapy (DP) group received three-injection regime with 3-weeks interval between injections. The VAS score, Quadriceps Femoris muscle thickness measured by musculoskeletal ultrasound, and VMO EMG activity recorded by surface EMG (sEMG) were measured before and after interventions. Results: There were significant improvement of VAS score in both DP group (p = 0.007) and ESWT group (p = 0.006). The Quadriceps Femoris muscle thickness showed no significant improvement in both groups (p > 0.05), while VMO sEMG activity showed improvement of VMOmax in ESWT group (p < 0.001), and VMOavg in both groups (p = 0.012 and p = 0.001). Conclusion: Both ESWT and DP improved pain and VMO EMG activity in knee OA patients, with comparable results between the two interventions. No significant changes of quadriceps femoris muscle thickness was found in both groups after interventions.
References
Abdel-Fattah, Y. H., Mohasseb, D. F., Kotb, H. T., Mostafa, S. I., & Abdelnaby, H. M. A. (2024). Effect of classical prolotherapy technique in knee osteoarthritis for a sample of Egyptian population: clinical and imaging study. Egyptian Rheumatology and Rehabilitation, 51(1), 53. https://doi.org/10.1186/s43166-024-00277-2
Abdelstar, A. A. (2024). Open versus closed kinetic chain exercise on quadriceps hamstring ratio and thickness in knee osteoarthritis. Egyptian Journal of Physical Therapy, 17(1). https://doi.org/10.21608/ejpt.2023.203784.1128
Abe, T., Loenneke, J. P., Thiebaud, R. S., & Loftin, M. (2014). Morphological and functional relationships with ultrasound measured muscle thickness of the upper extremity and trunk. Ultrasound, 22(4), 229–235. https://doi.org/10.1177/1742271X14554678
Avendaño-Coy, J., Comino-Suárez, N., Grande-Muñoz, J., Avendaño-López, C., & Gómez-Soriano, J. (2020). Extracorporeal shockwave therapy improves pain and function in subjects with knee osteoarthritis: A systematic review and meta-analysis of randomized clinical trials. Interna-tional Journal of Surgery, 82, 64–75. https://doi.org/10.1016/j.ijsu.2020.07.055
Bozan, A., & Erhan, B. (2023). The relationship between quadriceps femoris thickness measured by US and femoral cartilage thickness in knee osteoarthritis, its effect on radiographic stage and clini-cal parameters: comparison with healthy young population. Journal of Frailty, Sarcopenia and Falls, 8(3), 155–162. https://doi.org/10.22540/JFSF-08-155
Chen, W., Li, C., Wang, Y., Shen, X., Wu, Z., Li, J., Ye, Z., Xiang, R., & Xu, X. (2023). Comparison of the asymmetries in muscle mass, biomechanical property and muscle activation asymmetry of quadriceps femoris between patients with unilateral and bilateral knee osteoarthritis. Frontiers in Physiology, 14. https://doi.org/10.3389/fphys.2023.1126116
DeChellis, D. M., & Cortazzo, M. H. (2011). Regenerative medicine in the field of pain medicine: Prolo-therapy, platelet-rich plasma therapy, and stem cell therapy—Theory and evidence. Techniques in Regional Anesthesia and Pain Management, 15(2), 74–80. https://doi.org/10.1053/j.trap.2011.05.002
Distel, L. M., & Best, T. M. (2011). Prolotherapy: A Clinical Review of Its Role in Treating Chronic Muscu-loskeletal Pain. PM&R, 3(6S), S78–S81. https://doi.org/10.1016/j.pmrj.2011.04.003
Ferrari, B. S. ., Costa Ferreira, W. ., Rodrigues Lourenço de Morais, S. ., & Magnani Branco, . B. H. . (2024). The inter-relationship between obesity and symptomatology of knee osteoarthritis in older women: a cross-sectional study. Retos, 52, 115–120. https://doi.org/10.47197/retos.v52.101991
Gellhorn, A. C., Stumph, J. M., Zikry, H. E., Creelman, C. A., & Welbel, R. (2018). Ultrasound measures of muscle thickness may be superior to strength testing in adults with knee osteoarthritis: a cross-sectional study. BMC Musculoskeletal Disorders, 19(1), 350. https://doi.org/10.1186/s12891-018-2267-4
Geng, R., Li, J., Yu, C., Zhang, C., Chen, F., Chen, J., Ni, H., Wang, J., Kang, K., Wei, Z., Xu, Y., & Jin, T. (2023). Knee osteoarthritis: Current status and research progress in treatment (Review). Exp Ther Med, 26(4), 481. https://doi.org/10.3892/etm.2023.12180
Hermens, H. J., Freriks, B., Merletti, R., Stegeman, D., Blok, J., Rau, G., Disselhorst-Klug, C., & Hägg, G. (1999). European recommendations for surface electromyography. Roessingh Research and Development.
Hsu, H., & Siwiec, R. M. (2023). Knee Osteoarthritis. StatPearls Publishing, Treasure Island (FL). Availa-ble from: https://www.ncbi.nlm.nih.gov/books/NBK507884/
International Society for Medical Shockwave Treatment. (2023). ESWT Guidelines (3rd ed.). ISMST. Available from: https://shockwavetherapy.org/wp-content/uploads/2024/01/ISMST-Guidelines-for-ESWT-_-engl-20240103.pdf
Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., Callahan, L., Copenhaver, C., Dodge, C., Felson, D., Gellar, K., Harvey, W. F., Hawker, G., Herzig, E., Kwoh, C. K., Nelson, A. E., Samuels, J., Scanzello, C., White, D., … Reston, J. (2020). 2019 American College of Rheumatolo-gy/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis & Rheumatology, 72(2), 220–233. https://doi.org/10.1002/art.41142
Lewek, M. D., Rudolph, K. S., & Snyder-Mackler, L. (2004). Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis. Journal of Orthopaedic Re-search, 22(1), 110–115. https://doi.org/10.1016/S0736-0266(03)00154-2
Linderman, S. E., Scarborough, D. M., Aspenleiter, R., Stein, H. S., & Berkson, E. M. (2023). Assessing Quadriceps Muscle Contraction Using a Novel Surface Mechanomyography Sensor during Two Neuromuscular Control Screening Tasks. In Sensors (Vol. 23, Issue 13). https://doi.org/10.3390/s23136031
Ma, H., Zhang, W., Shi, J., Zhou, D., & Wang, J. (2020). The efficacy and safety of extracorporeal shock-wave therapy in knee osteoarthritis: A systematic review and meta-analysis. International Journal of Surgery, 75, 24–34. https://doi.org/10.1016/j.ijsu.2020.01.017
Rabago, D., Slattengren, A., & Zgierska, A. (2010). Prolotherapy in Primary Care Practice. Primary Care: Clinics in Office Practice, 37(1), 65–80. https://doi.org/10.1016/j.pop.2009.09.013
Randita, A. B. T., Subadi, I., Wardani, N. K., Santoso, A. W., & Melaniani, S. (2023). Improving Cadence and Walking Speed after Extracorporeal Shockwave Therapy: Preexperimental Study in Knee Oste-oarthritis Patients. Biomolecular and Health Science Journal, 6(2). https://doi.org/10.4103/bhsj.bhsj_9_23
Reeves, K. D., Fullerton, B. D., & Topol, G. (2008). Evidence-based regenerative injection therapy (prolo-therapy) in sports medicine. Elsevier Saunders. https://doi.org/10.1016/B978-141603197-0.10049-7
Rhatomy, S., Margaretha, E., & Rahmadian, R. (2020). Dextrose prolotherapy for muscle, tendon and ligament injury or pathology: a systematic review. Annu Res Rev Biol, 43–62. https://doi.org/10.9734/ARRB/2020/v35i1030288
Rice, David A, McNair, P. J., & Lewis, G. N. (2011). Mechanisms of quadriceps muscle weakness in knee joint osteoarthritis: the effects of prolonged vibration on torque and muscle activation in osteo-arthritic and healthy control subjects. Arthritis Research & Therapy, 13(5), R151. https://doi.org/10.1186/ar3467
Rice, David Andrew, & McNair, P. J. (2010). Quadriceps arthrogenic muscle inhibition: neural mecha-nisms and treatment perspectives. Seminars in Arthritis and Rheumatism, 40(3), 250–266. https://doi.org/10.1016/j.semarthrit.2009.10.001
Sert, A. T., Sen, E. I., Esmaeilzadeh, S., & Ozcan, E. (2020). The Effects of Dextrose Prolotherapy in Symptomatic Knee Osteoarthritis: A Randomized Controlled Study. The Journal of Alternative and Complementary Medicine, 26(5), 409–417. https://doi.org/10.1089/acm.2019.0335
Sit, R. W. S., Chung, V. C. H., Reeves, K. D., Rabago, D., Chan, K. K. W., Chan, D. C. C., Wu, X., Ho, R. S. T., & Wong, S. Y. S. (2016). Hypertonic dextrose injections (prolotherapy) in the treatment of symp-tomatic knee osteoarthritis: A systematic review and meta-analysis. Scientific Reports, 6(1), 25247. https://doi.org/10.1038/srep25247
Soliman, D. M. I., Sherif, N. M., Omar, O. H., & El Zohiery, A. K. (2016). Healing effects of prolotherapy in treatment of knee osteoarthritis healing effects of prolotherapy in treatment of knee osteoar-thritis. Egyptian Rheumatology and Rehabilitation, 43(2), 47–52. https://doi.org/10.4103/1110-161X.181858
Topol, G. A., Podesta, L. A., Reeves, K. D., Giraldo, M. M., Johnson, L. L., Grasso, R., Jamín, A., Clark, T., & Rabago, D. (2016). Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis. PM&R, 8(11), 1072–1082. https://doi.org/10.1016/j.pmrj.2016.03.008
Uysal, A., Yildizgoren, M. T., Guler, H., & Turhanoglu, A. D. (2020). Effects of radial extracorporeal shock wave therapy on clinical variables and isokinetic performance in patients with knee osteoar-thritis: a prospective, randomized, single-blind and controlled trial. International Orthopaedics, 44(7), 1311–1319. https://doi.org/10.1007/s00264-020-04541-w
Waluyo, Y., Artika, S. R., Wahyuni, I. N., Gunawan, A. M. A. K., & Zainal, A. T. F. (2023). Efficacy of Prolo-therapy for Osteoarthritis: A Systematic Review. Journal of Rehabilitation Medicine, 55, jrm00372. https://doi.org/10.2340/jrm.v55.2572
Waluyo, Y., Budu, Bukhari, A., Adnan, E., Haryadi, R. D., Idris, I., Hamid, F., Usman, A., Johan, M. P., & Zai-nuddin, A. A. (2021). Changes in levels of cartilage oligomeric proteinase and urinary C-terminal telopeptide of type II collagen in subjects with knee osteoarthritis after dextrose prolotherapy: A randomized controlled trial. Journal of Rehabilitation Medicine, 53(5), jrm00196. https://doi.org/10.2340/16501977-2835
Wee, T. C., Neo, E. J. R., & Tan, Y. L. (2021). Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis. Journal of Clinical Orthopaedics and Trauma, 19, 108–117. https://doi.org/https://doi.org/10.1016/j.jcot.2021.05.015
Wuerfel, T., Schmitz, C., & Jokinen, L. L. J. (2022). The Effects of the Exposure of Musculoskeletal Tissue to Extracorporeal Shock Waves. In Biomedicines (Vol. 10, Issue 5). https://doi.org/10.3390/biomedicines10051084
Yildiz Mursit, K., Guler, H., Ogut, H., Yildizgoren Turgut, M., & Turhanoglu Dicle, A. (2023). A comparison between hypertonic dextrose prolotherapy and conventional physiotherapy in patients with knee osteoarthritis. Med Int, 3(5), 45. https://doi.org/10.3892/mi.2023.105
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