Aug 2013 - Radial Shockwave Therapy

Journal Club
August 2013
Brought to you by the AOCPMR Student Council
Article title:
Effect of radial shock wave therapy on muscle spasticity in children with cerebral palsy.
Mariya I. Gonkova, Elena M Ilieva, Giorgio Ferriero, Ivan Chavdarov
International Journal of Rehabilitation Research, 2013;36:284-290
Cerebral palsy (CP) is an umbrella term encompassing disorders that cause major limitations in gait,
movement, and posture. It is caused by damage to the developing brain, typically occuring during
pregnancy, childbirth, or up to age three. It is characterized by spasticity. Spasticity is clinically defined
as velocity dependent resistance to stretch. As a result, limbs have tremors and increased deep tendon
reflexes. CP patients also demonstrate a scissors gait and toe walking. If spasticity is not well managed, it
can result in serious long-term consequences for children with CP. For example, muscle shortening and
tendon contractures cause further balance, sitting, and walking problems.
This study was an open observational, placebo-controlled double-blinded study in which each child
served as their own control. The effectiveness of one radial shock wave therapy (RSWT) treatment was
tested for plantar flexor muscles in children with CP. RSWT is a type of extracorpeal shock wave therapy
that has been used in medical practice for decades, typically for tendinopathies. Twenty-five children
were subjects in the study, and they had diagnoses of spastic hemiplegia or spastic diplegia. Spasticity
was assessed with passive range of motion, the Modified Ashworth Scale (MAS), and a baropodometric
measurement that used a force plate for foot and gait analysis.
After placebo treatments, no changes were observed in spasticity. After one treatment with RSWT,
however, spasticity was reduced in the study subjects. Specifically, there was a statistically significant
decrease in the MAS and an increase in the passive range of motion. Importantly, the reduction in muscle
tone also persisted 4 weeks post-RSWT treatment. The mechanism behind the effect of RSWT on
spasticity is not clear, but is thought to be an improvement in the connective tissue stiffness because the
chronically hypertonic muscles of CP patients become fibrotic. More studies will need to be done to
clarify the mechanism of action and evaluate the stability of these results in more than one rehabilitation
1. The study stated that forty plantar flexor groups were treated. Which muscle groups, specifically,
do you think were treated with RSWT?
2. Explain the difference between spastic hemiplegia and spastic diplegia.
3. What is the Modified Ashworth Scale? In what other PM&R patients could it be used to
qualitatively measure spasticity?
4. List the advantages of RSWT over FSWT.
5. If you were going to design the next study to follow up this one, how would you set it up? What
would be your primary and secondary outcome measures?
Sarah Welch, OMS-III, AOCPMR Student Council Education Committee Co-Chair