EXPLORATION OF THE THERAPEUTIC POTENTIAL OF EXTRACORPOREAL SHOCK WAVE
TO PREVENT/AMELIORATE INFLAMMATORY BOWEL DISEASE
STRATEGY
The innovation of this proposal is to explore the potential of extracorporeal shock wave to prevent/ameliorate the
intestinal inflammatory responses associated with inflammatory bowel disease in the dextran sodium sulfate (DSS) colitis
mouse model. Extracorporeal shock wave therapy (ESWT) is a low energy, unfocused acoustic pulse consisting of a fast
(<10nsec) peak pressure wave of up to 100 megapascal (MPa) with an energy flux density of 0.01-0.11 mJ/mm2 and a
10µsec duration that propagates into soft tissue. ESWT at cellular interfaces of different acoustic impedances produces
tensile forces, which produces high temperature, rapidly imploding microscopic cavitation bubbles (not sure for
unfocused low energy shockwaves). Consequently, data has shown that at appropriate energy flux densities specific
beneficial molecular pathways are triggered. Indeed, since 1980 extracorporeal shock wave therapy (ESWT) has been
employed for the treatment of a variety of diseases, including orthopedic diseases (pseudoarthosis, tendinitis calcarea of
the shoulder, epicondylitis, and plantar fasciitis), traumatic wound healing, burn injury, vessel injury/atherosclerosis and
ischemia. Interestingly, although the exact biochemical mechanisms remain unclear, ESWT has been shown to induce
tissue regeneration, neoangiogenesis, and a general anti-inflammatory modulation of the immune system. Our
collaborative group has previously shown that ESWT treatment of burn wounds 1 hour post-wounding potently attenuated
chemokine expression, suppressed pro-inflammatory cytokine production, decreased extracellular matrix proteolytic
activity at the wound margin, and significantly blunted neutrophil and macrophage infiltration into the wound. The
findings strongly indicate that ESWT may be a potential therapeutic modality which ameliorates inflammation and
accelerates the normal physiological repairs process of wound healing. Additionally, we have recently demonstrated that
abdominal ESWT preconditioning can limit the systemic inflammatory response syndrome (SIRS) and intestinal ileus
caused by traumatic peripheral tissue injury.
Our preliminary data suggest that ESWT can ameliorate weight loss and prevent death associated with the DSSinduced colitis in a mouse model of IBD. In a pilot study, sham mice lost on average a significantly higher percentage of
their body weight (14.4±3.55%) compared to q.a.d. ESWT treated mice (5.7±3.19%) in response to oral DSS 3% on day
7. Given this encouraging preliminary data, the aim of this proposal is to fully delineate the potential of ESWT to
prevention weight loss, ameliorate the detrimental histological changes within the intestinal mucosa, decrease the colitis
cellular inflammatory response, maintain colonic muscle function and prevent death in response to DSS-induced colitis.
AIM I. DEMONSTRATE THE POTENTIAL OF ESWT TO PREVENT THE SEQUELAE ASSOCIATED WITH DSS-COLITIS.
Rationale. Our data demonstrates the ESWT can ameliorate DSS-induced colitis, therapeutically prevent
postoperative ileus, and diminish the systemic consequences of traumatic peripheral tissue injury.
Hypothesis. We propose that ESWT induces an anti-inflammatory/tolerant protective state in the gut which
ameliorates the detrimental consequences of DSS-induced colitis in the mouse.
Approach. “Acute” DSS-induced colitis will be studied by exposing individual groups of mice to a low (2.5%) or
moderate (3.5%) dose of DSS in the drinking water for a continuous period of 14 days. ESWT will be delivered as a
single exposure treatment at the commencement of DSS exposure or delivered every other day (q.a.d.). Similarly,
“chronic” DSS-induced colitis will be studied by intermittently exposing individual groups of mice to a low (2.5%) or
moderate (3.5%) dose of DSS in the drinking water on a regimen of 7 days on/7 days off for three dosing cycles (35 days).
ESWT will be delivered at the commencement of each DSS cycle. A control group and sham groups of mice anesthetized
to mimic the treatment regimens will be used for comparison. Therapeutic un-focused electro-hydraulic acoustic shock
waves will be delivered to the shaved ultrasound gel coated abdomen of an anesthetized mouse as 600 pulses consisting of
a fast (10nsec) peak pressure wave of 100 megapascal (MPa) with an energy flux density of 0.03 mJ/mm2 and a 10 µsec
duration at a frequency of 3 to 4 Hz (note: energy flux density may be altered to optimize a therapeutic effect I would
recommend energy flux densities of 0.08 to 0.1 mJ/mm2)).
End-point Analyses. Each mouse in the individual groups will be weighed daily and plotted for changes in body
weight. From the anesthetized animals at the specified times of sacrifice for each group of mice, the colon will be
removed and placed in an oxygenated Krebs physiological solution. Proximal and distal segments of the colon will be
fixed in paraformaldehyde (2.5%), sectioned and histologically stained for changes in the mucosal architecture and
leukocytic infiltrates (neutrophils and monocytes/macrophages). Colonic circular muscle strips from the mid-colon will
be prepared, and muscle contractility and electrical field stimulated neurogenic contractions will be quantified.
AIM II. ELUCIDATE THE MOLECULAR MECHANISMS OF ESWT.
Rationale. If the above data confirms our preliminary findings, we will investigate two hypotheses which could
mechanistically explain the therapeutic effect of ESWT for inflammatory bowel disease. Based on previous observations
we will determine if ESWT induces a reactive oxygen-dependent molecular cascade which results in the suppression of
inflammation via the induction of Suppressors of Cytokine Signaling (SOCS)-1 and SOCS-3.
[ROIs → Egr-1/NF-κB → SOCS-1&3 → suppression of colitis]
Alternatively, we will investigate whether an ESWT-induced cellular permeabilization results in the “leakage” of
nucleic acids which triggers a local TLR3/TRIF signaling response causing an “immune tolerization” of the intestinal
structures to the chemically-induced DSS inflammation (hypothesis of J. Holfeld). A similar pathway is known to be
activated during LPS/TLR4 tolerization, which we have shown to be dramatically beneficial for preventing experimental
postoperative ileus. These two hypotheses are based on the current state-of-the-art knowledge in this field. Appropriate
molecular experiments will be designed to address each hypothesis.
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