The protocol follows the guidelines of the Buenos Aires British Hospital&#39;s human research ethics committee.
1. Patient evaluation
<ol>
	<li>Clinical evaluation
	<ol>
		<li>Evaluate patients clinically to rule out symptoms propagating from other anatomical regions or other associated pathology in the shoulder that may be the source of symptoms.</li>
		<li>Include shoulder inspection and palpation, evaluate the active and passive range of motion, and perform pain provocative maneuvers and integrity tests. In addition, evaluate the cervical spine and the elbow joint.</li>
	</ol>
	</li>
	<li>Radiological evaluation
	<ol>
		<li>Use radiographic anteroposterior (AP) projections, a lateral scapular view, and an axillary view of the shoulder.</li>
		<li>Classify the calcifications by their evolutionary stage according to G&#228;rtner6. Request an MRI to rule out any associated pathology in the shoulder.</li>
	</ol>
	</li>
	<li>Inclusion criteria
	<ol>
		<li>Include patients classified as having G&#228;rtner type I and II calcifications who have undergone at least 3 months of previous conservative treatment without result.</li>
		<li>Never inject corticosteroids into the subacromial space when treating rotator cuff tendinopathy, as they have a deleterious effect on the elastic fibers of the tendons40,41.</li>
	</ol>
	</li>
	<li>Exclusion criteria: Do not include patients with G&#228;rtner type III calcifications or other associated pathology in the affected shoulder.</li>
</ol>
2. Application technique
<ol>
	<li>Patient positioning: Position the patient comfortably and in a way that allows exposure to the area to be treated.
	<ol>
		<li>Supraspinatus or infraspinatus tendon location: Treat by placing the patient in the supine or sitting position.</li>
		<li>Subscapularis: Treat by placing the patient in the supine position.</li>
		<li>Teres minor: Treat by placing the patient in the sitting, lateral decubitus, or oblique decubitus position for better access to the posterior aspect of the shoulder.</li>
	</ol>
	</li>
	<li>Coupling pads 
	NOTE: Three pad sizes are available, each determining a specific depth of treatment focus (Figure 1).
	<ol>
		<li>Select a coupling pad size depending on the required penetration depth of the focused point (Table 1). The selection of the coupling pad varies in shoulder calcification cases according to patient&#39;s build and location. The most frequently used sizes are large and medium.</li>
	</ol>
	</li>
	<li>Location of the area to be treated: Locate the area to be treated, considering anatomical landmarks and, if necessary, with the help of ultrasound images (Figure 2). 
	NOTE: It is very important to locate the exact area of the calcification and to focus the treatment on it4,42. The use of anatomical references and the help of ultrasound localization allows identifying the correct location. The need for a diagnostic ultrasound to locate the area is disputed, as there are studies that have not found significant differences with its use43. The application of focused waves is risky if done on large vessels and nerves or in areas close to the pleura44. Anatomical approaches that avoid these structures should be used.</li>
	<li>Operator positioning: The use of this type of device implies the support of an applicator by the operator. Work in an ergonomic position. 
	NOTE: The operator must always be aware of the condition of the patient, as exceptional cases of fainting during treatment have been reported44.</li>
	<li>Anesthesia: Do not use anesthesia. The use of local anesthesia is contraindicated because the presence of fluids alters the acoustic impedance of the tissue. In general, tolerance to treatment with this type of device is good, even when working with high energy levels.</li>
	<li>Contact gel: Apply adequate contact gel to the skin in the area to be treated.</li>
	<li>Navigation controls: Turn on the computer and access the touch screen. Select the Manual option at the top of the screen. The controls of the various treatment parameters are displayed. Use the rotary selection knob to set the parameters, including the intensity, frequency, and number of shocks.</li>
	<li>Intensity: Set the initial intensity of the treatment. The energy flux density (EFD) is graduated in the device used in millijoules per square millimeter of tissue (mJ/mm2).
	<ol>
		<li>Increase the intensity progressively as tolerated by the patient. Start with low intensity. Reach at least an energy level above 0.40 mJ/mm2 to obtain reproducible results19,20,21,22,23,24,25,26. The mean maximum intensity used is 0.50 mJ/mm2.</li>
	</ol>
	</li>
	<li>Frequency: Select the frequency to be used. The equipment has a frequency between 1-25 Hz. Use 4-6 Hz.</li>
	<li>Number of shocks: Select the number of shocks to be applied using the rotary selection knob. Apply at least 4,000 shocks per session.</li>
	<li>Modification of parameters during treatment: Modify the frequency and especially the intensity during the application. Use the display located on the applicator head to easily modify the application parameters during the treatment without having to interrupt it.</li>
	<li>The interval between sessions: Carry out three sessions at weekly intervals.</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64426/64426fig01.jpg" /> 
Figure 1: Applicator and coupling pad variations. Three different sizes of coupling pads are available. Each one allows the focus to be taken to a different depth in the tissues. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64426/64426fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64426/64426fig02.jpg" /> 
Figure 2: Applicator positioning. Focused wave application in the supraspinatus tendon. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64426/64426fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
3. Post-treatment protocol
<ol>
	<li>After the first session, alert the patients that in approximately 5% of cases, they may suffer an acute resorption process with intense pain. If discomfort occurs, recommend the patient to apply ice to the areas of pain in short sessions of no more than 10 min. 
	NOTE: Paracetamol is preferred over non-steroidal anti-inflammatory drugs. Shock waves modulate the inflammatory process, and it is better not to alter it by other means while the treatment lasts.</li>
	<li>Immobilization: It is not necessary to immobilize the treated limb. Advise the patient to avoid extreme efforts and range of motions that may cause pain.</li>
	<li>Rehabilitation program
	<ol>
		<li>As the sessions progress, if tolerance is good, increase the range of movement and incorporate exercises to strengthen the depressors of the humeral head.</li>
		<li>If symptomatic relapses do not occur, include recovery exercises for the extreme ranges of movement. The strengthening of the three portions of the deltoid and the scapular stabilizers are also indicated.</li>
	</ol>
	</li>
	<li>Radiological follow-up:
	<ol>
		<li>Perform the first radiographic examination at 6 weeks after the sessions and the second one at 12 weeks. In the case of observing a partial resorption process that has not been completed after 12 weeks, continue the radiological follow-up.</li>
		<li>If there have been no changes, opt for a new treatment module or move on to invasive procedures. 
		NOTE: In many patients, very important changes can be seen in the first control x-ray. In other cases, variable changes can be seen from baseline studies, and there may be no change even on long-term radiographs in other cases.</li>
	</ol>
	</li>
</ol>

This study shows encouraging results with the application of focused shock waves generated by a single-crystal piezoelectric device in a series of retrospectively evaluated patients with calcific tendinitis of the shoulder. According to the bibliographic search we carried out, this is the first study that reports results with a single-crystal piezoelectric device. Recently, Louwerens39 published a study using a piezoelectric shock wave device for the treatment of rotator cuff calcifications. However, the author used a generator with multiple piezoelectric crystals in his study.
Significant publications34,35,36,37,38,39 show great radiological variability in the treatment of calcific tendinitis of the shoulder with the use of focused shock waves (Table 3). The rate of complete disappearance of calcifications ranges from 21.2%35 to 100%38, compared to 82.6% in the present series. The greater maneuverability of the application head of the device used and the better tolerance to the application compared to our experience with electromagnetic generators contribute to the reproducible results of this study.
Focused shock waves have therapeutic results like those of invasive methods such as UGI and surgery, but the potential complications are less frequent and less severe20,21. The effectiveness of shock waves has been compared with minimally invasive techniques; Kim et al.15 reported that ultrasound-guided needling was more effective than radial pressure waves for treating calcifications of the rotator cuff. However, the focused waves are in fact indicated for the treatment of calcifications, not radial waves17. Unfortunately, there is great confusion and erroneous overlap of concepts between focused and radial waves in the literature19. Furthermore, numerous methodological flaws have been pointed out in Kim&#39;s study25. Other studies have also suggested that UGI is effective in relieving pain and restoring shoulder function in the short term20,45,46. However, De Witte et al.16 concluded that a large part of the patients who underwent barbotage had a recurrence of symptoms. In comparison, in a 10 year follow-up study in patients treated with shock waves for calcific tendonitis of the shoulder, Raedel47&#160;demonstrated that the resorption rate was 90% with a recurrence rate of only 5%.
Louwerens et al.39 reported similar clinical results for high-energy focused waves and ultrasound-guided needling at 1 year of follow-up; however, they found that puncture was more effective in removing calcium deposits.
We believe that once the chance of rehabilitation has been exhausted, the ideal strategy is to consider shock waves as the first choice because it is a noninvasive procedure. The application of shock waves does not alter the good results of a future surgery48&#160;or puncture, which is why its indication is fully justified before moving on to invasive procedures.
This study does of course have limitations. It is a retrospective study without a control or sham group. The sample is small, and the follow-up is short. In any case, the short follow-up and the choice of G&#228;rtner I and II calcifications rule out the possibility of spontaneous reabsorption.
Focused shock waves are a noninvasive, efficient, and cost-effective therapeutic option for treating calcific tendinopathies of the shoulder. Single-crystal piezoelectric generators have a success rate comparable to electrohydraulic and electromagnetic generators.

Calcium crystal deposits can appear in different regions of the musculoskeletal system, but their most frequent location is in the shoulder region. Gondos1 reported that 69% of calcification cases occur in the shoulder location. Calcific shoulder tendinopathies are characterized by the presence of hydroxyapatite deposits in the rotator cuff tendons. It is estimated that the prevalence in the general population ranges from 2.7% to 20%2.
Calcific tendinitis of the shoulder typically affects patients between 30 to 60 years old2. It is also more frequent in women (57%-76.7%) with respect to men3. The location of the calcium deposit is much more frequent in the distal tendon of the supraspinatus muscle4, while localizations in the infraspinatus, teres minor, subscapularis, and long head of the biceps have also been reported4.
Women between 30 and 60 years old, with a calcification over 1.5 cm in length, have the highest chance of being symptomatic5. Although it tends to spontaneously resolve itself, the cycle can often be halted. In these cases, symptoms of pain and disability appear, and it is necessary to take active therapeutic action.
G&#228;rtner&#39;s radiological classification6 differentiates three types of images. In type I, the image is dense, with well-defined borders corresponding to the formative phase. In the type II image, the appearance is mixed, with a deposit that can be dense but with diffuse borders, or transparent with well-defined borders. Finally, type III, characteristic of the resorptive phase, presents a transparent deposit with diffuse borders. Active therapeutic action, including shock wave applications, ultrasound-guided interventions, or surgery, must be taken in G&#228;rtner type I and II, since in type III cases, the chance of short-term spontaneous resorption is very high6.
Conservative treatment is initially preferred. This classically includes rest, analgesics, non-steroidal and steroidal anti-inflammatory drugs, rehabilitation, and local injections. Good results of conservative treatment have been shown, especially in the resorptive stage, but a failure of conservative treatment has been reported in 27% to 39% of cases7,8,9. Several prognostic factors have been recognized as having a significant influence on the results of conservative treatment7,8. The location on both shoulders, the presence of a large-volume deposit, the location of the calcification in the anterior region of the acromion, and the spread of the deposit medially beyond the level of the acromioclavicular joint, are factors of poor prognosis7,8. A G&#228;rtner stage III calcification and lack of sonographic extinction of the calcific deposit are considered predictors of good prognosis for conservative treatment7.
When conservative treatment fails, many patients end up becoming chronic carriers of shoulder pain with similar clinical characteristics to chronic rotator cuff non-calcific tendinopathies. The usual alternative to conservative treatment failure was surgery. Gschwend10 formulated three precise surgical indications for rotator cuff calcifications: symptom progression, constant and unmanageable pain, and failure of conservative treatment. Surgical treatment can be performed open or arthroscopically. Although open treatment was historically performed with good results11, arthroscopic techniques have gained popularity12,13. Musculoskeletal ultrasound and ultrasound-guided interventions (UGI) have significantly developed and been used in clinical practice in recent years14,15,16.
Extracorporeal shock wave treatment (ESWT) has emerged as an effective option prior to invasive procedures when conservative treatment has failed. Its therapeutic effect is not just mechanical, but based on mechanotransduction, a phenomenon by which cells can recognize a mechanical stimulus and react biologically17. However, shock wave treatment has limitations. Unlike lithotripsy, in which we only depend on the mechanical effect of the waves, there must also be a biological response by the patient. This response does not always occur.
The generic term &#34;extracorporeal shock waves&#34; includes two different technologies: focused shock waves and radial pressure waves17,18,19. The two technologies have therapeutic efficacy but differ in their physical characteristics and indications. Focused shock waves have a wide frequency range (from approximately 150 kHz up to 100 MHz), large pressure amplitude (up to 150 MPa) with a short rise time and small pulse width, followed by a low-stress wave (up to -25 MPa)18,19. Focused shock waves are generated by electrohydraulic, electromagnetic, and piezoelectric sources17,18,19.
Radial pressure waves are sound waves with pressure peaks of up to 30 MPa and much higher rise times than focused shock waves (about 3 &#181;s)18,19. Radial pressure waves are generated by accelerating a projectile inside a cylindrical guiding tube by compressed air. The projectile hits an applicator at the end of the tube and produces a radial pressure wave that expands into the target tissue17,18,19.
Focused shock waves have a grade &#34;A&#34; recommendation for the treatment of rotator cuff calcifications17. This means that there is high-quality scientific evidence supported by level I studies with consistent findings. In the case of radial waves, the level of recommendation for rotator cuff calcifications is &#34;I&#34;. This means that the evidence is insufficient to make a recommendation17.
Therapeutical efficacy of focused shock waves in calcific tendinopathies of the shoulder has been compared with open20 and arthroscopic21 surgery, with comparable results. However, shock waves have less frequent and less severe complications20,21, and the method is also cost-effective. Haake22 reported a significant difference between surgical costs (&#8364;13,400-23,450) and those of focused shock waves (&#8364;2,700-4,300). His results match with other studies that have shown a five- to sevenfold decrease in the cost of shock wave treatment compared to arthroscopic surgery23,24. There are also studies in which shock waves have been compared with ultrasound-guided interventions with controversial results15,25. Several publications4,17,26,27,28,29,30,31,32,33 have reported that a high level of energy is more effective when treating calcific tendinitis of the shoulder. Verstraelen27 reported that the use of high energy determines a higher rate of calcific resorption in a level I evidence study. This is a clear advantage for focused devices over radial ones because they can generate higher levels of energy. Numerous studies have reported good results with electrohydraulic4,17,34,35 and electromagnetic4,17,36,37,38 focused devices. A report has also been published using a multi-crystal piezoelectric device to treat rotator cuff calcifications39. We are not aware of any reports publishing the technique and results of single-crystal piezoelectric devices as of yet.
This report aims to describe the treatment protocol using a single-crystal piezoelectric device and to report the preliminary results.

<table><tbody><tr><td>BTL 6000 FSWT&amp;nbsp;</td><td>BTL</td><td>09400B001107</td><td>Focused Shock Wave Piezoelectric Source</td></tr><tr><td>Ultrasound &amp;amp; SWT Gel 300 mL</td><td>BTL</td><td>237-GEL102</td><td>Alcohol free hypoallergic gel</td></tr></tbody></table>

treatment protocol for rotator cuff calcific tendinitis using a single-crystal piezoelectric focused shock wave source

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are three types of focused shock wave generators: electrohydraulic, electromagnetic, and piezoelectric. According to our literature search, there are no reports of results with the use of single-crystal piezoelectric generators in calcific tendinitis of the shoulder. In a consecutive retrospective series of 23 patients with G&#228;rtner type I and II calcifications of the rotator cuff, we performed three applications of high-energy piezoelectric focused waves (4,000 pulses per session with a frequency of 6 Hz). At the final follow-up (average of 14 months), 82.6% of the cases showed complete resorption of the calcification in radiographic controls. In 8.7% of the cases, partial disappearance of the calcification was achieved, and in the remaining 8.7% there were no significant changes. Single-crystal piezoelectric generators have a success rate comparable to those already reported with electrohydraulic and electromagnetic devices.

A retrospective study of a series of patients with shoulder pain due to calcium deposits in the rotator cuff tendons was carried out in our institution. The inclusion criteria were G&#228;rtner stage I and II calcifications and at least 3 months of previous conservative treatment without satisfactory results. Patients with G&#228;rtner III calcifications, other associated pathology in the affected shoulder, previous local cortisone injection, and a history of surgery in the affected shoulder were excluded.
The study group consisted of 23 consecutive patients (Table 2), 13 female and 10 male, with an average age of 52.8 years. The supraspinatus muscle was affected in 82.6% of cases (19 shoulders), the infraspinatus in 13% (three shoulders), and the subscapularis in 4.4% (one shoulder). In all cases in this series, only one tendon was involved.
The previously described treatment protocol was applied to all the patients. The minimum follow-up was 6 months, with an average of 14 months (6-30 months). Complete disappearance was considered when at least 90% of the deposit disappeared compared to the initial studies; when the disappearance was between 40% to 90%, it was considered partial. When the deposit was like the initial one, it was included in the group with no changes. When resorption was less than 40%, it was considered not significant. In all cases, the size of the calcification was measured in the coronal image of the subacromial space (AP view). All the previous and subsequent radiological studies were evaluated by the first author, an orthopedic surgeon specialized in shoulder pathology with 30 years of experience. In 82.6% of the cases, complete resorption of the calcification was achieved (Figure 3 and Figure 4) with the disappearance of the symptoms. In 8.7%, partial disappearance with symptomatic improvement was obtained but without complete disappearance of symptoms. In the remaining 8.7%, there were no significant changes, and an ultrasound-guided puncture was performed. With the exception of one case of fainting during application and two cases of transient pain during the resorption process, there were no complications. Tolerance to the application of focused waves was highly variable according to each patient, but in all cases, it was possible to reach a therapeutic dose.
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64426/64426fig03.jpg" /> 
Figure 3: Calcification of the tendon of the subscapularis muscle. (A) Before treatment (white arrows). (B) Control at 6 weeks. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64426/64426fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/64426/64426fig04.jpg" /> 
Figure 4: Calcification of the supraspinatus muscle tendon. (A) Before treatment (white arrows). (B) Control at 12 weeks. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64426/64426fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Coupling pad</td>
			<td>Focal point size</td>
			<td>Depth of focal zone</td>
		</tr>
		<tr>
			<td>Small</td>
			<td>45 mm</td>
			<td>30&#8211;65 mm</td>
		</tr>
		<tr>
			<td>Medium</td>
			<td>30 mm</td>
			<td>15&#8211;50 mm</td>
		</tr>
		<tr>
			<td>Large</td>
			<td>15 mm</td>
			<td>0&#8211;35 mm</td>
		</tr>
	</tbody>
</table>
Table 1: Coupling pad variations. Each type of coupling pad has a focal point of specific size and depth.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="3">Clinical findings</td>
		</tr>
		<tr>
			<td>Age</td>
			<td>52.8 years (range: 41&#8211;70)</td>
			<td></td>
		</tr>
		<tr>
			<td rowspan="2">Gender</td>
			<td>Female&#160;</td>
			<td>13 patients (56.5%)&#160;&#160;&#160;&#160;</td>
		</tr>
		<tr>
			<td>Male</td>
			<td>10&#160; patients (43.5%)</td>
		</tr>
		<tr>
			<td rowspan="3">Location</td>
			<td>Supraspinatus muscle&#160;</td>
			<td>82.60%</td>
		</tr>
		<tr>
			<td>Infraspinatus muscle&#160;</td>
			<td>13%</td>
		</tr>
		<tr>
			<td>Subscapularis muscle&#160;</td>
			<td>4.40%</td>
		</tr>
		<tr>
			<td>Follow-up</td>
			<td>14 months (range: 6&#8211;30)</td>
			<td></td>
		</tr>
		<tr>
			<td rowspan="3">&#160;Radiological results</td>
			<td>Complete resorption</td>
			<td>82.60%</td>
		</tr>
		<tr>
			<td>Partial resorption</td>
			<td>8.70%</td>
		</tr>
		<tr>
			<td>No changes&#160;</td>
			<td>8.70%</td>
		</tr>
		<tr>
			<td rowspan="2">Complications</td>
			<td>Faiting&#160;</td>
			<td>1 patient</td>
		</tr>
		<tr>
			<td>Transient pain&#160;</td>
			<td>2 patients</td>
		</tr>
	</tbody>
</table>
Table 2: Clinical findings. Demographic characteristics and follow-up data. Abbreviations: sup = supraspinatus, infra = infraspinatus, sub = subscapularis
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Author</td>
			<td>Device</td>
			<td>Complete resorption</td>
			<td>Partial resorption</td>
		</tr>
		<tr>
			<td>Cosentino et al34</td>
			<td>EH</td>
			<td>31%</td>
			<td>40%</td>
		</tr>
		<tr>
			<td>Hsu et al35</td>
			<td>EH</td>
			<td>21.2%</td>
			<td>36.3%</td>
		</tr>
		<tr>
			<td>Wang et al36</td>
			<td>EM</td>
			<td>57.6%</td>
			<td>15.1%</td>
		</tr>
		<tr>
			<td>Gerdesmeyer et al37</td>
			<td>EM</td>
			<td>86%</td>
			<td></td>
		</tr>
		<tr>
			<td>Peters et al38</td>
			<td>EM</td>
			<td>100%</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Louwerens et al39</td>
			<td>PMC</td>
			<td>34%</td>
			<td>25%</td>
		</tr>
	</tbody>
</table>
Table 3: Radiological results of the use of focused waves in calcified tendonitis of the shoulder. Abbreviations: EH = electrohydraulic, EM = electromagnetic, PMC = piezoelectric multi-crystal.

Watch this Scientific Journal Video about Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source at JoVE.com

Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source

Calcific tendinitis of the shoulder is a relatively common condition with numerous treatment options. Here, we discuss the indications of focused shock waves generated by a single-crystal piezoelectric device, describe a treatment protocol, and present the preliminary results.

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are ...

treatment-protocol-for-rotator-cuff-calcific-tendinitis-using-single

Nanyang Technological University

Research

JoVE Journal

Medicine

2.5K Views.  Buenos Aires British Hospital. Calcific tendinitis of the shoulder is a relatively common condition with numerous treatment options. Here, we discuss the indications of focused shock waves generated by a single-crystal piezoelectric device, describe a treatment protocol, and present the preliminary results.

Video: Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source

Evaluating Targeting Accuracy in the Focal Plane for an Ultrasound-guided High-intensity Focused Ultrasound Phased-array System

Phased arrays are increasingly used as high-intensity focused ultrasound (HIFU) transducers in the existing extracorporeal ultrasound-guided HIFU (USgHIFU) systems. The HIFU transducers in such systems are usually spherical in shape with a central hole where a US imaging probe is mounted and can be rotated. The image on the plane of treatment can be reconstructed through the image sequence acquired during the rotation of the probe. Therefore, the treatment plan can be made on the reconstructed images. In order to evaluate the targeting accuracy in the focal plane of such systems, the protocol of a method using a bovine muscle and marker-embedded phantom is described. In the phantom, four solid balls at the corners of a square resin model serve as the reference markers in the reconstructed image. The target should be moved so that both its center and the center of the square model can coincide according to their relative positions in the reconstructed image. Swine muscle with a thickness of about 30 mm is placed above the phantom to mimic the beam path in clinical settings. After sonication, the treatment plane in the phantom is scanned and the boundary of the associated lesion is extracted from the scanned image. The targeting accuracy can be evaluated by measuring the distance between the centers of target and lesion, as well as three derivative parameters. This method cannot only evaluate the targeting accuracy of the target consisting of multiple focal spots rather than a single focal spot in a clinically relevant beam path of the USgHIFU phased-array system, but it can be also used in the preclinical evaluation or regular maintenance of USgHIFU systems configured with phased-array or self-focused HIFU transducer.

This study describes a protocol to evaluate the targeting accuracy in the focal plane of an ultrasound-guided high-intensity focused ultrasound phased-array system.

Phased arrays are increasingly used as high-intensity focused ultrasound (HIFU) transducers in the existing extracorporeal ultrasound-guided HIFU ...

Engineering

Piezo High Accuracy Surgical Osteal Removal (PHASOR): A Technique for Improved Cranial Window Surgery in Mice

Multiphoton microscopy has been widely adapted for imaging neurons in vivo. Repeated imaging requires implantation of a cranial window or repeated thinning of the skull. Cranial window surgery is typically performed with a high speed rotary drill, and many investigators find it challenging to prevent the drill from damaging the delicate dura and blood vessels. Extensive training and practice is required to remove the bone without damage to underlying tissue and thus cranial window surgery can be difficult, time consuming, and produce tissue damage. Piezoelectric surgery, which is extensively used for maxillofacial and dental surgery, utilizes ultrasonic vibrations to remove bone without damaging soft tissues. We have developed a method applying piezoelectric surgery to improve cranial window surgery in mice in preparation for multiphoton imaging. Comparisons within our lab find that the method requires less surgery time and has a lower average rate of complications due to dural bleeding than cranial window surgery with a rotary drill.

Piezo High Accuracy Surgical Osteal Removal PHASOR: A Technique for Improved Cranial Window Surgery in Mice

Piezoelectric surgery has led to improvements in human maxillofacial and dental surgery. We have developed a protocol to optimize piezoelectric surgery for cranial window surgery in mice.

Multiphoton microscopy has been widely adapted for imaging neurons in vivo. Repeated imaging requires implantation of a cranial window or repeated ...

Neuroscience

A Protocol to Acquire the Degenerative Tenocyte from Humans

Tendinopathy, a painful condition that develops in response to tendon degeneration, is on the rise in the developed world due to increasing physical activity and longer life expectancy. Despite its increasing prevalence, the underlying pathogenesis still remains unclear, and treatment is generally symptomatic. Recently, numerous therapeutic options, including growth factors, stem cells, and gene therapy, were investigated in hopes of enhancing the healing potency of the degenerative tendon. However, the majority of these research studies were conducted only on animal models or healthy human tenocytes. Despite some studies using pathological tenocytes, to the best of our knowledge there is currently no protocol describing how to obtain human degenerative tenocytes. The aim of this study is to describe a standard protocol for acquiring human degenerative tenocytes. Initially, the tendon tissue was harvested from a patient with lateral epicondylitis during surgery. Then biopsy samples were taken from the extensor carpi radialis brevis tendon corresponding to structural changes observed at the time of surgery. All of the harvested tendons appeared to be dull, gray, friable, and edematous, which made them visually distinct from the healthy ones. Tenocytes were cultured and used for experiments. Meanwhile, half of the harvested tissues were analyzed histologically, and it was shown that they shared the same key features of tendinopathy (angiofibroblastic dysplasia or hyperplasia). A secondary analysis by immunocytochemistry confirmed that the cultured cells were tenocytes with the majority of the cells having positive stains for mohawk and tenomodulin proteins. The qualities of the degenerative nature of tenocytes were then determined by comparing the cells with the healthy control using a proliferation assay or qRT-PCR. The degenerative tenocyte displayed a higher proliferation rate and similar gene expression patterns of tendinopathy that matched previous reports. Overall, this new protocol might provide a useful tool for future studies of tendinopathy.

In vitro use of degenerative tenocytes is essential when investigating the efficacy of novel treatment on tendinopathy. However, most research studies use only the animal model or a healthy tenocyte. We propose the following protocol to isolate human degenerative tenocytes during surgery.

Tendinopathy, a painful condition that develops in response to tendon degeneration, is on the rise in the developed world due to increasing physical ...

Clinical Protocol of Producing Adipose Tissue-Derived Stromal Vascular Fraction for Potential Cartilage Regeneration

Osteoarthritis (OA) is one of the most common debilitating disorders.&#160;Recently, numerous attempts have been made to improve the functions of the knees by using different forms of mesenchymal stem cells (MSCs). In Korea, bone marrow concentrates and cord blood-derived stem cells have been approved by the Korean Food and Drug Administration (KFDA) for cartilage regeneration. In addition, an adipose tissue-derived stromal vascular fraction (SVF) has been allowed by the KFDA for joint injections in human patients. Autologous adipose tissue-derived SVF contains extracellular matrix (ECM) in addition to mesenchymal stem cells. ECM excretes various cytokines that, along with hyaluronic acid (HA) and platelet-rich plasma (PRP) activated by calcium chloride, may help MSCs to regenerate cartilage and improve knee functions. In this article, we presented a protocol to improve knee functions by regenerating cartilage-like tissue in human patients with OA. The result of the protocol was first reported in 2011 followed by a few additional publications. The protocol involves liposuction to obtain autologous lipoaspirates that are mixed with collagenase. This lipoaspirates-collagenase mixture is then cut and homogenized to remove large fibrous tissue that may clog up the needle during the injection. Afterwards, the mixture is incubated to obtain adipose tissue-derived SVF. The resulting adipose tissue-derived SVF, containing both adipose tissue-derived MSCs and remnants of ECM, is injected into knees of patients, combined with HA and calcium chloride activated PRP. Included are three cases of patients who were treated with our protocol resulting in improvement of knee pain, swelling, and range of motion along with MRI evidence of hyaline cartilage-like tissue.

Here, we present a protocol to produce an adipose tissue-derived stromal vascular fraction and its application to improve knee functions by regenerating cartilage-like tissue in human patients with osteoarthritis.

Osteoarthritis (OA) is one of the most common debilitating disorders.&#160;Recently, numerous attempts have been made to improve the functions of the ...

A Standardized Murine Model of Extracorporeal Shockwave Therapy Induced Soft Tissue Regeneration

Shockwave therapy (SWT) shows promising regenerative effects in several different tissues. However, the underlying molecular mechanisms are poorly understood. Angiogenesis, a process of new blood vessel formation is a leading driver of regeneration in softer tissues as well as a recently discovered effect of SWT. How the mechanical stimulus of SWT induces angiogenesis and regeneration and which pathways are involved is not fully understood. To further improve the clinical use of SWT and gain valuable information about how mechanical stimulation can affect tissue and tissue regeneration, a standardized model of SWT is needed. We, hereby, describe a standardized, easy to implement murine model of shockwave therapy induced regeneration, utilizing the hind-limb ischemia model.

This article describes a standardized murine model of tissue regeneration via shockwave treatment.

Shockwave therapy (SWT) shows promising regenerative effects in several different tissues. However, the underlying molecular mechanisms are poorly ...

Therapeutic Efficacy of Small Needle Knife Therapy in Treating Frozen Shoulder

Clinical Efficacy of Small Needle Knife Therapy on Stage I-II Frozen Shoulder

Frozen shoulder is a kind of aseptic inflammatory disease of the shoulder caused by strain, trauma, and other reasons, resulting in shoulder joint pain and limited function. The protocol presented here demonstrates the operation of a small needle knife in treating frozen shoulders, including patient management, material preparation, positioning, operation, and postoperative care. The purpose of this protocol is to relieve the pain and functional limitations and improve the living ability of patients with frozen shoulders. In our study, 76 stage I-II frozen shoulder patients who met the inclusion criteria were randomly divided into a control group and a treatment group (n=38). Patients in the control group received functional exercise, while the treatment group received small needle knife therapy with functional exercise. The visual analogue scores (VAS), the Constant and Murley scores (CMS), and the thickness of the coracohumeral ligament (CHL) under ultrasound were evaluated. After small needle knife therapy, the VAS score was significantly lower in the treatment group (5.11 &plusmn; 0.89) than in the control group (5.49 &plusmn; 0.65; t=-2.065, p&lt;0.05); the CMS score was significantly higher in the treatment group (64.72 &plusmn; 4.78) than in the control group (60.97 &plusmn; 6.00; t=2.947, p&lt;0.05); the CHL thickness was significantly decreased in the treatment group (2.38 &plusmn; 0.36) than in the control group (2.57 &plusmn; 0.42; t=-2.117, p&lt;0.05). These results indicate that the small needle knife significantly relieved the pain symptoms, improved the shoulder function, reduced the CHL thickness, and improved the quality of life and, therefore, had significant therapeutic efficacy in stage I-II frozen shoulder patients.

Author Spotlight: Treating Frozen Shoulder with Small Needle Knife Therapy 

The protocol presented here describes the detailed operation method and proves the effectiveness of a small needle knife in the treatment of frozen shoulders.

Frozen shoulder is a kind of aseptic inflammatory disease of the shoulder caused by strain, trauma, and other reasons, resulting in shoulder joint pain ...

Transcranial Pulse Stimulation for Alzheimer's Patients

Transcranial pulse stimulation (TPS) is a noninvasive neuromodulation therapy with Conformit&#233; Europ&#233;enne (CE) marking for the treatment of Alzheimer's disease (AD). Initial pilot studies have demonstrated promising effects on cognitive function. This article focuses on the procedure for treating patients with AD using an MRI-guided, neuro-navigated TPS device. The protocol to be followed for this is described in detail, including the necessary procedures and device settings. A brief overview of the representative clinical results published to date is also provided. In addition to significant clinical improvements in cognition and affect, adverse events (AE) and possible adverse device events (ADE) are presented to provide safety data. Finally, the method is critically discussed. In the future, randomized controlled trials should be conducted to rule out any placebo effects. There is also currently a lack of long-term studies with a larger number of patients. Despite these unresolved questions, TPS has the potential as an adjunct treatment for Alzheimer's patients when used in a controlled, scientifically guided setting.

This article describes the procedure of transcranial pulse stimulation in patients with Alzheimer's disease. It discusses the indications, methodology, and future prospects in detail.

Transcranial pulse stimulation (TPS) is a noninvasive neuromodulation therapy with Conformit&#233; Europ&#233;enne (CE) marking for the treatment of ...

Exosome Isolation after in vitro Shock Wave Therapy

Shock wave therapy is routinely applied in orthopedic indications including tendinopathies such as lateral epicondylitis (tennis elbow) and Achilles tendinitis (heel spurs) as well as non-healing wounds and bones. Despite different pathologies, the combination of an angiogenic and an anti-inflammatory effect of shock wave therapy leads to regeneration in soft tissue and bones. In over 30 years of clinical application, no side effects were observed. Furthermore, basic research even revealed regenerative effects on ischemic myocardium.
In a previous work we could show that the mechanical stimulus of cultured cells is translated via an exosome release into a biological response. However, the exact mechanism remains to be elucidated. Mechanical coupling is crucial when applying shock wave therapy as even small air bubbles can absorb shock waves. The previously described water bath method is a valid method to guarantee adequate and reproducible shock wave application in vitro.
We were able to develop a feasible and replicable protocol to isolate exosomes from cultured cells after shock wave application. Thereby we demonstrate a possibility to study underlying mechanisms of mechanotransduction as well as the regenerative and angiogenic potential of shock wave released exosomes.

Exosomes are released upon in vitro application of shockwaves. Here, we describe how to apply shockwaves on cultured endothelial cells and subsequently isolate exosomes for further investigation.

Shock wave therapy is routinely applied in orthopedic indications including tendinopathies such as lateral epicondylitis (tennis elbow) and Achilles ...

Biology

Combination of Anatomical Plates and Rotator Cuff Reinforcement for Minimally Invasive Treatment of Greater Tuberosity Fractures of the Humerus

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

Here, we present a protocol to utilize anatomical plates alongside rotator cuff reinforcement in a minimally invasive surgery to efficiently treat humerus greater tuberosity fractures, promising quicker healing and improved stability.

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. ...

Using Extracorporeal Shockwave Therapy (ESWT) for Treating Achilles Tendinopathy

A Treatment Protocol for Achilles Tendinopathy with Extracorporeal Shockwave Therapy

Achilles tendinopathy is a common musculoskeletal condition characterized by pain, lower muscle strength, gait abnormality, and reduced quality of life. There are two categories of Achilles tendinopathy: insertional Achilles tendinopathy and mid-portion Achilles tendinopathy. Currently, mechanical loading programs are considered the standard of care for the population with Achilles tendinopathy.
Extracorporeal shockwave therapy (ESWT) is considered a secondary conservative treatment for tendinopathy as it is effective and safe. It can be used either as a monotherapy or as part of a multimodal treatment plan. ESWT has been extensively studied in orthopedics, where it was shown to intensify fracture healing and successfully treat overuse conditions of tendons and fascia. It is believed that shockwaves have both mechanical and cellular effects that ultimately result in the repair of damaged tendinous tissue and improved function of the Achilles tendon. However, there is a lack of consistency in the literature surrounding the effectiveness, especially the protocols. Therefore, we enrolled 36 patients with a diagnosis of Achilles tendinopathy, using radial ESWT (0.48 mJ/mm2, 2,000 shockwaves, 10 Hz, 1.6&#160;bars, 2 sessions once a week). Freedom from pain was experienced by 16.7% of these participants, and there was a significant decrease in pain in all of them.

Author Spotlight: Effectiveness of Extracorporeal Shockwave Therapy in Achilles Tendinopathy Treatment

Achilles tendinopathy is a common musculoskeletal condition for which loading programs are currently the standard of care. However, the treatment protocols vary. We therefore propose a protocol for Achilles tendinopathy treatment using extracorporeal shockwave therapy.

Achilles tendinopathy is a common musculoskeletal condition characterized by pain, lower muscle strength, gait abnormality, and reduced quality of life. ...