Cross-Over and Longitudinal Shockwave Studies in a Patient with Intermittent Claudication and Buerger’s Disease: A Case Report

Robin Koertshuis¹ & Michael Naafs, A. B.^2*

¹Claudication Physiotherapist, Physical Rehabilitation Trainer IAS, Plaza Medical, Netherlands
²Department of Medicine, Naafs International Health Consultancy, Netherlands

*Correspondence to: Dr. Michael Naafs, A. B., Department of Medicine, Naafs International Health Consultancy, Netherlands.

Copyright © 2019 Dr. Michael Naafs, A. B., et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
Extracorporal shockwave therapy (ESWT) can be used in patients with peripheral arterial disease (PAD) and as well as cardiac shockwave therapy (CSWT) in chronic refractory angina pectoris [1] Increased expression of growth factors such as endothelial nitric oxide (eNOS) and vascular endothelial growth factors (VGEFs) are induced by ESWT. IKL, integrin linked kinase, plays a key factor in this process of angiogenesis, believed to be responsible for the beneficial effects of ESWT [1].

Both CSWT in chronic refractory angina pectoris as well as ESWT in PAD patients show a uniformly consistent, beneficial effect in all studies until now [1].

For that reason we performed cross-over and longitudinal shockwave studies in a patient with intermittent claudication and Buerger’s disease, described in detail elsewhere [2].

Study Design
After conventional treadmill exercising walking distance increased from 70m to 200m in 6 months without further improvement. Therefore, shockwave studies were started.

Shockwaves were given at the calf of the left leg for 4 weeks followed by direct treadmill exercising and after this period the same was done at the right leg during 4 weeks, creating a cross-over model. Subsequently both legs received shockwave pulses for a period of 8 weeks, followed by direct treadmill exercising after the shockwave sessions again.

Methods
Shockwaves were delivered by a radial pulse Shock master 500 RSWT, Shock master, B.3740 Bilzen, Belgium.

In the cross-over setting 2000 2Hz pulse of 1,7 bar equivalent to 0,2mJ/mm2 were applied (Table 1). In the longitudinal study 1000 8Hz, 1,7 bar pulses were given on each leg, followed by 2000 pulses on the calves of both legs of 1,6bar, 17Hz in each session, followed by straight away treadmill exercising.

Results
Results for the cross-over study are shown in fig. 1a and 1b. Walking distance increased again significantly as it also did progressively in the longitudinal study (fig.2) Individual walking distance data for the combined experiment are shown in table 2 as maximal distance and functional distance, the latter defined when ischemic pain started. Total walking distance increase is shown in fig.3

Conclusion
ESWT improved walking distance significantly in a patient with Buerger’s intermittent claudication. The method was feasible and without adverse effects such as hematoma’s, thrombo-embolic events, pain etc. As this is the first case in the literature applying ESWT in Buerger’s intermittent claudication, comparisons with other studies can’t be made.

Bibliography

1. Naafs, M. A. (2018). Shockwave Therapy in Atherosclerosis. LOJ. Med. Sci., 1(2), 11-13.
2. Naafs, M. A. (2019). Autoimmune Buerger’s Disease Joining Polymyalgia Rheumatica: A Case Report. Adv. Case. Stud., 1(4), 1-2.