2021 SCIENCELINE

Journal of Life Science and Biomedicine

Volume 11, Issue 1: 13-19; January 25, 2021

License: CC BY 4.0

ISSN 2251-9939

DOI: https://dx.doi.org/10.51145/jlsb.2021.2

Effect of extracorporeal shockwave therapy on

palmar fibromatosis

Menna Allah M. SAAD¹^, Amal M. ABD ELBAKY², Ashraf ABO ALFOTOOH³and Karim I. SAAFAN²

¹Department of Physical Therapy for Surgery, Faculty of Physical Therapy, MTI University, Cairo, Egypt

²Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt

³Department of Plastic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt

Corresponding author’s Email: mennasaad6917@gmail.com;

: 0000-0001-9045-7175

ABSTRACT

Original Article

Introduction. Extracorporeal shock wave therapy (ESWT) is therapeutic modality that

applies shockwave from outer part of the body to a specific lesion and promotes PII: S225199392100002-11

revascularization and hence stimulates the curing process of connective tissues, relieves

pain and improves function. Aim. The present study was done to detect the role of

extracorporeal shock wave therapy in reducing palmar fibromatosis using Arabic version of

Rec. 21 November 2020

Rev. 17 January 2021

Acc. 25 January 2021

modified QuickDASH-9 scale. Methods. Thirty patient with age ranged from 50 to 70

suffering from palmar fibromatosis were randomly selected from faculty of physical therapy

modern technology and information university outpatient hand clinic, Cairo, Egypt and

distributed into two equal groups: study group (A) received ESWT once a week for six weeks,

done at frequency of 6–8 Hz with 1700 pulse/session at 0.18 mj/cm2 with traditional

physical therapy protocol (U.S, massage, stretching ex, range of motion (ROM) ex and

splinting). Group B received traditional physical therapy protocol. The measurements were

conducted pre and post six weeks of treatment using Arabic version of Modified Quick

DASH-9 scale and Jamar hand dynamometer. The study was carried out from April to

December 2020. Descriptive statistics and unpaired t-test were conducted for comparison

of age between groups. Results. There was a significant decrease in the score of Arabic

modified Quick DASH scoring which is a good sign of improvement and increase in the hand

grip strength. Conclusion. Extracorporeal shockwave is a beneficial method in reducing the

progress of palmar fibromatosis.

Keywords

Extracorporeal shock

wave therapy (ESWT),

Shockwave Therapy,

Palmar fibromatosis,

Arabic Modified Quick

DASH-9 scale,

Jamar hand

dynamometer

INTRODUCTION

Palmar fibromatosis is a disease which develops gradually in stages as a result of thickening of palmar facia that

provides cords and nodules and it reveals loss or decrease in ROM of the involved fingers and pain with

tenosynovitis. Male people are the most affected, more than 50 years old with different and un known factors

(liquor addiction, smoking, thyroid issues, liver illness, diabetes, past hand injury, epilepsy) and with certain

hereditary factors. Palmar fibromatosis is diagnosed by fibrotic stage that generate from fibrocellular

proliferation. The most affected finger normally is the ring finger then the little and center fingers (Figure 1)

Can make certain tasks more difficult of day living, for example, face washing, brushing hair and placing hand

in a glove and shaking hands [1].

The inception of palmar fibromatosis is yet unclear, although there are various physicians that specialists

have gone over consistently. Generally medical procedure has been the main therapy for palmar fibromatosis

however it’s not the only one [2]. Numerous non-surgical treatments have been explored for the therapy of

palmar fibromatosis, needle fasciotomy, nonstop gradual skeletal traction, radiation, dimethyl sulfoxide,

vitamin E, steroid infusions, radiation, interferon and enzymatic fasciotomy. A large portion of these treatments

have no longer confirmed or demonstrated to be clinically valuable. After all, Shockwave treatment has shown

empowering results [3]. Finding is typically based on signs and symptoms; Patients, at first, may be

symptomless and they may introduce withdrawal of palmar facia related with nodules, at a later stage their

capacity to hold and maintain items plus ache and pain logically decline [4].

Extracorporeal shockwave treatment (ESWT) as a noninvasive treatment is utilizing acoustic waves

described by a sharp, unexpected, and quick change in pressure factor as a wave front with a speed higher than

the speed of sound followed by a more drawn out negative tail to get a body reaction. Since the principal clinical

report performed on kidney stone destruction goal by high excessive electrohydraulic ESWT on Dec 13, 1980 in

Citation: Saad MAM, Abd ELBaky AM, Abo Alfotooh A and Saafan KI. Effect of extracorporeal shockwave therapy on palmar fibromatosis. J Life Sci Biomed, 2021;

11(1): 13-19. DOI: https://dx.doi.org/10.51145/jlsb.2021.2

the Lancet by Chaussy et al. [5] in palmar fibromatosis, just two ongoing case arrangement have been accounted

for either high vivacious centered ESWT in four patients [6] or radial ESWT in a solitary case [7] with no long

term follow it was conjectured comparative consequences for palmar fibromatosis in decreasing contracture

and pain. ESWT has more extensive and more secure than medical procedures with minimal effort in

correlation with medical procedures. Taking into account that palmar fibromatosis contractures are shallow,

we speculated that a treatment with ESWT was compelling to decrease them and improve hand work.

Figure 1. Palmar fibromatosis.

MATERIALS AND METHODS

Thirty patients who diagnosed with palmar fibromatosis of stage N & one according to staging system of

tubiana classification, with age ranged from 50 to 70 years have been selected for this study. The participants

have been selected from faculty of physical therapy modern technology and information university outpatient

hand clinic Cairo, Egypt. The study was conducted from April 2020 to December 2020, and participants were

divided randomly into 2 groups: study group (A) that was composed of 15 patients who received ESWT once a

week for six weeks, done at a frequency of 6–8 Hz with 1700 pulse/session at 0.18 mj/cm2 with traditional

physical therapy protocol (U.S, massage, stretching ex, ROM ex and splinting). Group B that was composed of 15

patients who received traditional physical therapy protocol (U.S, massage, stretching ex, ROM ex and splinting),

twice a week for 6 weeks.

Ethical approval

The protocol of this study was approved by the ethical committee board of the Faculty of Physical Therapy

Cairo University; Giza, Egypt [No. P.T.REC/012/002688]. Every participant applied informed consent before

starting the study. All participants were informed about the nature and the effect of the treatment and

measurement tools. The Participants were also instructed to report any side effects during the treatment

protocol like itching etc.

Inclusive and exclusion criteria

Inclusive criteria was included of patients with palmar fibromatosis are presented to our out faculty of

physical therapy modern technology and information university outpatient hand clinic were signed in the

study, based on the following inclusion criteria: 1) Diagnosis of palmar fibromatosis in a minimum of one finger;

2) Patients who were able to attend the follow up visites; 3) Age ranged from 50 to 70 years of age; 4) Those with

a flexion of 30 degrees or less in the metacarpophalangeal (MP) joint.

Exclusion criteria were included: A) Patient who had any neurological, neuromuscular and chronic

disorder affect the hands; B) Patients who did not accept treatment; C) Patients who were contraindicated for

the ESWT; D) Loss of extension in the involved the metacarpophalangeal (MP), proximal interphalangeal (PIP)

and Distal interphalangeal (DIP) joints.

Citation: Saad MAM, Abd ELBaky AM, Abo Alfotooh A and Saafan KI. Effect of extracorporeal shockwave therapy on palmar fibromatosis. J Life Sci Biomed, 2021;

11(1): 13-19. DOI: https://dx.doi.org/10.51145/jlsb.2021.2

The application of treatment method

All patients were applied the table top test. The extracorporeal shockwave treatment (ESWT) application

was performed with the patient sitting on a gurney with the elbow flexed at 30 degrees, the forearm in

supination and the probe of the ESWT device positioned 90 degrees tangent to the pain site. Povidone-iodine

solution was used for cleaning the application site and gel was applied on the skin for conductivity. There was

one no any local anesthesia applied for patient. The regions with nodules were marked and the probe was

moved around this mark in a circular fashion.

Same

physiotherapist

performed

the

treatment using the ESWT device (gymna

code: SN 4300431 made in USA) once a week

for six weeks, at a frequency of 6 to 8 Hz with

1700 pulse/session at 0.18 mJ/cm2 [8] (Figure

2).

The physiotherapist and the patient had

to wear earmuffs because of high noise of the

operation device. The application of hot or cold

pack after the treatment is not allowed

following ESWT application. None of the

patients reported the rarely seen of redness,

pain or swelling. The patients were evaluated

with Arabic modified Quick DASH-9

questionnaire and their grip strength were

measured using a Jamar dynamometer. Grip

strength of the patients was measured three

times with one minute intervals between

measurements and the average of the three

measurements was noted.

Figure 2. Application of extra corporeal shock wave therapy.

Measurements

Arabic

modified

Quick

DASH

questionnaire. The Arabic Modified Quick

DASH–9 is consisted of the following: A) Brief

instructions that informed the patients about how

to do the questionnaire; B) The point number (1-6)

that are about the degree of hardness in doing

various physical activities related to the arm,

shoulder or hand problems; C) The two points (7

and 8) are about the impact of upper extremities

problems in the social activities; D) Point number

9 as about arm, shoulder or hand pain; E) Each

point as five response scores, ranging from no

problem to unable to perform activity (0–4) Likert

scale; F) The Arabic modified Quick DASH–9

allows for one missing response.

The Arabic Modified Quick DASH–9 Score =

[(sum) *1.1] * 5/2, a missing response is added as

the average of the remaining [9] (Figure 3).

Figure 2. Modified QuickDASH-9 scale.

Citation: Saad MAM, Abd ELBaky AM, Abo Alfotooh A and Saafan KI. Effect of extracorporeal shockwave therapy on palmar fibromatosis. J Life Sci Biomed, 2021;

11(1): 13-19. DOI: https://dx.doi.org/10.51145/jlsb.2021.2

Jamar hand grip dynamometer. Therapeutic

grip strength was measured by using a Jamar hand

grip dynamometer with one-minute intervals

between measurements and the average of the three

measurements was noted, the patient position was

as sitting with shoulder adduction. The elbow was

flexed to 90º and the forearm was in neutral

rotation. The wrist was at neutral to 30º extension

while gripping. The patient was asked to grip with

full power of force for at least 2 seconds for full

muscle recruitment. The therapist provided verbal

words (i.e., "Ready? Steady, go! More, Much more!")

until grip strength increased to the top, then said,

"enough stop" grip strength was recorded, rounded

to the nearest pound and the sign has been returned

to zero [10] (Figure 4).

Figure 4. Measurment of hand grip using jamar

hand grip dynamometer.

Treatment procedures

Study group (A). Patient treated as outpatient was given information about the measurement and

treatment procedures as well as about the extracorporeal shockwave before the beginning of the treatment,

was asked to follow and physical therapist instruction like wearing the splint and doing daily stretching, and

was asked to avoid predisposing factors as any trauma to the affected hand.

Groupe B (traditional physical therapy protocol). Only received two sessions per week for 6 weeks

involved ultrasound, massage splinting and stretching techniques: Low-intensity pulsed ultrasound (LIPUS) is a

sort of ultrasound that produced at a way lower intensity (<3 W/cm²) than traditional ultrasound energy and

output within the mode of pulse wave, and it’s typically used for therapeutic purpose in rehabilitation

treatment, patient position sitting with forearm supination elbow flexion 30 degree and the probe of the

ultrasound was perpendicular at the site of the contracture at pulsed mode with intensity lower than 3 w/cm2

at circular motion for 5 min every session [11].

Splinting

Thermoplastic palmar is totally based finger extension supports, developed with Velcro fastenings. The

patients were trained to wear the supports during rest around evening time. The braces were remolded as

upgrades were made [12].

Massage therapy

1) Before extending, the hand must be in warm water or a warm pack; 2) Intensely scented creams were

kept away from; 3) Creams with hydrocarbons and synthetic inflammation substances have been

additionally avoided; 4) A characteristic plant-based lotion with common calming properties was utilized;

4) Rub the palms every which way on particularly around the thickening 5 min each meeting [13].

Stretching

1) Gently twist the fingers in reverse from the palm; 2) Placing fingers on the edge of a table, palm down,

and afterward lift the palm upward slowly, as you keep your fingers level on the table; 3) The wrist should be

moved from side to side; 4) Putting his/her hand in a petition position pushing the palms and fingers together

as home program and little change in way of life; 5) Don’t over stretch the wrist and fingers which might be

counter beneficial [14].

Statistical analysis

Descriptive statistics and unpaired t-test were done for comparison of age between groups. Fisher exact

was carried out for comparison of sex distribution between groups. Normal distribution of data was checked

using the Shapiro-Wilk test for all variables. Levene’s test for homogeneity of variances was conducted to test

Citation: Saad MAM, Abd ELBaky AM, Abo Alfotooh A and Saafan KI. Effect of extracorporeal shockwave therapy on palmar fibromatosis. J Life Sci Biomed, 2021;

11(1): 13-19. DOI: https://dx.doi.org/10.51145/jlsb.2021.2

the homogeneity between groups. Unpaired t-test was conducted to compare the mean values of regarding

Modified Arabic DASH-9 scorring and hand grip strength between the groups A and B. Paired t-test was

conducted for comparison between pre and post treatment in each group. The level of significance for all

statistical tests was set at p<0.05. All statistical analysis was conducted through the statistical package for

social studies (SPSS) version 25 for windows (IBM SPSS, Chicago, IL, USA).

RESULTS

Subject characteristics

Table 1 showed the subject characteristics of the groups A and B. There was no significant difference

between groups in age and sex distribution (P>0.05).

Effect of treatment on Modified Arabic DASH score and hand grip strength

Within group comparison. There was a significant decrease in modified Arabic DASH-9 scoring post

treatment in the group A and B compared with that pretreatment (P<0.001). The percent of decrease in Modified

Arabic DASH score in the group A was 34.68% and that for group B were 11.17%. There was a significant increase

in hand grip strength post treatment in the groups A and B compared with that pretreatment (P<0.001). The

percent of increase in hand grip strength in group A were 30.07 while that in group B was 10.73% (Table 2).

Between groups comparison. There was no significant difference between groups pre-treatment (P>0.05).

Comparison between the groups A and B post treatment revealed a significant decrease in Modified Arabic

DASH-9 score of the group A compared with that of group B (P=0.02) and a significant increase in hand grip

strength of the group A compared with that of group B (P=0.01) (Table 2).

Table 1. Basic characteristics of participants.

Group A

Mean ± SD

55.4 ± 4.91

1 (7%)

Group B

Mean ± SD

55 ± 5.61

2 (18%)

Items

P-value

0.38

Age (years)

Sex (n, %)

Females

Males

14 (ꢀ8%)

18 (37%)

SD, standard deviation; p-value= level of significance

Table 2. Mean modified Arabic DASH score and hand grip strength pre and post treatment of the groups A & B.

Group A

Mean ± SD

Group B

Mean ± SD

Items

T-value

P-value

Modified Arabic DASH-9 score

Pre treatment

26.73 ± 5.2

20.5ꢁ ± 5.1

1.67

-4.8

0.88

0.83

0.02

Post treatment

17.46 ± 5.04

9.27

22.26 ± 5.67

2.8

-2.44

% of change

T-value

34.68

11.17

15.40

4.03

P-value

p = 0.001

Hand grip strength (lb)

Pre treatment

Post treatment

15.78 ± 2.48

20.46 ± 2.5

-4.73

16.13 ± 2.74

17.86 ± 3.13

-1.73

-0.4

-0.42

0.ꢁ7

2.6

2.0

0.01

% of change

30.07

10.73

T-value

P-value

-12.70

-3.4

p = 0.001

Group A= study group (the extracorporeal shockwave therapy); Group B= traditional physical therapy protocol (only received two sessions

per week for 6 weeks involved ultrasound , massage splinting and stretching techniques); SD= standard deviation; MD= mean difference; p-

value= probability value.

Citation: Saad MAM, Abd ELBaky AM, Abo Alfotooh A and Saafan KI. Effect of extracorporeal shockwave therapy on palmar fibromatosis. J Life Sci Biomed, 2021;

11(1): 13-19. DOI: https://dx.doi.org/10.51145/jlsb.2021.2

DISCUSSION

Palmar fibromatosis is pathological condition which affects the palmar facia of the hand ensuing flexion

disfigurements of the affected fingers. The earliest posted details and description of the problem was reported

in 1614 by Felix Platter, yet it was Guillian Dupuytren who introduced a careful anatomic and obsessive

investigation in 1831. What was extraordinary about palmar fibromatosis was that he accentuated the clinical

course of the illness, the palmar fibromatosis influencing the hands frequently brings about constraints in

aptitude and can fundamentally affect a person's capacity to participate in professional and a vocational

exercises [15].

The condition is a significant reason for morbidity which diminishes their personal satisfaction, patients

report feeling danger concerns, communicating dread that the fixed flexion of the finger will make it more

defenseless to wounds. At the end, patients living with palmar fibromatosis additionally express worries about

what their contracture restrict their social contact, mostly their capacity to give an appropriate handshake.

Therefore, fixation of flex disfigurements is very important. Tragically, in the within side the lack a complete

knowledge and comprehension of the molecular pathology, treatment is presently pointed toward disposing of

the contracted pathologic disease tissue, without tending to the basic pathophysiology. As far as the best and

the most widely recognized methodology is the surgical resection followed concentrated physical therapy

program, in severe cases palmar fibromatosis may lead to amputation of the affected finger [7].

We found that one session of ESWT is an applicable and safe, and noninvasive can decrease palmar

fibromatosis over a time of one month and half essentially. At this point, various gainful impacts of ESWT on

different tissues have been accounted, for example, stem cell proliferation [16], growth factor stimulation [17]

and anti-inflammatory actions via COX2-pathways [18]. Direct pain modulation via neuropeptides like

calcitonin gene related peptide (CGRP) and substance P (SP) might explain part of the beneficial ESWT action in

this trial [19]. Aykut et al. [8] revealed that ESWT in the early term can be chosen over the expensive infusion

and surgical procedures as it expands the personal satisfaction and postpones the repeat of contractures. We

accept a substantial treatment convention for ESWT must be set up with additional randomized controlled

series with long term results and an absolute treatment for palmar fibromatosis still doesn't exist. Knobloch et

al. [20] revealed that high energetic focused electromagnetic extracorporeal shockwave treatment (ESWT) is a

successful and safe noninvasive treatment to decrease the pain in the early nodular phase of palmar

fibromatosis. Three focused type of ESWT could show a considerable pain decrease and a supported impact

more than year and a half of follow up in this randomized controlled trial. Abdulsalam et al. [6] reported that

extracorporeal shock wave therapy effectively reduced pain and tenderness symptoms of patients with palmar

fibromatosis, assesed the effectiveness of shock wave therapy on four patients by referring some of the items of

the Michigan Hand Outcome Questionnaire. Brunelli et al. [7] announced that a low intensity ESWT (Li-ESWT)

session might be done by physiotherapists in clinics with low cost in comparison with the surgical procedures,

not harmful. It is by all accounts successful in the palmar fibromatosis treatment. Further investigations,

including randomized controlled trials, are expected to assess the adequacy of outspread ESWT in palmar

fibromatosis. Kumar et al. [21] reported that Shockwave treatment ends up being promising successful non-

intrusive treatment in decrease of palmar fibromatosis.

CONCLUSION

It was concluded that extracorporeal shockwave therapy is a successful and effective treatment in reducing

palmar fibromatosis.

DECLARATIONS

Corresponding Author

E-mail: mennasaad6917@gamil.com; ORCİD: 0000-0001-9045-7175

Authors’ contribution

All authors contributed equally to this work.

Competing interests

The authors declare that they have no competing interests.

Citation: Saad MAM, Abd ELBaky AM, Abo Alfotooh A and Saafan KI. Effect of extracorporeal shockwave therapy on palmar fibromatosis. J Life Sci Biomed, 2021;

11(1): 13-19. DOI: https://dx.doi.org/10.51145/jlsb.2021.2

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Citation: Saad MAM, Abd ELBaky AM, Abo Alfotooh A and Saafan KI. Effect of extracorporeal shockwave therapy on palmar fibromatosis. J Life Sci Biomed, 2021;

11(1): 13-19. DOI: https://dx.doi.org/10.51145/jlsb.2021.2