Keywords costochondritis - extracorporeal shock-wave therapy - quality of life - pressure pain
threshold - intra-articular steroid injection
Schlüsselwörter Costochondritis - Extrakorporale Stoßwellentherapie - Intraartikuläre Steroid injection
- Lebensqualität - Druckschmerzschwelle
Introduction
Costochondritis is a painful condition caused by inflammation of sternocostal joints
without swelling. The causes of costochondritis are unknown, but genetic, viruses,
and injury are possible causes. Inflammation can occur in bilateral sternocostal
junction, but is usually only on one side. There is no specific diagnostic test for
costocontritis. The diagnosis of costochondritis is made on the physical examination
with tenderness and pain. Pain is typically reproducible by palpation and radiates
to chest [1 ]. It affects as many as
30% of patients presenting to emergency departments with chest pain [2 ]. The pain may occur during physical activity
or inspiration [3 ].
Although no consensus has been established upon the treatment of costochondritis,
treatment usually focuses on pain relief with acetaminophen, non-steroidal
anti-inflammatory drugs, physical therapy modalities, and intra-articular steroid
injections (IASI) [4 ]
[5 ].
Extracorporeal shock wave therapy (ESWT) is a non-invasive procedure which has been
proven to be effective in treating musculoskeletal system diseases including PF,
calcific tendinopathies, lateral and medial epicondylitis, and myofascial pain
syndrome (MPS) [6 ]
[7 ]
[8 ]. Although the mechanism of action of ESWT
in costochondritis is still unclear, the energy crisis hypothesis may explain how
ESWT affects other conditions [9 ]
[10 ]. The mechanisms through which ESWT exerts
its therapeutic effects are thought to be increased tissue perfusion, increased
vascularization, and altered pain stimuli in ischemic tissues by an increased intake
of calcium.
In the literature, there are some reports investigating the efficacy of ESWT in
costochondritis; however, there is a very limited number of studies comparing ESWT
and IASI in this patient population. In the present study, we, therefore, aimed to
compare the effects of ESWT vs. IASI on pain, depression, quality of life, and
pressure pain threshold (PPT) in patients with costochondritis.
Methods
Study population
This single-blind, prospective, randomized-controlled clinical study was
conducted at the University of Health Sciences, Umraniye Training and Research
Hospital, Musculoskeletal Outpatient Clinic between September 2019 and February
2020. A total of 67 patients (10 males, 57 females; mean age: 43.4±13.2
years; range, 19–67 years) with the diagnosis of costochondritis were
included in the study. Inclusion criteria were as follows: having a clinical
diagnosis of costochondritis; reproducible pain by palpation of costal
cartilages and sternocostal ribs radiating to the chest wall; and having
persistent pain at least for six months as assessed by a Visual Analog Scale
(VAS) [11 ]. Exclusion criteria were as
follows: no prior treatment including ESWT and steroid injection within the past
6 months; having a diagnosis of other cardiovascular and lung diseases; having a
malignancy, vitamin D deficiency, other inflammatory disease, pregnancy, cardiac
pacemaker, local infections, or severe cardiac and renal diseases. To rule out
other cardiovascular and lung diseases, all patients underwent a detailed
physical examination and laboratory testing. In addition, posterioanterior (PA)
and lateral plain chest radiographs, electrocardiography and thoracic computed
tomography (CT) scans were obtained. A written informed consent was obtained
from each patient. The study protocol was approved by the University of Health
Sciences, Umraniye Training and Research Hospital Ethics Committee
(06/09/2019 54132726-000-18027). The study was conducted in
accordance with the principles of the Declaration of Helsinki.
Randomization
Randomization was performed using sequentially numbered, opaque, sealed
envelopes. The investigators who assessed pre- and post-treatment measurements
were not allowed to attend to the intervention period and were blinded to group
allocation. The patients were divided into two groups. Group 1 (n=34)
received high-energy flux density (H-ESWT)
(0.26 mJ/mm2 ) for a total of seven sessions at
3-day intervals. Group 2 (n=33) received IASI for 2 times at 2-week
intervals. Data including baseline demographic characteristics of all patients
were recorded. The study flow chart is shown in [Fig. 1 ].
Fig. 1 Study flow chart.
Interventions
The ESWT group received ESWT using Modus Inceler Medikal, Ankara, Turkey. A total
of 7 sessions of focused ESWT was performed at 3-day intervals. The ESWT was
applied at costal cartilages and sternocostal joints at 500 pulses/point, a
total of 1,500 to 3,000 pulses/session 1.5 to 3 bars with H-ESWT
(> 0.28 mJ/mm2 ) in each session.
The IASI group received IASI for 2 times at 2-week intervals. 2 mL of
betamethasone was injected to each painful point by a specialist. After the
patient was given the appropriate position, the costosternal joints to be
injected were determined and marked with a ballpoint pen. The area to be
injected was cleaned without touching it. After wearing a sterile glove,
corticosteroid was injected into the joints at a 90 degree angle after negative
aspiration before injection. After the injection, pneumothorax was excluded with
chest radiograph.
Chest stretching exercises were given to all patients in both groups. All
patients were instructed about the exercises by physiotherapists and the first
set of exercises were performed under the supervision of clinical
physiotherapists. All patients were instructed to do 10 repetitions of each
exercise set 3 times a day for 2 weeks.
Primary outcome measures
The PPT was defined as the point at which a sensation of pressure changed into a
sensation of pain. The PPT was evaluated using the Baseline®
Dolorimeter-22 lb Capacity (Fabrication Enterprises, NY, USA). Pressure pain in
the upper trapezius was measured using a baseline dolorimeter (Pain Diagnosis
and Treatment Inc., CA, USA). The instrument consists of a gauge attached to a
hard rubber tip 1 cm in diameter. The dial gauge can be calibrated in kg or
pounds (lb), ranging from 1 to 30 kg or from 1 to 60 lb at an interval
of 0.25 kg or 0.5 lb. The force recorded is the amount of pressure which
causes pain. Inter-individual reliability is good to excellent (interclass
correlation coefficient=0.75–0.89) [12 ].
Secondary outcome measures
All pre- (at baseline) and post-treatment (at one month) measurements were
evaluated by a single investigator. The VAS was used to evaluate pain severity.
The score ranges from 0 to 10, and 0 indicates no pain, while 10 indicates
unbearable pain.
The Short Form-36 (SF-36), which consists of 8 subscales and 36 items, was used
to evaluate physical and mental health of the patients. It is a valid survey for
the evaluation of quality of life and consists of the following subscales:
physical functioning (PF), limitations of daily activities by difficulty in
physical role (DPR), pain severity by bodily pain (BP), rating of health by
general health (GH), energy and fatigue by vitality (VT), limitations of daily
activities by social functioning (SF), and limitation of regular daily
activities by difficulty in emotional role (DER) and mental health (MH) [13 ].
The Beck Depression Inventory (BDI) was used to evaluate depressive
symptomatology. It is a 21-item, self-reporting questionnaire which measures
characteristic attitudes and symptoms of depression. The maximum total score is
63, and higher scores indicate greater symptom severity. The validity and
reliability studies of the Turkish version of the BDI have been shown [14 ].
Statistical analysis
A power analysis was performed using the G*Power version 3.1.0 software
(Heinrich Heine University, Düsseldorf, Germany) and the sample size was
calculated. Based on an alpha value of 0.05 for statistical significance, 33
patients in each group could achieve 80% statistical power. Finally, a
total of 66 patients were planned to be recruited in both groups. Assuming a
dropout of 15%, 75 patients were expected to be included.
Statistical analysis was performed using the Statistical Package for the Social
Sciences (SPSS) version 25.0 software (IBM Corp., Armonk, NY, USA). Descriptive
data were expressed in mean±standard deviation (SD), or number and
frequency. The Kolmogorov-Smirnov test was used for normality test of data. The
Mann-Whitney U test was performed to analyze non-parametric data. The Wilcoxon
signed-rank test was used to compare non-normally distributed data. The Pearson
correlation analysis was done to analyze possible correlations between the
variables. A p value of<0.05 was considered statistically
significant.
Results
Of a total of 67 patients, 57 were females and 10 were males with a mean age of
43.4±13.2 (range, 19–67) years. Totally, there were 34
(50.74%) patients in Group 1 and 33 patients (49.26%) in Group 2.
There were no statistically significant differences in the baseline demographic
characteristics between the groups (p>0.05). Demographic characteristics of
the patients are shown in [Table 1 ].
Table 1 Baseline demographic characteristics of the patients.
Group 1
Group 2
Total
n (%)
n (%)
n (%)
Age, years, mean±SD (range)
19–44 (33.6±13.4)
23–47 (33.8±13.2)
19–47 (33.4±13.2)
Sex, n (%)
Male
5 (14.7)
5 (14.2)
10 (14.9)
Female
29 (85.3)
28 (84.8)
57 (85.1)
Marital status, n (%)
Married
29 (85.3)
25 (75.8)
54 (80.6)
Single
5 (14.7)
8 (24.2)
13 (19.4)
Educational status, n (%)
None
2 (5.9)
1 (3.0)
3 (4.5)
Primary
17 (50.0)
15 (45.5)
32 (47.8)
Secondary
6 (17.6)
7 (21.2)
13 (19.4)
High
2 (5.9)
3 (9.1)
5 (7.5)
Graduate/Post graduate
7 (20.6)
7 (21.2)
14 (20.9)
Income level, n (%)
Low
23 (67.6)
17 (51.5)
40 (59.7)
Middle
5 (14.7)
10 (30.3)
15 (22.4)
High
6 (17.6)
6 (18.2)
12 (17.9)
ESWT, extracorporeal shock wave therapy; IASI, intra-articular steroid
injection; SD, standard deviation.
No ESWT-related side effects or tissue damage were seen in any of the patients in
the
ESWT group. Also, there was no statistically significant difference in the baseline
VAS, BDI, PPT, SF-36 subscale scores between the groups (p>0.05). However,
there was a statistically significant decrease in the VAS scores at month after the
treatment in both groups, compared to baseline scores (p<0.05), although the
decrease was statistically significantly higher in the ESWT group (p<0.05).
In addition, there was a statistically significant increase in the SF-36 subscale
and PPT scores at one month after the treatment in both groups (p<0.05) with
a statistically significantly higher increase in the ESWT group (p<0.05).
Although there was a statistically significant decrease in the BDI scores at one
month after the treatment in both groups, compared to baseline scores
(p=0.854), there was no statically significant difference between the
groups. Pre- and post-treatment VAS, BDI, SF-36, and PPT scores in Group 1 and Group
2 are presented in [Table 2 ].
Table 2 Comparison of VAS, BDI, SF-36, and pain threshold scores
before and after treatment in ESWT and IASI groups.
Group 1
Group 2
(inter-group) p
1
Mean±SD (range)
Mean±SD (range)
VAS
Pre-treatment
6.35±1.04
6.33±0.98
0.984
Post-treatment
2.73±0.93
3.66±0.98
<0.05*
Pre-post-treatment p
2
<0.05*
<0.05*
BDI
Pre-treatment
14.29±8.58
14.45±8.09
0.905
Post-treatment
9.82±6.14
10.12±6.30
0.845
Pre-post-treatment p
2
<0.05*
<0.05*
SF-36 PF
Pre-treatment
79.8±13.9
81.6±15.0
0.478
Post-treatment
92.7±9.14
90.1±11.4
0.301
Pre-post-treatment p
2
<0.05*
<0.05*
SF-36 DPR
Pre-treatment
44.1±28.9
59.0±32.3
0.049
Post-treatment
89.7±19.5
81.0±25.0
0.119
Pre-post-treatment p
2
<0.05*
<0.05*
SF-36 DER
Pre-treatment
41.1±27.2
61.6±29.0 (35)
0.008*
Post-treatment
87.2±18.3 (65)
86.8±20.3 (45)
0.935
Pre-post-treatment p
2
<0.05*
<0.05*
SF-36 VT
Pre-treatment
40.1±24.2 (32)
39.5±24.0 (32)
0.920
Post-treatment
56.4±21.6 (60)
48.6±23.5 (40)
0.101
Pre-post-treatment p
2
<0.05*
<0.05*
SF-36 MH
Pre-treatment
52.4±21.6 (25)
53.2±21.3 (32.5)
0.860
Post-treatment
65.0±18.6 (62.5)
61.2±20.8 (37.5)
0.428
Pre-post-treatment p
2
<0.05*
<0.05*
SF-36 SF
Pre-treatment
66.7±23.9 (32.5)
67.6±25.1 (32.5)
0.888
Post-treatment
84.2±13.0 (62.5)
79.3±17.5 (45)
0.194
Pre-post-treatment p
2
<0.05*
<0.05*
SF-36 BP
Pre-treatment
53.7±25.0 (30)
54.2±25.8 (30)
0.929
Post-treatment
80.5±14.2 (60)
74.0±20.4 (40)
0.135
Pre-post-treatment p
2
<0.05*
<0.05*
SF-36 GH
Pre-treatment
55.1±22.2
54.3±22.1
0.885
Post-treatment
65.4±20.8
61.2±20.8
0.410
Pre-post-treatment p
2
<0.05*
<0.05*
PPT
Pre-treatment
3.93±1.04
3.98±1.09
0.793
Post-treatment
11.7±1.28
10.8±1.66
<0.05*
Pre-post-treatment p
2
<0.05*
<0.05*
ESWT, extracorporeal shock wave therapy; IASI, intra-articular steroid
injection; SD, standard deviation; VAS, Visual Analog Scale; SF-36 PF, Short
Form-36 physical functioning; SF-36 DPR, Short Form-36 difficulty in
physical role; SF-36 DER, Short Form-36 difficulty in emotional role; SF-36
VT, Short Form-36 vitality; SF-36 MH, Short Form-36 mental health; SF-36 SF,
Short Form-36 social functioning; SF-36 BP, Short Form-36 bodily pain; SF-36
GH, Short Form-36 general health; BDI, Beck Depression Inventory; PPT,
pressure pain threshold; 1Mann-Whitney U test; 2Wilcoxon signed-rank test
* p<0.05.
The correlation analysis revealed a moderate, negative, and statistically significant
relationship between the changes in the VAS scores and changes in the SF-36 PF
scores (r=−0.541) after the treatment in the ESWT group. In
addition, there was a weak, negative, and statistically significant relationship
between the changes in the VAS and the changes in the SF-36 BP subscale scores
(r = − 0.472) after the treatment in the ESWT group.
In the IASI group, there was also a weak, negative, and statistically significant
relationship between the changes in the SF-36 PF and the changes in the VAS scores
(r=− 0.419) after the treatment. The results of the
correlation analysis of all scales in the ESWT and control groups are summarized in
[Table 3 ].
Table 3 Correlation analysis results.
Group
VAS
Group 1
BDI
r
0.176
p
0.319
SF-36 PF
r
−0.541**
p
0.001
SF-36 DPR
r
−0.278
p
0.111
SF-36 DER
r
−0.064
p
0.721
SF-36 VT
r
−0.119
p
0.501
SF-36 MH
r
−0.119
p
0.501
SF-36 SF
r
−0.267
p
0.126
BP
r
−0.472**
p
0.005
GH
r
−0.158
p
0.372
PPT
r
−0.161
p
0.362
Group 2 (ISAI)
BDI
r
0.192
p
0.286
SF-36 PF
r
−0.419**
p
0.015
SF-36 DPR
r
−0.271
p
0.127
SF-36 DER
r
0.237
p
0.184
SF-36 VT
r
0.121
p
0.502
SF-36 MH
r
0.162
p
0.369
SF-36 SF
r
−0.171
p
0.342
BP
r
−0.095
p
0.600
GH
r
0.129
p
0.474
PPT
r
−0.137
p
0.448
ESWT, extracorporeal shock wave therapy; IASI, intra-articular steroid
injection; SD, standard deviation; VAS, Visual Analog Scale; SF-36 PF, Short
Form-36 physical functioning; SF-36 DPR, Short Form-36 difficulty in
physical role; SF-36 DER, Short Form-36 difficulty in emotional role; SF-36
VT, Short Form-36 vitality; SF-36 MH, Short Form-36 mental health; SF-36 SF,
Short Form-36 social functioning; SF-36 BP, Short Form-36 bodily pain; SF-36
GH, Short Form-36 general health; BDI, Beck Depression Inventory; PPT,
pressure pain threshold;
Pearson correlation analysis*p<0.05.
Discussion
In the present study, we investigated the effects of ESWT and IASI on quality of
life, mental health, and PPT in patients with costochondritis. Our study results
showed that that H-ESWT was more effective than IASI on pain, quality of life, and
PPT scores in this patient population.
Steroids have a broad set of physiological effects in the treatment and prognosis
of
inflammatory diseases [15 ]. Ostergaard et al.
[16 ] showed that one or more injections
into a joint with aseptic arthritis could significantly alter the joint status as
pain decreased and joint mobility increased.
Extracorporeal shock wave therapy is a proven treatment modality in several
conditions such as calcific tendinopathies, lateral and medial epicondylitis, and
MPS [6 ]
[7 ]
[8 ]. Based on the literature data, in the
present study, we used this method vs. IASI in patients with costochondritis which
is an inflammatory condition and responds well to anti-inflammatory drugs. In
general, ESWT exerts its effects through mechanotransduction which produces pressure
and delivers tensile and shearing forces by shock waves to the cells and, therefore,
the extracellular matrix messengers are liberated and a varying number and groups
of
genes in the cell nucleus are activated [17 ].
Although the working mechanism of ESWT has not been fully demonstrated, several
possible mechanisms have been proposed. In a study, ESWT was shown to inhibit
overstimulation of the nerves and nociceptors and increased the blood flow,
resulting in to pain relief through reduced muscle stiffness and contractions [17 ] Similarly, ESWT disrupted non-myelinated
fibers, decreased the production of substance P level at the dorsal root ganglia,
and relieved musculoskeletal pain [18 ]
[19 ].
In general, ESWT can be classified into 3 categories based on its energy levels:
low-energy (<0.08 mJ/mm2 ), medium-energy
(0.08–0.28 mJ/mm2 ), and high-energy
(0.28 mJ/mm2 ) [20 ]
[21 ]
[22 ]. High-energy ESWT can induce
fragmentation and destruction of solid bodies such as kidney stones, gallstones, and
body tissues and is often requires sedation or anesthesia, while low-energy ESWT
(L-ESWT) exerts its therapeutic effect through neurophysiological mechanisms and
does not require the use of sedation or anesthesia and can be applied in the
outpatient setting [23 ]. However, there is no
consensus on the optimal therapeutic intensity and dose-response relation [24 ].
In a study conducted by Müller et al., [25 ] focused H-ESWT was used in MPS patients and decreased VAS scores at 3
months. Gur et al. [26 ] used focused H-ESWT
and compared 3 sessions vs. a single session of treatment in MPS patients and
reported that 3-session treatment improved pain more effectively. In another study,
Park et al. [27 ] examined the efficacy of
H-ESWT vs. L-ESWT in MPS patients of the upper trapezius and found improvements in
the Verbal Numeric Pain Scale and pressure threshold in both groups, although it was
statistically significant in the H-ESWT group. Similarly, Chow et al. [28 ] divided 57 patients with chronic heel pain
into 3 groups to receive either fixed energy density or maximum tolerable energy
density or control treatment (30 impulses at a frequency of 3 Hz at the
lowest level [0.03 mJ/mm2 ]) once a week for 3 weeks. The
maximum tolerable energy density group showed a significant improvement in the FFI
and pain scores, while the control group had no improvement after treatment. This
finding indicates that the delivery of ESWT with a maximum tolerable energy density
is more effective than a fixed energy density. In a meta-analysis of randomized,
placebo-controlled trials, the efficacy of different energy levels of ESWT was
examined in patients with plantar fasciitis and focused ESWT was found to be more
effective than radial ESWT and H-ESWT/medium energy-ESWT were more effective
than L-ESWT in the long-term follow-up [29 ].
In addition, anesthetic premedication was shown to reduce the effectiveness of
treatment. Altogether, these findings suggest that an increased number of sessions
of ESWT and its use in high-energy density may promote its effectiveness on pain,
depression, quality of life, and PPT. Consistent with the previous studies, we used
H-ESWT for 7 sessions in our study group. In the current study, we found
statistically significant improvements in the SF-36 and BDI scores and pain relief
in our patients with costochondritis after the treatment. These findings indicate
the importance of H-ESWT for a high number of sessions in pain management in
patients with costochondritis. In addition, we found a significant correlation
between the VAS and SF-36 PF and BP subscale scores in the ESWT group.
Weak correlation between SF-36 BP and VAS after treatment in the H-ESWT group
indicates a faster improvement in ESWT group in patients’ pain. However,
there was a weak, negative, and statistically significant relationship between the
changes in the SF-36 PF and the changes in the VAS scores in the IASI group,
suggesting that H-ESWT for a higher number of sessions than a lower number of
sessions may be a more effective treatment than IASI.
Nonetheless, there are some limitations to this study. First, relatively small sample
size and the presence of a non-treatment group might have affected the results.
Second, as the present study included only costochondritis patients, the results
cannot be generalized to the general population. Third, the treatment results were
only able to be evaluated at one month and, thus, its long-term outcomes are
unclear. Further large-scale, long-term studies are needed to confirm these
findings.
Conclusions
In conclusion, pain management is of utmost importance in the treatment of
costochondritis with reduced pain and improved quality of life, depression, and PPT
scores. As data regarding the efficacy of ESWT vs. IASI are scarce, the present
study provides valuable implications to guide physicians in the treatment of
costochondritis. Based on our study results, we suggest that H-ESWT for a high
number of sessions is more effective than IASI in patients with costochondritis.
