Background

Proximal suspensory desmitis (PSD) is a commonly diagnosed condition affecting a range of equine populations, but most commonly seen in mature sports horses (Dyson 1994). Previous studies have shown that the percentage of those horses affected returning to their previous level of work varies greatly with conservative management (40%) or surgical treatment (70–87%) (Norvall et al. 2015). Which limb is affected also plays a significant role with up to 90% of forelimb injuries returning to work compared to only 40% of hindlimb injuries (Dyson 1994). Extracorporeal shockwave therapy ECSWT and radial pressure wave therapy (RPWT) have been advocated for the management of many tendon and ligament disorders, such as superficial flexor tendinitis (Kersh et al. 2018) and PSD (Caminoto et al. 2005) based on results in experimental research models. The exact mechanism by which ECSWT or RPWT exerts their effect within tendon and ligaments is not known. One theory is that it relates to induction of analgesia from the effect on sensory nerves (Bolt et al. 2004). Experimental studies have, however, also demonstrated deleterious effects on tendon explant cultures (Bosch et al. 2007). The relevance of this in the clinical situation is not known. ECSWT and RPWT are both included in this critically appraised topic (CAT) to enable a larger body of literature to be used. Multiple theories regarding the mechanisms and relative efficacy of the two methods are offered in the literature, with many suggesting ECSWT to be superior. However, large meta‐analyses within human rehabilitation literature have concluded the modalities are equally as efficacious for the management of tendon and ligament disorders, and that the majority of available ECSWT devices generate waveforms rather than true shockwaves (Schmitz 2015). This study aims to evaluate the literature relevant to functional outcomes following the use of ECSWT or RPWT in PSD in horses.

PICO question

Does RPWT or ECSWT improve the return to function in horses with proximal suspensory desmitis?

Population‐ Horses with proximal suspensory desmitis

Intervention‐ Extracorporeal shockwave therapy or radial pressure wave therapy

Control‐ Horses with PSD managed conservatively

Outcome‐ return to previous athletic activity

Search strategy

CAB Abstracts were used to search for relevant literature. The following terms were used, and four relevant papers were identified.

• Horse AND proximal suspensory desmitis
• Horse AND extracorporeal shockwave therapy
• Horse AND extracorporeal shockwave therapy AND proximal suspensory desmitis
• Horse AND radial pressure wave therapy
• Horse AND shockwave

The first paper from Löffeld et al. (2002) was a prospective clinical trial of 61 horses with proximal suspensory desmitis. Horses included in the trial met the following criteria: (i) diagnosis of chronic proximal suspensory desmitis >3 months duration, (ii) previous unsuccessful treatment with systemic or local anti‐inflammatories and (iii) no systemic or other orthopaedic disease. Thirty horses with chronic PSD were compared to 31 control cases. Within the paper, it is not detailed as to whether the cases were forelimb or hindlimb cases. Cases were prospectively enrolled to be part of the treatment or control group; no details within the paper are found as to the randomisation process. The control group included horses treated by corticosteroids injected around the proximal suspensory ligament, blistering or field rest. The blistering process was not detailed in the paper as to the method used or if the method was consistent throughout. Similarly, the injection site, corticosteroid used or total volume injected are not clearly stated. The ECSWT group were treated with 2000 impulses at 2.5 bar with a frequency of 8 Hz for three sessions with a 2‐ to 4‐week interval. Both groups were subject to the same ascending exercise programme beginning with 20 min of hand walking increasing up to short periods of trot. Cases treated with ECSWT alongside the exercise programme had increased rates of return to previous activity level with 71% compared to 50% of the control group being in full work at 6 months.

The control group in this study was not homogenous and subject to different treatment protocols. Overall this leaves us unable to draw strong conclusions to the benefits of the pressure wave treatment applied to this population compared with the control group.

Following this Crowe et al. (2004) reported 65 horses with chronic forelimb or hindlimb PSD seen at two UK referral centres. Their inclusion criteria were as follows: (i) lameness present for greater than 3 months; (ii) a positive response to local anaesthesia of the deep branch of the lateral plantar or palmar metacarpal nerve; where a positive response was defined as abolishment of lameness or substantial improvement; (iii) a negative response to intra‐articular anaesthesia of the tarsometatarsal or middle carpal joint; (iv)ultrasonographic evidence of proximal suspensory desmitis. Of the 65 cases, 20 cases had forelimb PSD, 43 had hindlimb PSD and two cases had both forelimb and hindlimb PSD. Cases were additionally assessed for lameness grade and ultrasonographic appearance of lesions at the beginning and end of treatment. All horses were subject to the same treatment protocol; radial pressure wave therapy (2000 impulses at 10 Hz) given at 2‐week intervals for 3 treatments followed by an ascending exercise programme. Horses then had a further lameness examination at 6 months. Fifty horses were reassessed by the author, 8 horses by the referring vet and the final 2 horses’ results were obtained via telephone consultation with the owner. Of the 19 forelimb cases re‐examined by the authors, 10 (53%) were in full work at 6 months, and for the 43 hindlimb cases, 18 (41%) were in full work. These results were then compared with the results of a previous series of cases of acute hindlimb PSD seen at one of the clinics where they found 18–21% in full work at 6 months and a previous series of cases of chronic PSD where 0/11 cases were in full work at 6 months (Dyson 1994). The authors concluded that for chronic PSD in the forelimb and hindlimb, RPWT resulted in more horses being in work at 6 months compared to that of a controlled exercise program alone. The control populations were not contemporaneous and the outcomes for forelimb PSD cases were compared with those in a previous series of hindlimb cases. Forelimb PSD cases are reported to respond better to conservative management than hindlimb PSD so it becomes difficult to draw firm conclusions from these results.

Lischer et al. (2006) reported a retrospective series of 52 cases seen between 1999 and 2003. Their inclusion criteria were as follows: (i) improvement by one AAEP lameness grade in response to palmar metacarpal or deep branch of the lateral plantar nerve anaesthesia; (ii) negative or mild improvement to intraarticular anaesthesia of the tarsometatarsal joint. This mild improvement was not defined by the authors. Within the group of the 52 horses, 34 forelimbs had PSD (1 bilateral) and 22 hindlimbs had PSD (3 bilateral). Cases were assessed for lameness grade, ultrasonographic appearance of the lesions and radiographic assessment of any sceloris at the origin of the suspensory ligament (graded from mild to moderate). Radiographs were taken to exclude other pathologies, but it is not stated by the authors whether cases were excluded if they had concomitant orthopaedic problems. Ultrasonographic evidence of proximal suspensory desmitis was not a prerequisite for inclusion in this study. The affected limbs were then subject to the same ECSWT protocol of 2000 impulses at 240 Hz over three treatments spaced 2 weeks apart followed by an ascending exercise programme. The lameness was then reassessed at weeks 3, 6, 12, 26 and 52 post‐treatment. Of the forelimb PSD cases, mean lameness grade at 26 weeks was improved from 1.8/5.0 to 0.5/5.0 with 61.0% in full work. For hindlimb PSD cases, mean lameness grade was improved from 1.95/5.0 to 1.29/5.0 with 40.8% in full work at 26 weeks. These results were compared to the 13% in full work at 6 months previously reported with rest and rehabilitation alone (Dyson 1994). A degree of interobserver error may be present with assessment performed by more than one individual. This paper has no contemporaneous control group(s) and relies on comparisons with the previous literature. There is lack of blinding of assessors leading to treatment bias and lack of contemporaneous control groups.

A more recent paper by Norvall et al. (2015) compared the outcome and time to return to work for horses with hindlimb PSD that were treated either surgically with neurectomy and fasciotomy or with ECSWT. This study is the only one of those described to compare ECSWT to surgical management rather than to conservative management. The inculsion criteria were as follows: (i) improvement of lameness to deep branch of the lateral plantar nerve analgesia; (ii) ultrasonographic findings consistent with PSD. Seventy‐five horses with hindlimb proximal suspensory desmitis were included in the study. Initially, 41 horses were treated surgically, and 34 cases with ECSWT. Of the 41 surgically treated cases, 24 horses (58%) returned to their previous level of work with a mean time to return to work of 10.1 months. Twenty of the 34 cases (59%) treated with ECSWT returned to their previous level of work with a mean time to return to work of 7.4 months. The authors claimed their results indicated that within this study ECSWT resulted in a faster return to work with success rates similar to that of surgical treatment of PSD. Fifteen horses remained lame following their initial treatment and were then treated with the other modality. Seven of these horses returned to their previous level of work following both treatments. Previously reported results of surgical treatment with neurectomy and fasciotomy reported 44% of horses with concurrent lameness issues to be in work at one year, compared to 77% of horses where PSD was the sole complaint (Dyson and Murray, 2012). Within this paper, it is not discussed if there were any concurrent lameness problems, however, both treatment groups results fall within these ranges. The limitations of the study by Norvall et al. (2015) include lack of randomisation of treatment groups; however, it is less subject to interobserver error and provides a more straightforward account of the prognosis to inform owners.

Conclusion

The question this paper asked (Does RPT or ECSWT improve the return to function in horses with proximal suspensory desmitis?) is not able to be unequivocally answered based on the literature reviewed. Studies published to date on ECSWT and PSD mostly comprise retrospective case series, with only one prospective case‐control study. The follow‐up within all the studies is of limited duration (between 6 months and one year), providing little information on the long‐term prognosis for horses with PSD. Outcome measures are not standardised not assessors blinded as to treatment.

Inclusion criteria were often limited to clinical investigation without diagnostic imaging which may influence the population studied and means improvement in appearance on imaging could not be incorporated into outcome measures. There are two studies supporting an improved outcome with either ECSWT or RPT over rest and rehabilitation alone, but both studies had significant weaknesses that make drawing any firm conclusion impossible. None of the case series included indicated a worse functional outcome for horses treated with ECSWT or RPT compared to other regimes. Further prospective randomised case‐control studies would be required to fully elucidate the impact of ECSWT and RPWT. It would be helpful to standardise both the inclusion criteria and outcome measures for future studies.

中文翻译：

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在患有近端悬垂性皮炎的马匹中，体外冲击波疗法或放射状压力波疗法是否能改善保守治疗和/或外科治疗的功能恢复？

背景

近端悬垂性皮炎（PSD）是一种普遍诊断的疾病，会影响一系列马群，但最常见于成熟的运动马（Dyson 1994）。以往的研究表明，那些马受影响的百分比回到他们以前的工作水平与保守的管理（40％）或手术治疗（70-87％）（Norvall良莠不齐等。  2015年）。受影响的四肢也起着重要作用，多达90％的前肢受伤恢复工作，而后肢受伤只有40％（Dyson 1994）。体外冲击波治疗ECSWT和径向压力波疗法（RPWT）已经被主张许多腱和韧带的病症，如浅屈肌肌腱炎的管理（克什等人。  2018）和PSD（Caminoto等人。  2005基于在结果）实验研究模型。ECSWT或RPWT在肌腱和韧带内发挥作用的确切机制尚不清楚。一种理论是，它涉及从感觉神经（螺栓的效果镇痛感应等人。  2004年）。然而，实验研究也显示了对肌腱外植体培养物的有害影响（Bosch等人，  2007年）。）。这在临床情况下的相关性尚不清楚。ECSWT和RPWT都包含在此关键评估主题（CAT）中，以便可以使用更多的文献。文献中提供了关于这两种方法的机理和相对功效的多种理论，其中许多理论表明ECSWT是更好的。但是，在人类康复文献中进行的大型荟萃分析得出的结论是，这种方式对肌腱和韧带疾病的治疗同样有效，并且大多数可用的ECSWT设备产生的是波形而不是真实的冲击波（Schmitz 2015）。这项研究的目的是评估在马的PSD中使用ECSWT或RPWT后与功能结局相关的文献。

PICO问题

RPWT或ECSWT是否可以改善马匹近端悬垂性皮炎的功能恢复？

人口-马匹近端悬垂性皮炎

干预-体外冲击波治疗或径向压力波治疗

PSD的控制马保守管理

结果-恢复以前的体育活动

搜索策略

CAB摘要用于搜索相关文献。使用了以下术语，并确定了四篇相关论文。

• 马和近端悬垂性皮炎
• 马与体外冲击波疗法
• 马和体外冲击波治疗及近端悬垂性皮炎
• 马与放射状压力波疗法
• 马与冲击波

Löffeld等人的第一篇论文。（2002年）是对61匹患有近端悬垂性皮炎的马进行的前瞻性临床试验。纳入试验的马匹符合以下标准：（i）诊断持续时间> 3个月的慢性近端悬垂性皮炎；（ii）先前未曾使用全身性或局部性抗炎药治疗；（iii）没有全身性或其他骨科疾病。将30匹患有慢性PSD的马与31例对照病例进行比较。在本文中，没有详细说明案件是前肢案件还是后肢案件。前瞻性地将病例纳入治疗组或对照组。在本文中没有找到有关随机化过程的详细信息。对照组包括在近端悬韧带周围，水疱或野外休息时注射皮质类固醇激素治疗的马匹。对于所使用的方法，或者该方法在整个过程中是否一致，起泡过程未在本文中进行详细介绍。同样，注射部位，使用的皮质类固醇激素或注射的总体积也没有明确说明。ECSWT组以2.5 bar的频率以8 Hz的频率进行2000次脉冲治疗，疗程为3至2周至4周。两组都接受相同的上升运动程序，从20分钟的步行开始，直至短时小跑。与运动计划一起使用ECSWT治疗的病例，其恢复至先前活动水平的比率提高了71％，而对照组的50％的患者在6个月时处于完全工作状态。ECSWT组以2.5 bar的频率以8 Hz的频率进行2000次脉冲治疗，疗程为3至2周至4周。两组都接受相同的上升运动程序，从20分钟的步行开始，直至短时小跑。与运动计划一起使用ECSWT治疗的病例，其恢复至先前活动水平的比率提高了71％，而对照组的50％的患者在6个月时处于完全工作状态。ECSWT组以2.5 bar的频率以8 Hz的频率进行2000次脉冲治疗，疗程为3至2周至4周。两组都接受相同的上升运动程序，从20分钟的步行开始，直至短时小跑。与运动计划一起使用ECSWT治疗的病例，其恢复至先前活动水平的比率提高了71％，而对照组的50％的患者在6个月时处于完全工作状态。

这项研究中的对照组不是同质的，并且接受不同的治疗方案。总体而言，这使我们无法得出强有力的结论，即与对照组相比，对该人群进行压力波治疗的益处。

随后，克劳等人。（2004年）报告在英国的两个转诊中心看到65匹患有慢性前肢或后肢PSD的马。它们的纳入标准如下：（i）出现la足超过3个月；（ii）对外侧足底或掌掌掌骨神经深支的局部麻醉有积极反应；正面反应被定义为取消la行或实质性改善；（iii）睑板或腕中关节的关节内麻醉反应不良；（iv）近端悬垂性皮炎的超声检查证据。65例中，前肢PSD 20例，后肢PSD 43例，前肢PSD和后肢PSD 2例。在治疗开始和结束时还对病例的la行度和病变的超声检查表现进行了评估。所有的马都接受相同的治疗方案。每2周间隔进行一次径向压力波疗法（在10 Hz处产生2000次脉冲），进行3种治疗，然后进行递增运动计划。然后在6个月时对马进行进一步的la行检查。作者对50匹马进行了重新评估，推荐的兽医对8匹马进行了重新评估，最后2匹马的结果是通过与所有者的电话咨询获得的。作者重新检查的19例前肢病例中，有10例（53％）在6个月时处于正常工作状态，而43例后肢病例中，有18例（41％）在正常工作状态。然后将这些结果与以前一系列在一家诊所中发现的后肢PSD病例的结果进行比较，在这些诊所中，他们发现6个月的全职工作率为18–21％，而先前一系列慢性PSD在0/11的情况下发现病例在6个月时处于充分工作状态（Dyson 每2周间隔进行一次径向压力波疗法（在10 Hz时产生2000次脉冲），进行3种治疗，然后进行递增运动计划。然后在6个月时对马进行进一步的me行检查。作者对50匹马进行了重新评估，推荐的兽医对8匹马进行了重新评估，最后2匹马的结果是通过与所有者的电话咨询获得的。作者重新检查的19例前肢病例中，有10例（53％）在6个月时处于正常工作状态，而43例后肢病例中，有18例（41％）在正常工作状态。然后将这些结果与以前一系列在一家诊所中发现的后肢PSD病例的结果进行比较，在这些诊所中，他们发现6个月的全职工作率为18–21％，而先前一系列慢性PSD在0/11的情况下发现病例在6个月时处于充分工作状态（Dyson 每2周间隔进行一次径向压力波疗法（在10 Hz处产生2000次脉冲），进行3种治疗，然后进行递增运动计划。然后在6个月时对马进行进一步的me行检查。作者对50匹马进行了重新评估，推荐的兽医对8匹马进行了重新评估，最后2匹马的结果是通过与所有者的电话咨询获得的。作者重新检查的19例前肢病例中，有10例（53％）在6个月时处于正常工作状态，而43例后肢病例中，有18例（41％）在正常工作状态。然后将这些结果与以前一系列在一家诊所中发现的后肢PSD病例的结果进行比较，在这些诊所中，他们发现6个月的全职工作率为18–21％，而先前一系列慢性PSD在0/11的情况下发现病例在6个月时处于充分工作状态（Dyson1994）。作者得出的结论是，相对于单独的受控运动计划，RPWT导致前肢和后肢的慢性PSD在6个月时工作的马更多。对照人群不是同期的，并且将前肢PSD病例的结果与先前系列的后肢病例的结果进行了比较。据报道，前肢PSD病例比后肢PSD对保守治疗的反应更好，因此很难从这些结果中得出明确的结论。

Lischer等。（2006年）回顾性分析了1999年至2003年间发生的52例病例。纳入标准如下：（i）对掌掌掌或足底外侧神经麻痹的深部分支的反应，AAEP improvement行等级提高了1级。（ii）some趾关节的关节内麻醉阴性或轻度改善。作者没有定义这种轻微的改进。在这52匹马中，有34条前肢患有PSD（双侧1例），有22条后肢患有PSD（双侧3例）。评估病例的la行度，病变的超声影像学表现以及悬韧带起源处任何巩膜的影像学评估（从轻度到中度）。射线照相被排除在其他疾病之外，但是作者没有说明是否有伴随骨科疾病的病例被排除在外。近端悬垂性皮炎的超声检查证据并非纳入本研究的前提。然后在间隔2周的三种治疗方法中，对受影响的四肢进行相同的ECSWT规程，以240 Hz的频率进行2000次脉冲刺激，然后进行递增运动程序。然后在治疗后第3、6、12、26和52周重新评估行。在前肢PSD病例中，第26周的平均grade行度从1.8 / 5.0提高到0.5 / 5.0，全职工作的比率为61.0％。对于后肢PSD病例，平均full行度从1.95 / 5.0提高到1.29 / 5.0，在26周的全职工作中达到40.8％。将这些结果与之前报告的仅休息和康复的6个月全职工作的13％进行了比较（Dyson 近端悬垂性皮炎的超声检查证据并非纳入本研究的前提。然后在间隔2周的三种治疗方法中，对受影响的四肢进行相同的ECSWT规程，以240 Hz的频率进行2000次脉冲刺激，然后进行递增运动程序。然后在治疗后第3、6、12、26和52周重新评估行。在前肢PSD病例中，第26周的平均grade行度从1.8 / 5.0提高到0.5 / 5.0，全职工作的比率为61.0％。对于后肢PSD病例，平均full行度从1.95 / 5.0提高到1.29 / 5.0，在26周的全职工作中达到40.8％。将这些结果与之前报告的仅休息和康复的6个月全职工作的13％进行了比较（Dyson 近端悬垂性皮炎的超声检查证据并非纳入本研究的前提。然后在间隔2周的三种治疗方法中，对受影响的四肢进行相同的ECSWT规程，以240 Hz的频率进行2000次脉冲刺激，然后进行递增运动程序。然后在治疗后第3、6、12、26和52周重新评估行。在前肢PSD病例中，第26周的平均grade行度从1.8 / 5.0提高到0.5 / 5.0，全职工作的比率为61.0％。对于后肢PSD病例，平均full行度从1.95 / 5.0提高到1.29 / 5.0，在26周的全职工作中达到40.8％。将这些结果与之前报告的仅休息和康复的6个月全职工作的13％进行了比较（戴森 然后在间隔2周的三种治疗方法中，对受影响的四肢进行相同的ECSWT规程，以240 Hz的频率进行2000次脉冲刺激，然后进行递增运动程序。然后在治疗后第3、6、12、26和52周重新评估行。在前肢PSD病例中，第26周的平均grade行度从1.8 / 5.0提高到0.5 / 5.0，全职工作的比率为61.0％。对于后肢PSD病例，平均full行度从1.95 / 5.0提高到1.29 / 5.0，在26周的全职工作中达到40.8％。将这些结果与之前报告的仅休息和康复的6个月全职工作的13％进行了比较（Dyson 然后在间隔2周的三种治疗方法中，对受影响的四肢进行相同的ECSWT规程，以240 Hz的频率进行2000次脉冲刺激，然后进行递增运动程序。然后在治疗后第3、6、12、26和52周重新评估行。在前肢PSD病例中，第26周的平均grade行度从1.8 / 5.0提高到0.5 / 5.0，全职工作的比率为61.0％。对于后肢PSD病例，平均full行度从1.95 / 5.0提高到1.29 / 5.0，在26周的全职工作中达到40.8％。将这些结果与之前报告的仅休息和康复的6个月全职工作的13％进行了比较（Dyson 后处理分别为26和52。在前肢PSD病例中，第26周的平均grade行度从1.8 / 5.0提高到0.5 / 5.0，全职工作的比率为61.0％。对于后肢PSD病例，平均full行度从1.95 / 5.0提高到1.29 / 5.0，在26周的全职工作中达到40.8％。将这些结果与之前报告的仅休息和康复的6个月全职工作的13％进行了比较（Dyson 后处理分别为26和52。在前肢PSD病例中，第26周的平均grade行度从1.8 / 5.0提高到0.5 / 5.0，全职工作的比率为61.0％。对于后肢PSD病例，平均full行度从1.95 / 5.0提高到1.29 / 5.0，在26周的全职工作中达到40.8％。将这些结果与之前报告的仅休息和康复的6个月全职工作的13％进行了比较（Dyson1994）。一个以上观察者之间可能存在一定程度的观察者间错误，而且评估的对象可能不止一个。本文没有同期对照组，并依靠与以前的文献进行比较。缺乏评估者的盲目性导致治疗偏倚，同时缺乏对照组。

Norvall等人的最新论文。（2015年）比较了通过神经切除和筋膜切开术或ECSWT手术治疗的后肢PSD马的结果和恢复工作的时间。本研究是描述的将ECSWT与手术治疗而非保守治疗进行比较的唯一研究。灌输标准如下：（i）me足到足底外侧神经镇痛的深部分支的改善；（ii）与PSD一致的超声检查结果。该研究纳入了75匹患有后肢近端悬垂性皮炎的马。最初，对41匹马进行了手术治疗，并对34例ECSWT进行了治疗。在41例接受手术治疗的病例中，有24匹马（58％）恢复了以前的工作水平，平均恢复工作时间为10.1个月。经ECSWT治疗的34例患者中有20例（59％）恢复到以前的工作水平，平均恢复工作时间为7.4个月。作者声称他们的结果表明，在这项研究中，ECSWT可以更快地恢复工作，其成功率与PSD的外科治疗相似。15匹马在接受最初的治疗后仍然la腿，然后接受了另一种方式的治疗。两种治疗后，其中七匹马恢复了以前的工作水平。先前报道的通过神经切除术和筋膜切开术进行手术治疗的结果报告，有44％患有并发44行问题的马只在一年内工作，而只有PSD是唯一主诉的马匹为77％（Dyson和Murray，作者声称他们的结果表明，在这项研究中，ECSWT可以更快地恢复工作，其成功率与PSD的外科治疗相似。15匹马在接受最初的治疗后仍然la腿，然后接受了另一种方式的治疗。两种治疗后，其中七匹马恢复了以前的工作水平。先前报道的通过神经切除术和筋膜切开术进行手术治疗的结果报告，有44％患有并发44行问题的马只在一年内工作，而只有PSD是唯一主诉的马匹为77％（Dyson和Murray，作者声称他们的结果表明，在这项研究中，ECSWT可以更快地恢复工作，其成功率与PSD的外科治疗相似。15匹马在接受最初的治疗后仍然la腿，然后接受了另一种方式的治疗。两种治疗后，其中七匹马恢复了以前的工作水平。先前报道的通过神经切除术和筋膜切开术进行手术治疗的结果报告，有44％患有并发44行问题的马只在一年内工作，而只有PSD是唯一主诉的马匹为77％（Dyson和Murray，两种治疗后，其中七匹马恢复了以前的工作水平。先前报道的通过神经切除术和筋膜切开术进行手术治疗的结果报告，有44％患有并发44行问题的马只在一年内工作，而只有PSD是唯一主诉的马匹为77％（Dyson和Murray，两种治疗后，其中七匹马恢复了以前的工作水平。先前报道的通过神经切除术和筋膜切开术进行手术治疗的结果报告，有44％患有并发44行问题的马只在一年内工作，而只有PSD是唯一主诉的马匹为77％（Dyson和Murray，2012）。在本文中，没有讨论是否存在并发la行问题，但是，两个治疗组的结果均在这些范围内。Norvall等人的研究的局限性。（2015）包括缺乏治疗组的随机化；但是，它较少受到观察者间错误的影响，并提供了更直接的预后说明，以告知所有者。

结论

本文回顾的文献不能明确回答本文提出的问题（RPT或ECSWT是否能改善马匹近端悬垂性皮炎恢复功能？）。迄今为止，有关ECSWT和PSD的研究主要包括回顾性病例系列，只有一项前瞻性病例对照研究。所有研究的随访时间有限（在6个月至一年之间），很少提供有关PSD马的长期预后的信息。结果指标未标准化，评估人员对治疗无知。

入选标准通常限于没有诊断影像学的临床研究，这可能会影响所研究的人群，这意味着影像学外观的改善不能纳入结局指标。有两项研究表明，仅靠休息和康复，无论采用ECSWT还是RPT均可改善结局，但两项研究均存在明显的弱点，因此无法得出确切的结论。所包括的病例系列均未显示与其他方案相比，用ECSWT或RPT治疗的马的功能结局更差。为了进一步阐明ECSWT和RPWT的影响，需要进行进一步的前瞻性随机病例对照研究。标准化纳入标准和结局指标对将来的研究将是有帮助的。