***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Background Diabetes is becoming one of the most common chronic diseases , and ulcers are its most serious complication . Beginning with neuropathy , the subsequent foot wounds frequently lead to lower extremity amputation , even in the absence of critical limb ischemia . In recent years , some research ers have studied external shock wave therapy ( ESWT ) as a new approach to soft tissue wound healing . The rationale of this study was to evaluate if ESWT is effective in the management of neuropathic diabetic foot ulcers . Methods We design ed a r and omized , prospect i ve , controlled study in which we recruited 30 patients affected by neuropathic diabetic foot ulcers and then divided them into two groups based on different management strategies . One group was treated with st and ard care and shock wave therapy . The other group was treated with only st and ard care . The healing of the ulcers was evaluated over 20 weeks by the rate of re-epithelization . Results After 20 weeks of treatment , 53.33 % of the ESWT-treated patients had complete wound closure compared with 33.33 % of the control patients , and the healing times were 60.8 and 82.2 days , respectively ( p < 0.001 ) . Significant differences in the index of the re-epithelization were observed between the two groups , with values of 2.97 mm2/die in the ESWT-group and 1.30 mm2/die in the control group ( p < 0.001 ) . Conclusion Therefore , ESWT may be a useful adjunct in the management of diabetic foot ulceration . Trial registration Current Controlled Trials IS RCT OBJECTIVE This study was conducted to evaluate the efficacy of extracorporeal shock wave therapy ( ESWT ) on the healing rate , wound surface area and wound bed preparation in chronic diabetic foot ulcers ( DFU ) . METHODS Thirty eight patients with 45 chronic DFU were r and omly assigned into ; the ESWT-group ( 19 patients /24 ulcers ) and the control-group ( 19 patients /21 ulcers ) . Blinded therapist measured wound surface area ( WSA ) , the percentage of reduction in the WSA , rate of healing and wound bed preparation at baseline , after the end of the interventions ( W8 ) , and at 20-week follow-up ( W20 ) . The ESWT group received shock wave therapy twice per week for a total of eight treatments . Each ulcer was received ESWT at a frequency of 100 pulse/cm(2 ) , and energy flux density of 0.11mJ/cm(2 ) . All patients received st and ardized wound care consisting of debridement , blood-glucose control agents , and footwear modification for pressure reduction . RESULTS The overall clinical results showed completely healed ulcers in 33.3 % and 54 % in ESWT-groups and 14.28 % and 28.5 % in the control group after intervention ( W8 ) , and at follow-up ( W20 ) respectively . The average healing time was significantly lower ( 64.5 ± 8.06 days vs 81.17 ± 4.35 days , p<0.05 ) in the ESWT-group compared with the control group . CONCLUSION ESWT-treated ulcers had a significant reduction in wound size and median time required for ulcer healing , with no adverse reactions . So , the ESWT is advocated as an adjunctive therapy in chronic diabetic wound BACKGROUND This prospect i ve study compared extracorporeal shockwave treatment ( ESWT ) with hyperbaric oxygen therapy ( HBO ) in chronic diabetic foot ulcers . PATIENTS AND METHODS Seventy-two patients with 72 chronic diabetic foot ulcers were r and omly divided into two groups of similar demographics with 34 patients with 36 ulcers in the ESWT group and 36 patients with 36 ulcers in the HBO group . Patients in the ESWT group received 300 + 100/cm(2 ) impulses of shockwave at 0.11 mJ/cm(2 ) energy flux density every 2 wk for 6 wk , whereas patients in the HBO group received HBO daily for 20 treatments . The evaluations included clinical assessment of the ulcers with photo-documentation , blood flow perfusion scan , bacteriological examination , histological study , and immunohistochemical analysis . RESULTS The overall results showed completely healed in 31 % , improved in 58 % , and unchanged in 11 % for the ESWT group and 22 % completely healed , 50 % improved , and 28 % unchanged for the HBO group . The ESWT group showed significantly better clinical results and local blood flow perfusion , higher cell concentration , and activity than the HBO group . On immunohistochemical analysis , the ESWT group demonstrated significant increases in endothelial nitric oxide synthase , vessel endothelial growth factor , and proliferation cell nuclear antigen expressions and a decrease in transference-mediated digoxigenin-deoxy-UTP nick end-labeling expression than the HBO group . CONCLUSIONS ESWT appears to be more effective than HBO in chronic diabetic foot ulcers BACKGROUND Intermittent claudication is the most common symptom of peripheral arterial disease . Previous research has suggested that extracorporeal shockwave therapy ( ESWT ) may induce angiogenesis in treated tissue . The objective of this feasibility pilot trial was to assess the safety , tolerability , and efficacy of ESWT as a novel treatment . METHODS Patients with unilateral claudication were r and omized to receive ESWT or sham treatment to the calf muscle three times per week for 3 weeks . Primary outcomes were pain-free walking distance ( PFWD ) and maximum walking distance ( MWD ) . Secondary outcomes included safety and tolerability of ESWT treatment , ankle-brachial index before and after exercise , and quality of life assessed using generic ( 36-Item Short Form Health Survey , EuroQol-5 Dimension 3-Level ) and disease-specific ( Vascular Quality of Life ) instruments . Participants were assessed at baseline and 4 , 8 , and 12 weeks after treatment . Feasibility outcomes included recruitment and attendance rates for treatment and follow-up . RESULTS Thirty patients were recruited in total . Statistically significant ( P < .05 ) improvements at all time points were observed in the active treatment group for both MWD and PFWD compared with the sham treatment group . PFWD improved by 276 % in the active group and MWD improved by 167 % in the active group at 12 weeks after treatment . There were no immediate or delayed treatment safety concerns or documented adverse effects of treatment with ESWT in this trial . CONCLUSIONS ESWT is safe and well tolerated when it is applied to the calf and demonstrated significant improvements in walking distances . Current conservative management of intermittent claudication includes supervised exercise . The early results with ESWT as an alternative , noninvasive treatment option show great potential . The mechanism of action , durability of the clinical effect , and cost-effectiveness of ESWT for claudication require further investigation Objective : The Society for Vascular Surgery Wound , Ischemia , and foot Infection ( WIfI ) threatened limb classification has been shown to correlate well with risk of major amputation and time to wound healing in heterogeneous diabetic and nondiabetic population s. Major amputation continues to plague the most severe stage 4 WIfI patients , with 1‐year amputation rates of 20 % to 64 % . Our aim was to determine the association between WIfI stage and wound healing and major amputation among patients with diabetic foot ulcers ( DFUs ) treated in a multidisciplinary setting . Methods : All patients presenting to our multidisciplinary DFU clinic from July 2012 to December 2015 were enrolled in a prospect i ve data base . Wound healing and major amputation were compared for patients stratified by WIfI classification . Results : There were 217 DFU patients with 439 wounds ( mean age , 58.3 ± 0.8 years ; 58 % male , 63 % black ) enrolled , including 28 % WIfI stage 1 , 11 % stage 2 , 33 % stage 3 , and 28 % stage 4 . Peripheral arterial disease and dialysis were more common in patients with advanced ( stage 3 or 4 ) wounds ( P ≤ .05 ) . Demographics of the patients , socioeconomic status , and comorbidities were otherwise similar between groups . There was a significant increase in the number of active wounds per limb at presentation with increasing WIfI stage ( stage 1 , 1.1 ± 0.1 ; stage 4 , 1.4 ± 0.1 ; P = .03 ) . Mean wound area ( stage 1 , 2.6 ± 0.6 cm2 ; stage 4 , 15.3 ± 2.8 cm2 ) and depth ( stage 1 , 0.2 ± 0.0 cm ; stage 4 , 0.8 ± 0.1 cm ) also increased progressively with increasing wound stage ( P < .001 ) . Minor amputations ( stage 1 , 18 % ; stage 4 , 56 % ) and revascularizations ( stage 1 , 6 % ; stage 4 , 55 % ) were more common with increasing WIfI stage ( P < .001 ) . On Kaplan‐Meier analysis , WIfI classification was predictive of wound healing ( P < .001 ) but not of major amputation ( P = .99 ) . For stage 4 wounds , the mean wound healing time was 190 ± 17 days , and risk of major amputation at 1 year was 5.7 % ± 3.2 % . Conclusions : Among patients with DFU , the WIfI classification system correlated well with wound healing but was not associated with risk of major amputation at 1 year . Although further prospect i ve research is warranted , our results suggest that use of a multidisciplinary approach for DFUs may augment healing time and reduce amputation risk compared with previously published historical controls of st and ard wound care among patients with advanced stage 4 disease OBJECTIVE To investigate the efficacy of extracorporeal shockwave therapy ( ESWT ) on healing  chronic diabetic foot ulcers ( DFU ) . METHOD Patients with chronic DFUs were r and omised ( 1:1 ) to receive a series of six ESWT treatments over 3 weeks in combination with st and ard care or st and ard care alone . ESWT was performed on DFUs using 250 shocks/cm2 and 500 shocks on arterial beds supplying the ulcer location . RESULTS We recruited 23 patients , 11 in the intervention group and 12 in the control .  Transcutaneous oxygen tension was significantly increased in patients treated with ESWT compared with those receiving st and ard care alone at 3 weeks ( p=0.044 ) . Ulcer area reduction was 34.5 % in the intervention group versus 5.6 % in the control group at 7 weeks ( p=0.387 ) . Within-group analysis revealed a significant reduction of ulcer area in the intervention group ( p<0.01 ) , while healing was not demonstrated in the control group ( p>0.05 ) ( data tested for trend ) . CONCLUSION This r and omised study indicates a potential beneficial effect of ESWT on ulcer healing as well as tissue oxygenation . Owing to weaknesses of the study and the fact that ulcer healing was not significantly improved in the intervention group compared with the control group , a larger r and omised trial with blinded design is suggested AIM To identify any significant differences in physiological test results between healing and non healing amputation sites . METHODS A single center prospect i ve non-experimental study design was conducted on fifty subjects living with type 2 diabetes and requiring a forefoot or toe amputation . Subjects underwent non-invasive physiological testing preoperatively . These included assessment of pedal pulses , preoperative arterial spectral waveforms at the ankle , absolute toe pressures , toe-brachial pressure index and ankle-brachial pressure index . After 6 weeks , patients were examined to assess whether the amputation site was completely healed , was healing , had developed complications , or did not heal . RESULTS There was no significant difference in ABPI  between the healed/healing and the non-healing groups .  Mean TBI ( p=0.031 ) and toe pressure readings ( p=0.014 ) were significantly higher in the healed/healing group compared to the non healing group . A significant difference was also found in ankle spectral waveforms between the two groups ( p=0.028 ) . CONCLUSIONS TBIs , toe pressures and spectral waveforms at the ankle are better predictors of likelihood of healing and non-healing after minor amputation than ABPIs . ABPI alone is a poor indicator of the likelihood of healing of minor amputations and should not be relied on to determine need for revascularization procedures before minor amputation 
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There was variable evidence of effect on the blood flow perfusion rate .
This systematic review concludes that ESWT has the potential to improve healing in DFUs , although there is , as yet , insufficient evidence to justify its use in routine clinical practice .