Kevin Jones Medical Services Director

MSK 2016Extra Corporeal Shockwave Therapy

Shock !

Some Examples Of A Shockwave

Atomic Bomb

Mathematician. Invented the WWII 1945 Atomic Bomb Defined the direct and indirect effect of shockwaves. Effect between compressed and undisturbed air. Object to be supersonic to create shockwave (Sonic)

768mph /343.2 m/s in air at sea level 20 centigrade.3316mph / 1482 m/s in water at 20 centigrade.

John Non Neumann 1945

History & Background

Dr Frank Rieber 1891-1948

1951

Yutkin et al 1950

Chaussy, Eisenberger & Forssman1974

In vitro and In Vivo Experiements

The Early HM1 1980

Human Model 3 1983

1951

Electrohydraulic HM1(1980) & HM3 (1983)

Piezoelectric Array Single & Dual

Electromagnetic Coil with Lens.

Electromagnetic Cylindrical Coil.

Types Of Shockwave Generator

Test stone

Renal ESWL

Latest Lithotripter

Dual Layer technology

MSK ESWT

ESWT Technology

Radial Pressure Devices

Radial Pressure Devices

Radial Pressure Properties

Focussed Shockwave Devices

Focussed Shockwave Properties

Plug & Play Transducers

Linear & Cylindrical Transducers

Penetration depth

The Piezo shockwave technology uses interchangeable gel pads which contact the patient to ensure that the shockwave penetrates precisely to the desired depth with as little scattering as possible. These gel pads are used as spacers andchange the penetration depth in increments of 5 mm.

Energy % v Depth

Ultrasound

Focussed Shockwave

Radial Pressure Wave

Biphasic Low bar pressure 0.5 bar

Up to 1000 times more pressure than ultrasound

Low to High Energy pressure Short duration Focussed and depths from skin

surface to 20cm.

Low energy pressure Superfical depth 5mm

ESWT Biological Effects

Mechanotransduction

Mechanical Stressors causing a biological effect

Increased fibroblast proliferation and Differentiation by activation of gene expression for transforming Growth factor TGF-1 with an effect on collagen type I & lll. Tenocytes are elongated fibroblast cells in tendons.

ESWTAngiogenesis Stage - Week 1 to 4 Certain healing expressions called eNOS , VEGF and PCNA all increase.

Revascularisation - PCNA Markers remain up to week 12. This period allows new blood vessels to be created and grow forming new tissue growth.

Important NOT to review patient outcomes until week 12. Effect continues up to 6 months.

ENOS - Endothelial Nitric Oxide SynthaseImportant cellular signalling molecule and involved with

angiogenesis.

VEGF – Vessel Endothelial Growth Factor is a signal protein responsible for new blood vessel formation and restoring oxygen supply to tissues.

PCNA - Proliferating Cell Nuclear Antigen is a protein that acts as a processivity factor for DNA polymerase ε in eukaryotic cells. Within the nucleus and involved with repair of DNA.

Inhibits inflammatory mediators such as COX II

Hyperstimulation of nerve endings, increasing analgesic effect (Melzak & Wall Gate control theory)

Substance P increase?

Increase in free radicals.

Other Biological Effects

Calcific Tendinitis of the shoulder 2003

Refractory Achilles Tendinopathy 2009

Refractory Plantar Fasciitis 2009

Refractory Lateral Epicondylitis 2009

Refractory Trochanteric Pain Syndrome 2011

NICE Approved ESWT Indications

Calcified Tendinitis of Shoulder

Achilles Tendinopathy

Plantar Fasciitis

Lateral Epicondyitis

Trochanteric Hip Syndrome

3 – 6 treatment sessions.

Frequency of treatment once every 1-2 weeks

2000 shockwaves

Energy flux density of 0.271-.331 mJ/mm2

Repetition rate 5-6 Hz

Depth of focus 10-40mm

Review at 3 months.

No Local anaesthetic

Proceed with physiotherapy/eccentric loading and Orthotics.

Treatment Protocol

Proceed with Loading/ stretching exercises

Patients not to take anti-inflammatories

No sport for 4 weeks

Use of orthotics should be encouraged

Inflammatory response seen about 2-3 days Post ESWT.

Post treatment patient care

Anticoagulant Therapy

Patients <18 years old

Patients had steroid injection <3 months.

Pregnancy

Focus to air filled such as lung fields and bowel.

Brain

Spinal cord

Full muscle/tendon ruptures (grade 3)

Localised malignancy.

Contraindications

Medial Epicondylitis

Infrapatellar Tendinitis

Medial Tibial stress syndrome

Popliteal tendinitis

Myofascia Pain Syndrome

Pseudathrosis

Myositis Ossificans (Little evidence)

Other Orthopaedic indications

Non or Delayed Union

Optimum focal energy for safety and efficacy.

Optimal focal area dependant on technology.

Shockwave repetition rate 5-6HZ Versus 15-20hz

Insertion plus trigger points causing referred pain

Patient positioning utilising limb Extension

Optimum number of treatment sessions

Therapy technique for transducer

Focussing upon correct area. Focussed v Radial

Clinical & Technical Considerations

Complications

A Study performed that included world wide literature on complications related to ESWT did not find any substantial adverse side effects from shockwave therapy (Siebert 1996)

More high quality level 1 research.

Greater understanding of the technical differences in technology and limitations

Heterogeneity of evidence

Greater Author understanding when writing papers regardless of type including Systematic reviews.

Papers need to be more pragmatic and include Operator dependency.

Evidence Issues

Renal Stones Pancreatic stones Peyronies Disease Erectile Dysfunction Diabetic Ulcers & Wound healing Spasticity Salivary tones Peripheral Arterial Disease. Pre surgical Conditioning Cellulite

Other Indications

ESWT For Wound Healing

July 30th 2014

September 10th 2014

October 17th 2014

ESWT for Wound Healing

Post Surgery Wound

Thank You