Ứng dụng trong việc điều trị nhức cơ xương khớp của sóng xung kích Shockwave therapy in musculoskeletal treatment

Shockwave therapy in musculoskeletal treatmentMgr. Ondrej ProuzaPhysiotherapist BTL medical consultant Shockwave therapy Ondrej Prouza2Shockwave therapy contentsContents of presentation:Shockwave Therapy– physical principles technologyShockwave Therapy – medical backgroundShockwave Therapy clinical demoShockwave therapy Ondrej Prouza33Biophysical backgroundShockwave therapy Ondrej Prouza44Shockwave therapy Ondrej Prouza5Shock wave is atransient acoustic waveUnique opportunity to transmit high energy for longdistancesFirst observation – Second World WarFirst technicalinterest in 1966 Dornier Aircraft Labs5Biophysical backgroundShockwave therapy Ondrej Prouza66Picture by Shriwastava, J.Biosci., March2005Shockwave therapy Ondrej Prouza7Shockwaves in medicineShockwave is an acoustic wave which carries its´ high energy to the painful spotand provokes healing and repair processesMain fields of application: OrthopedicsRehabilitationSport medicineOther veterinary, aesthetics, urology, dermatology Most common applications:Shoulder tendonitisAchillodyniaHeel spur calcar calcanei Lateral epicondylitisShockwave therapy Ondrej Prouza8Terminology Low energyshockwaveRadial shockwavetherapyPressure pulsetherapyAcoustic wavetherapy All refer to onetherapy defined by: Shape of the pulse Energy1 5 bar = 0.15–0.47 mJmm2EFDShockwave therapy Ondrej Prouza9Energy Flux Density vs Pressure in BarsEnergy flux density00,050,10,150,20,250,30,350,40,450,51,5 2 2,5 3 3,5 4 4,5 5Pressure (Ba r)Energy fl ux densi ty (mJ mm2)15 m m fo ku s9 m m m u ltifo kus15 m m m u ltifoku sShockwave therapy Ondrej Prouza10SWT TECHNOLOGIESShockwave therapy Ondrej Prouza11 1985 Extracorporeal Shock Wave LithotripsyESWL kidney stones disintegration11The beginnings..Shockwave therapy Ondrej Prouza12121990 First applications inmusculoskeletal apparatus1999 – Radial schockwaveprinciple introduced2011: more than 1000 clinical studieswidely accepted therapy in rehabilitation orthopaedicsurgeryEmerging new fieldsclinical indications1993 1997 TODAYFrom history to presentShockwave therapy Ondrej Prouza13SHOCKWAVE TECHNOLOGIESShockwave therapy Ondrej Prouza1414Radial = BTL pneumatic principle Focused:Electrohydraulic principle Electromagnetic principle Piezoelectric principleRadial vs. Focused principleShockwave therapy Ondrej Prouza15Radial vs Focused devices•Differences in size, cost per therapy and treatment and in the procedure..•Both the same shape of the pulse and clinicall effect when equal energies are usedShockwave therapy Ondrej Prouza16Radial vs focused principleRadial: • Designed for superficial treatment• Clinically focused• No anesthesia, no analgesics• Higher comfortof the therapy• Low costs of the unit = faster reimburstmentFocused:• Developed to reach internal organs• Xray or ultrasoundguided• Anesthesia necessary• Costs per unit, treatmentShockwave therapy Ondrej Prouza17More of terminologyESWT vs. RSWT• ESWT=Extracorporeal Shockwave therapy= applied outside of the body, treatment of musculoskeletal apparatus• RSWT=Radial Shockwave therapy • RSWT is ESWTShockwave therapy Ondrej Prouza18Radial, pneumatic principleby BTLProjectileisaccelerated by high pressure pulse Hits the transmiter, emits the SWSemifocused, focused and trigger tip18Radial Shockwave DevicesApplicators Transmitters:• 9 mm – for acupuncture points and for more accurate applications (finger joints)• 15 mm – universal transmitter for all applications• Focused 15 mm – for more targeted applications ( deep trigger points)Shockwave therapy Ondrej Prouza20Shockwave energy What energy is still meaningful?Litothriptors, HE focused shockwaves, radial acoustic waves :Shockwave therapy Ondrej Prouza21SHOCKWAVE THERAPY – BIOLOGICAL EFFECTSShockwave therapy Ondrej Prouza2223ESWT – effects generally Tissue regeneration and repairNeovascularization and angiogenesisAnalgesia, myorelaxationCalcific deposits reabsorptionShockwave therapy Ondrej Prouza23Promptand longlasting analgesic effect Extracorporeal shockwaves induce the expression of ATF3 and GAP43 genes in rat dorsal root ganglion neuronsMurata et al., Auton.Neurosci.,2006Initiation and acceleration of tendon healing process involving collagen and glycosamino glycan GAGproduction.Significant increase in degraded collagen and GAGlevels shortly after treatment. After 6 weeks, metabolism Decreased significantly as GAG levels were lower than in untreated controls. Bosch et al., EquineVet J., 200724SHOCKWAVE THERAPY – BIOLOGICAL EFFECTS I.Shockwave therapy Ondrej Prouza24Stimulation of local metabolism, neovascularisation, osteogenesis and bone remodellingIn adult hip necrosis, significant increase in vWF, platelet endothelial cell adhesion molecule, VEGF, proliferation cell nuclear antigen PCNA levels was observed in patients undergoing SWT prior to total hip arthroplasty.Wang et al., Rheumatology,2004Resorption of calcium depositscaused by tensile part of shockwave Cosentino R et al., Ann Rheum Dis, 200325SHOCKWAVE THERAPY – BIOLOGICAL EFFECTS II. Shockwave therapy Ondrej Prouza25ESWT – Biological mechanism in the tissue Wang 2005Shockwave therapy Ondrej Prouza26 27Immediate effectsLocal increase of microcirculation Immediate myorelaxationImmediate and strong analgesiaESWT Effects on the Tissue I.Shockwave therapy Ondrej Prouza27 28„Shockwave effects“Stimulation of activity of osteoblasts– increase of osteogenesisStimulation of production of collagen by fibroblasts acceleration of healing processesLigament and bone neovascularizationESWT Effects on the Tissue II.Shockwave therapy Ondrej Prouza28 29Analgesia how does it act?inhibition of spasminhibition of nociceptive fibres Gate mechanismendorfines and serotonine releaseacceleration of substance PwashoutESWT Effects on the Tissue III.Substance P: excitation mediator, stimulates nociceptive nervous fibres, supports resorption of oedema andsecretion of histamineantiinflammatory effects of swtShockwave therapy Ondrej Prouza29Repair of the mechanical destruction caused by shockwave „hammer“ or just startup of healing processes?Mechanical model„ minor mechanical destruction causes repair reactions“Biomechanical modelShockwave therapy and healing – the conceptShockwave therapy Ondrej Prouza30Shockwaves in the cell mechanotransductionCells sensetheir physical surroundings through mechanotransduction=translating mechanical forces into biochemical signalssuch aschanges in intracellular calcium concentration or by activating diverse signalling pathways.In turn, these signals adjust cellularand extracellular structure.This mechanosensitive feedback modulates cellular functionsas diverse as migration, proliferation, differentiation and apoptosis, a thoughcrucial for organ development and homeostasis.Mechanotransduction gone awry Diana E. Jaalouk and Jan Lammerding, 2009Shockwave therapy Ondrej Prouza31SHOCKWAVES IN THE TISSUEWhat cell are involved in this reaction?Specific cells activation: Neovascularization pericytes Osteoblasts osteogenesis Fibroblasts collagen productionSupported by vasodilatationShockwave therapy Ondrej Prouza32SWT effects on tissue WANG 2005 Shockwave therapy Ondrej Prouza33 34Most Frequent Indications?Pain in muscles, insertions, TendonsGroin pain AchillodyniaBack painPlantar fascitis Patellar tendinopathy jumper´s kneeEpicondylitis tennis elbowCalcificationsHeel spur (calcar calcanei)Tendinosis calcarea Long tendon ofbiceps calcificationShockwave therapy Ondrej Prouza34Shoulder tendonitis – Xray documentation Moreover, efficacyof ESWT in calcifying shoulder tendonitis was proved in 70% patients Cosentino R et al., Ann Rheum Dis, 200335Shockwave therapy Ondrej Prouza3536Before treatmentAfter 3 SWT sessions, 1500 pulses at 3 bars per session Impingement sy Xray proved calcification–clinical example Shockwave therapy Ondrej Prouza36 37Trigger points treatmentFrozen shouldersyndromeCoxarthrosis, gonarthrosisArthrosis of small finger jointsMuscle spasticityAcupuncturepoints stimulationScarsMOST FREQUENT INDICATIONS II.Shockwave therapy Ondrej Prouza37Unusuall clinical experience6 moths old forefinger extensors incision injuryrigid and prominent scar tissuefirst IP joint fixedin 30° flexion position4SWT applications with 2.5 Bars intensity the scar reformed, ROM full extensionand 100° flexion Shockwave therapy Ondrej Prouza38Shockwaves in sports medicineWhat are the greatest deals of sports medicine?Quick recovery and fast returnto sport activity and training Symptoms asociated with injury – pain, swelling, muscle spasm Shockwave therapy Ondrej Prouza39Shockwaves in sports medicineWhat is the main effectivity of shockwaves?Pain relief Muscle relaxationLocal microcirculation increaseHealingprocesses enhancement and speedingShockwave therapy Ondrej Prouza40Sports medicine most frequent indicationsThree indication groups, is SWT for all?Chronic pain and overuse syndromesAcute pain minor injuriesback pain, muscle distensions, minor ruptures Serious injuriescomplete ruptures, fractures Shockwave therapy Ondrej Prouza41Shockwaves in sport – new indications I.„Overuse“, chronic subacute disordersEpicondilitisJumper´s kneeAchillodyniaChronic back painShoulder tendinitisHuge variety depending on the type of sports activityUnique efficiencyShockwave therapy Ondrej Prouza42Shockwaves in sport – new indications II. Acute injuries or postsurgicalstatusesMuscle and tendon strains– distensions and partial rupturesLigaments sprains– distorsionsAcute vertebrae blockageRegeneration support Postsurgical or post imobilization healingenhancement Shockwave therapy Ondrej Prouza43CLINICAL EXPERIENCE – MUSCLE RUPTURE AFTER ESWT THERAPY Acute muscle rupturetreated with ESWT (1st, 7th and 14th day)Shockwave therapy Ondrej Prouza44Shockwaves in sport – therapeutic procedureSupport with other available therapies – healing and antioedematory effectLaserafter and between the sessions Lymphatic drainageThermopositive therapyMagnetotherapy maximum frequency of the sessions UltrasoundElectronalgesiaCryotherapy or spa proceduresShockwave therapy Ondrej Prouza45Emerging fields otherDermatology, Aesthetics: CelluliteScarsDiabetic ulcersUrology, veterinaryShockwave therapy Ondrej Prouza46SWT IN SPASTICITY TREATMENTOnose, T. EXTRACORPOREAL SHOCKWAVE THERAPY FOR SPASTICITY MANAGEMENT, IN CHILDREN WITH CEREBRAL PALSY,2010Servodio F,et Al. Unfocused shock wave therapy for focal spasticity in the infantile cerebral palsy:Evaluation of results through computerised gait , 2008Amelio E, Mangnotti P Effect of Extracorporeal Shock Wave Therapy on Spastic Hypertonia “7th International Symposium on Experimental Spinal Cord Repair and Regeneration”, Brescia, Italia, 2009SWT can decrease all types of muscle hypertoniaLocal muscle hypertonus or spasmPartial hypertonus – TrpMuscular spasticitycaused by neurological disorderShockwave therapy Ondrej Prouza47SWT SUMMARYChronicor semichronic conditions – non comparable resultsMuscle, soft tissue and bone healing process startupNo harm of the tissue, only anabolic processes provedLongterm followup efficiency about 7080%in main indications36 sessionsusually maximumNecessary to follow regimen restrictions and contraindicationsAlternative to surgeryShockwave therapy Ondrej Prouza48SWT AND OTHER CLINICAL MODALITIES Shockwave therapy Ondrej Prouza49Reduction of side effects and support of desired clinical resultLaser therapy– more intense healing support in chronic inflammationElectrotherapy– to support analgesic effectLymphatic drainage– sports medicine – regeneration and oedema removalMagnetotherapy – acceleration of bone and cartilage healingSWT AND OTHER CLINICAL MODALITIES Shockwave therapy Ondrej Prouza50Synergic Effect of SWT Laser CombinationBiostimulation– physiologically different supportive effect of SWT Antiswelling and anti–inflammatoryeffect support of healing dg associated with inflammation to reduce possible side effects of SWT = shorter interval between sesions : 45 daysRevascularization= both effects of SWT and laser Shockwave therapy Ondrej Prouza51Rest therapy after treatment? Stretching and postisometrical relaxation during or immediately after treatmentInstruct patient to do stretching and postisometrical relaxationbetween sessions i.e. elbow tendinopathiesActive training up to 40% of the muscle capacity, starting from 2nd dayRegional stabilization and dysbalance correctionsSWT AND OTHER CLINICAL MODALITIES – ACTIVE TRAININGShockwave therapy Ondrej Prouza52RELATIVESkindefects– relative, some studies show improvement i.e. in DM ulcerTBCTumordiseases Fever, flu or other infectious diseaseApplication in the area of varicesApplication just above the nerve Application on certain tissues (eyes and periorbital area, myocardium, spinal cord, gonads, kidneys, liver)53CONTRAINDICATIONS OF ESWT Shockwave therapy Ondrej Prouza53CONTRAINDICATIONS OF ESWT Application of therapeutic X rays within last 6 weeksPharmacotherapy by corticosteroids within last 6 weeksSensational deficite in the treated areaDisc hernia or protrusion ABSOLUTEBlood coagulation disorders, anticoagulation treatmentPregnancyAbdominal or frontal pelvic applicationShockwave therapy Ondrej Prouza54 55Possible Temporary Side EffectsTemporary hyperhypo sensitivityErythemaPetechiaHaematomaOedemaMost of the patients never experience any of these side effectsCan be maximally reduced in combination with other therapies e.g. Lasertherapy, magnetotherapyShockwave therapy Ondrej Prouza55DISCUSSION

Shockwave therapy in musculoskeletal

treatment

Mgr Ondrej Prouza

Physiotherapist & BTL medical consultant

Shockwave therapy - contents

Contents of presentation:

Shockwave Therapy– physical

principles & technology

Shockwave Therapy – medical

background

Shockwave Therapy - clinical demo

Biophysical background

Shock wave is a transient acoustic wave

Unique opportunity to transmit high energy for long

distances First observation – Second World War First technical interest in 1966 Dornier Aircraft Labs

Biophysical background

Shockwaves in medicine

Shockwave is an acoustic wave acoustic wave which carries its´ high energy to the painful spot and provokes

healing and repair processes

Main fields of application:

Orthopedics

Rehabilitation

Sport medicine

Other /veterinary, aesthetics, urology, dermatology /

Most common applications:

Shoulder tendonitis

Achillodynia

Heel spur /calcar calcanei/

Lateral epicondylitis

Terminology

Low energy shockwave Radial shockwave therapy Pressure pulse therapy

Acoustic wave therapy

All refer to one therapy defined by:

 Shape of the pulse

 Energy 1 - 5 bar = 0.15–0.47

mJ/mm 2 EFD

Energy Flux Density vs Pressure in Bars

Energy flux density

SWT - TECHNOLOGIES

 1985 Extracorporeal Shock Wave Lithotripsy /ESWL/ -

kidney stones disintegration

The beginnings

1990 - First applications in musculoskeletal apparatus

1999 – Radial schockwave principle introduced

2011:

more than 1000 clinical studies

widely accepted therapy in rehabilitation &

orthopaedic surgery

Emerging new fields&clinical indications

From history to present

SHOCKWAVE TECHNOLOGIES

Radial = BTL pneumatic principle

Radial vs Focused devices

•Differences in size, cost per therapy and treatment

and in the procedure

•Both the same shape of the pulse and clinicall effect when equal energies are used!

Radial vs focused principle

Radial:

• Designed for superficial treatment

• Clinically focused

• No anesthesia, no analgesics

• Higher comfort of the therapy

• Low costs of the unit = faster reimburstment

Focused:

• Developed to reach internal organs

• X-ray or ultrasound guided

• Anesthesia necessary

• Costs per unit, treatment

More of terminology

ESWT vs RSWT

• ESWT=Extracorporeal Shockwave therapy=

applied outside of the body, treatment of

musculoskeletal apparatus

• RSWT=Radial Shockwave therapy

• RSWT is ESWT!!!

Radial, pneumatic principle by BTL

Projectile is accelerated by high

-pressure pulse

Hits the transmiter, emits the SW

Semi-focused, focused and trigger tip

Radial Shockwave Devices

Applicators-

Transmitters:

• 9 mm – for acupuncture

points and for more accurate

applications (finger joints)

• 15 mm – universal

transmitter for all applications

• Focused 15 mm – for more

targeted applications ( deep

trigger points)

Shockwave energy

What energy is still meaningful?

Litothriptors, HE focused shockwaves,

radial acoustic waves :

SHOCKWAVE THERAPY –

BIOLOGICAL EFFECTS

ESWT – effects generally

Tissue regeneration and repair

Neovascularization and angiogenesis

Analgesia, myorelaxation

Calcific deposits reabsorption

Prompt and longlasting analgesic effect

Extracorporeal shockwaves induce the expression of ATF3

and GAP-43 genes in rat dorsal root ganglion neurons

Murata et al., Auton.Neurosci.,2006

Initiation and acceleration of tendon healing

process involving collagen and

glycosamino- glycan /GAG/ production.

Significant increase in degraded collagen and GAG

levels shortly after treatment After 6 weeks, metabolism

Decreased significantly as GAG levels were lower than in

untreated controls

Bosch et al., EquineVet J., 2007

SHOCKWAVE THERAPY – BIOLOGICAL EFFECTS I.

Stimulation of local metabolism,

neovascularisation, osteogenesis and bone

remodelling

In adult hip necrosis, significant increase in vWF, platelet endothelial

cell adhesion molecule, VEGF, proliferation cell nuclear antigen

/PCNA/ levels was observed in patients undergoing SWT prior to total

hip arthroplasty.

Wang et al., Rheumatology,2004

Resorption of calcium deposits caused by

tensile part of shockwave

Cosentino R et al., Ann Rheum Dis, 2003

SHOCKWAVE THERAPY – BIOLOGICAL EFFECTS II

ESWT – Biological mechanism in the tissue

„Shockwave effects“

Stimulation of activity of osteoblasts – increase

of osteogenesis

Stimulation of production of collagen by

fibroblasts- acceleration of healing processes

Ligament and bone neovascularization

ESWT Effects on the Tissue II.

Analgesia- how does it act?

inhibition of spasm

inhibition of nociceptive fibres - Gate

mechanism

endorfines and serotonine release

acceleration of substance P washout

ESWT Effects on the Tissue III.

*Substance P:

excitation mediator, stimulates nociceptive nervous fibres,

supports resorption of oedema and

secretion of anti-inflammatory effects

histamine-of swt

Repair of the mechanical destruction

caused by shockwave „hammer“ or just

start-up of healing processes?

Mechanical model „ minor

mechanical destruction causes

repair reactions“

Biomechanical model

Shockwave therapy and healing – the concept

Shockwaves in the cell - mechanotransduction

Cells sense their physical

surroundings through

mechano-transduction

= translating mechanical forces into

biochemical signals such as

changes in intracellular calcium

concentration or by activating diverse

signalling pathways.

In turn, these signals adjust

cellular and extracellular structure

This mechanosensitive feedback

modulates cellular functions as

diverse as migration, proliferation,

differentiation and apoptosis, a

though crucial for organ development

and homeostasis.

Mechanotransduction gone awry Diana E Jaalouk and Jan Lammerding, 2009

SHOCKWAVES IN THE TISSUE

What cell are involved in this

SWT effects on tissue

/ WANG 2005 /

Most Frequent Indications?

Pain in muscles, insertions,

Patellar tendinopathy - jumper´s knee

Epicondylitis - tennis elbow

Shoulder tendonitis – X-ray documentation

Moreover, efficacy of ESWT in calcifying

shoulder tendonitis was proved in 70%

patients

Cosentino R et al., Ann Rheum Dis,

2003

Before treatment After 3 SWT sessions, 1500

pulses at 3 bars per session

Impingement sy & X-ray proved calcification–clinical example

Trigger points treatment

Frozen shoulder syndrome

Unusuall clinical experience

6 moths old forefinger extensors incision injury

rigid and prominent scar tissue

first IP joint fixed in 30° flexion position

4 SWT applications with 2.5 Bars intensity the

scar reformed, ROM - full extension and 100°

flexion

Shockwaves in sports medicine

What are the greatest deals of sports

medicine?

Quick recovery and fast return to sport

activity and training

Symptoms asociated with injury – pain,

swelling, muscle spasm

Shockwaves in sports medicine

What is the main effectivity of

shockwaves?

Pain relief

Muscle relaxation

Local microcirculation increase

Healing processes enhancement and

speeding

Sports medicine most frequent indications

Three indication groups, is SWT for all?

Chronic pain and overuse syndromes

Acute pain & minor injuries /back pain,

muscle distensions, minor ruptures/

Serious injuries /complete ruptures,

fractures/

Shockwaves in sport – new indications I.

„Overuse“, chronic subacute disorders

Shockwaves in sport – new indications II

Acute injuries or post-surgical statuses

Muscle and tendon strains – distensions

and partial ruptures

Ligaments sprains – distorsions

Acute vertebrae blockage

Regeneration support

Post-surgical or post imobilization

healing enhancement

CLINICAL EXPERIENCE – MUSCLE RUPTURE AFTER ESWT THERAPY

Acute muscle

rupture treated with

ESWT (1st, 7th and

14th day)

Shockwaves in sport – therapeutic procedure

Support with other available therapies –

healing and anti-oedematory effect

 Laser /after and between the sessions/

Emerging fields - other

SWT IN SPASTICITY TREATMENT

Onose, T EXTRACORPOREAL SHOCKWAVE THERAPY FOR SPASTICITY

MANAGEMENT, IN CHILDREN WITH CEREBRAL PALSY, 2010

Servodio F,et Al Unfocused shock wave therapy for focal spasticity in the infantile

cerebral palsy: Evaluation of results through computerised gait , 2008

Amelio E, Mangnotti P Effect of Extracorporeal Shock Wave Therapy on Spastic

Hypertonia - “7th International Symposium on Experimental Spinal Cord Repair and

SWT can decrease all types of muscle

3-6 sessions usually maximum

Necessary to follow regimen restrictions and

contraindications!

Alternative to surgery

SWT AND OTHER CLINICAL

MODALITIES

Reduction of side effects and support of

desired clinical result

Laser therapy – more intense healing support in

chronic inflammation

Electrotherapy – to support analgesic effect

Lymphatic drainage – sports medicine –

regeneration and oedema removal

Magnetotherapy – acceleration of bone and

cartilage healing

SWT AND OTHER CLINICAL MODALITIES

Synergic Effect of SWT &

Laser Combination

Biostimulation – physiologically different

supportive effect of SWT

Antiswelling and anti–inflammatory effect

support of healing - dg associated with inflammation to reduce possible side effects of SWT = shorter interval

between sesions : 4-5 days Revascularization = both effects of SWT and

laser

Rest therapy after treatment?

Stretching and post-isometrical

relaxation during or immediately after

treatment

Instruct patient to do stretching and

post-isometrical relaxation between

sessions /i.e elbow tendinopathies/

Active training up to 40% of the muscle

capacity, starting from 2nd day

Regional stabilization and dysbalance

corrections

SWT AND OTHER CLINICAL MODALITIES – ACTIVE TRAINING

Shockwave therapy / Ondrej Prouza 52

RELATIVE

Skin defects – relative, some studies show

improvement i.e in DM ulcer

TBC

Tumor diseases

Fever, flu or other infectious disease

Application in the area of varices

Application just above the nerve

Application on certain tissues (eyes and periorbital area,

myocardium, spinal cord, gonads, kidneys, liver)

 Pharmacotherapy by corticosteroids within last 6 weeks

 Application of therapeutic X-rays within last 6 weeks

ABSOLUTE

53

CONTRAINDICATIONS

OF ESWT

CONTRAINDICATIONS OF ESWT

Application of therapeutic X - rays within last 6

weeks

Pharmacotherapy by corticosteroids within last

6 weeks

Sensational deficite in the treated area

Disc hernia or protrusion

Possible Temporary Side

Effects

Temporary hyper/hypo- sensitivity Erythema

Petechia Haematoma Oedema

Most of the patients never experience any of these side effects

Can be maximally reduced in combination with other

therapies e.g Lasertherapy, magnetotherapy

DISCUSSION