Extracorporeal Shockwave Therapy

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Original Editor - Ayushi Tomer

Top Contributors - Cindy John-Chu, Sue Safadi, Amanda Ager, Ayushi Tomer, Kim Jackson and Carina Therese Magtibay  

History of Extracorporeal Shockwave Therapy[edit | edit source]

Extracorporeal Shockwave Therapy (ESWT) otherwise referred to as shockwave therapy, was first introduced into clinical practice in 1982 for the management of urologic conditions [1]. The success of this technology for the treatment of urinary stones quickly made it a first-line, noninvasive, and effective method [2]. Subsequently, ESWT was studied in orthopedics where it was identified that it could loosen the cement in total hip arthroplasty revisions[3]. Further, animal studies conducted in the 1980s revealed that ESWT could augment the bone-cement interface, enhance osteogenic response and improve fracture healing [4][5]. While shockwave therapy has been shown to be beneficial in fracture healing, most orthopedic research has focused on upper and lower extremity tendinopathies, fasciopathies, and soft tissue conditions.

Physiology of ESWT[edit | edit source]

Shockwaves are sound waves that have specific physical characteristics, including nonlinearity, high peak pressure followed by low tensile amplitude, short rise time, and short duration (10 ms). They have a single pulse, a wide frequency range (0-20 MHz), and a high pressure amplitude (0-120 MPa)

These characteristics produce a positive and negative phase of shockwave. The positive phase produces direct mechanical forces, whereas the negative phase generates cavitation and gas bubbles that subsequently implode at high speeds, generating a second wave of shockwaves.[6]

In comparison to ultrasound waves, the shockwave peak pressure is approximately 1000 times greater than the peak pressure of an ultrasound wave.[7]

Mechanism of Action[edit | edit source]

The effects of ESWT treatment are unknown[8]. However, the proposed mechanisms of action for ESWT include the following: promote neovascularization at the tendon-bone junction [9], stimulate proliferation of tenocytes [10] and osteoprogenitor differentiation [11], increase leukocyte infiltration [12], and amplify growth factor and protein synthesis to stimulate collagen synthesis and tissue remodeling [10] [11] [13] [14].

Principles of Shockwave Therapy[edit | edit source]

  • Extracorporeal Shock Wave Therapy.png

Shockwaves are transient pressure disturbances that propagate rapidly in three-dimensional space. They are associated with a sudden rise from ambient pressure to their maximum pressure. Significant tissue effects include cavitation, which are consequent to the negative phase of the wave propagation.

  • Electromagnetic shock.png

Direct shockwave and indirect cavitation effects cause hematoma formation and focal cell death, which then stimulate new bone or tissue formation.

Indications for Shockwave Therapy[edit | edit source]

Shockwave therapy is primarily used in the treatment of common musculoskeletal conditions. These include:

  • Upper and lower extremity tendinopathies
  • Greater trochanteric pain syndrome
  • Medial tibial stress syndrome
  • Patellar tendinopathy
  • Plantar fasciopathy.
  • Adhesive capsulitis[15]
  • Non-unon of long bone fracture
  • Avascular necrosis of femoral head[7]
  • Osteoarthritis of the knee[16]

There is no standardized ESWT protocol for the treatment of musculoskeletal conditions.

Contraindications[17][edit | edit source]

  1. Acute urinary tract infection urosepsis,
  2. Renal cancer.
  3. Obstruction distal to the stone.
  4. Life-threatening cardiac problems.
  5. Uncorrected coagulation abnormalities.
  6. Active pyelonephritis.
  7. Pathological changes, or an aneurysm.
  8. Malformations of the kidney,
  9. Renal insufficiency,
  10. Hypertension
  11. Spinal deformities and a compromised mental status of the patient, and the inability to cooperate.

Evidence-based[edit | edit source]

According to a study performed by Rompe and coworkers[18], stretching exercises in combination with radial shock wave therapy is more efficient for the treatment of chronic symptoms of proximal plantar fasciopathy than repetitive radial pressure wave therapy alone. Patients were subjected to three sessions of 2000 radial pressure pulses (EFD = 0.16 mJ/mm 2) in weekly intervals, generated with a ballistic device (air compressor pressure 4 bar; rate 8 Hz) manufactured by Electro Medical Systems.

  • Tendinopathy of the Shoulder.png

A study to investigate the clinical outcomes of ESWT on calcaneal spurs of 108 patients and its correlation with radiologic changes were reported by Yalcin et al. [19]. All the patients underwent radial pressure wave therapy once a week for 5 weeks (2000 pressure waves starting at an EFD of 0.05 mJ/mm 2 and increasing up to 0.4 mJ/mm 2). After the therapy, approximately 67 % of the patients reported no pain; however, there was no correlation between clinical outcome and radiologic changes. The authors concluded that even without radiologic change.

Resources[edit | edit source]

[20]

References[edit | edit source]

  1. ↑ Chaussy C, Schmiedt E, Jocham D, Brendel W, Forssmann B, Walther V. First clinical experience with extracorporeally induced destruction of kidney stones by shock waves. Jour Urol 1982;127: 417-420
  2. ↑ Argyropoulos AN, Tolley DA. Optimizing shock wave lithotripsy in the 21st century. Eur Urol 2007; 52: 344-352
  3. ↑ Park SH, Park JB, Weinstein JN, Loening S. Application of extracorporeal shock wave lithotripter (ECSWL) in orthopedics. I. Foundations and overview. J Appl Biomater 1991; 2:115-126
  4. ↑ Weinstein JN, Oster DM, Park JB, Park SH, Loening S. The effect of the extracorporeal shock wave lithotriptor on the bone-cement interface in dogs. Clin Orthop Relat Res 1988; 235:261-267.
  5. ↑ Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M. Influence of shock waves on fracture healing. Urology 1992; 39: 529-532
  6. ↑ van der Worp H, van den Akker-Scheek I, van Schie H, Zwerver J. ESWT for tendinopathy: Technology and clinical implications. Knee Surg Sports Traumatol Arthrosc 2013; 21:1451-1458
  7. ↑ 7.0 7.1 Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res 2012; 7:11
  8. ↑ Reilly JM, Bluman E, Tenforde AS. Narrative Review on the Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions PMR 2018; 10(12): 1385-1403.
  9. ↑ Wang CJ, Huang HY, Pai CH. Shockwave-enhanced neovascularization at the tendon-bone junction: An experiment in dogs. J Foot Ankle Surg 2002; 41:16-22
  10. ↑ 10.0 10.1 Chen YJ, Wang CJ, Yang KD, et al. Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression J Orthop Res 2004; 22: 854-861
  11. ↑ 11.0 11.1 Wang FS, Yang KD, Chen RF, Wang CJ, Sheen-Chen SM. Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-beta. J Bone Joint Surg Br 2002; 84: 457-46.
  12. ↑ Rompe JD, Kirkpatrick CJ, Kullmer K, Schwitalle M, Krischek O. Dose-related effects of shock waves on rabbit tendo Achillis. A sonographic and histological study. J Bone Joint Surg Br 1998; 80: 546-552.
  13. ↑ G. Bosch, Y.L. Lin, H.T. van Schie, C.H. van De Lest, A. Barneveld, P.R. van Weeren Effect of extracorporeal shock wave therapy on the biochemical composition and metabolic activity of tenocytes in normal tendinous structures in ponies Equine Vet J, 39 (2007), pp. 226-231
  14. ↑ C.M. Waugh, D. Morrissey, E. Jones, G.P. Riley, H. Langberg, H.R. Screen In vivo biological response to extracorporeal shockwave therapy in human tendinopathy Eur Cell Mater, 29 (2015), pp. 268-280
  15. ↑ Vahdatpour B, Taheri P, Zwre Zade A, Moradian S. Efficacy of Extracorporeal Shockwave Therapy in Frozen Shoulder. International Journal of Preventive Medicine 2014; 5(7): 875-881
  16. ↑ Wang CJ, Ko JY, Weng LH, Wang JW, Chen JM, Sun YC, Yang YJ. Extracorporeal Shockwave Shows Regression of Osteoarthritis of the Knee in Rats. J Surg Res. 2011; 171(2): 601-608.
  17. ↑ Chaussy C, Tailly G, Forssmann B, Bohris C, Lutz A, Tailly-Cusse M, Tailly T. Extracorporeal shock wave lithotripsy in a nutshell. Booklet presented to European Association of Urology. 2013.
  18. ↑ Rompe JD, Furia J, Cacchio A, Schmitz C, Maffulli N. Radial shock wave treatment alone is less efficient than radial shock wave treatment combined with tissue-specific plantar fascia-stretching in patients with chronic plantar heel pain. International Journal of Surgery. 2015 Dec 1;24:135-42.
  19. ↑ Ogden JA, Tóth-Kischkat A, Schultheiss R. Principles of shock wave therapy. Clinical Orthopaedics and Related Research (1976-2007). 2001 Jun 1;387:8-17.
  20. ↑ Langmore Podiatry. Shockwave Therapy Demonstration. Available from: https://www.youtube.com/watch?v=P5dibaAu7pQ [last accessed 6/17/2018]
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