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Shock Wave Therapy

Shock Wave Therapy. Shock Wave Therapy: Objectives . Following completion of this lecture the student will be able to: Describe the mechanical characteristics of ESW. Identify musculoskeletal pathology that may benefit from ESWT.

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Shock Wave Therapy

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  1. Shock Wave Therapy

  2. Shock Wave Therapy: Objectives Following completion of this lecture the student will be able to: • Describe the mechanical characteristics of ESW. • Identify musculoskeletal pathology that may benefit from ESWT. • Discuss the biological effects of ESW on soft tissue and bone .

  3. Shock Wave Therapy: Outlines • Essential and History • Principle of Production • Characteristics of ESW &Energy production • Physiological Effects &Mechanism of Action • Clinical Applications • Adverse effects of ESW • Evidence-Base of ESWT

  4. ESWT: Essential and History • Therapeutic shockwave was first introduced into medicine over 30years ago for kidney stones . • Recently, ESW was used for musculoskeletal disorders in the early 1980's. • By the early 1990s, reports to start to appear in the journals and conference about use of ESW for soft-tissue problems. • Although becoming much more popular (especially in Europe and to some extent in the UK), it is still a relatively new technology for musculoskeletal intervention.

  5. ESWT: Definition • Shock-waveis an acoustic large-amplitude compression wave, which is made by high pressure peak, adjustable in a limited frequency range with on the wave side, the positive pressure increases in a short time follows at negative pressure.

  6. ESW: Characteristic The characteristics of a shock wave are: • HIGH Peak pressure typically ≈100MPa • 50-80MPa • 35 - 120MPa • Fast pressure rise (usually less than 10 ns • Short duration ≤10 microseconds • Narrow effective beam (2-8mm diameter) • Frequency range 16-20Hz • Pause of negativepressure

  7. ESW: Principles of Production • Four principle to generate ESW

  8. ESW: Comparison of different types

  9. Shock Wave : Principles of Production The amount of space over which the ESW induces therapeutic effects The amount of acoustic energy delivered in one SW pulse Measure of peak pulse energy within a focal volume Measure of the energy flux /square area (mm2)

  10. Shock Wave : Energy Flux Density LOW: Up to 0.08mJ/mm2 MEDIUM :Up to 0.28mJ/mm2 HIGH : > 0.28mJ/mm2 Rompe et al,1998

  11. Biological Physical ESW: Physiological Effects &Mechanism of Action Direct Indirect Mechanical

  12. Physical ESW: Physiological Effects &Mechanism of Action Mechanical Molecular ionization Increasing of membrane permeability.

  13. ESW: Physiological Effects &Mechanism of Action

  14. ESW: Physiological Effects &Mechanism of Action • 1-Mechanical stimulation • 2-Increased local blood flow • 3-Increase in cellular activity: release of • Substance P, • Prostaglandin E2 • NO, TGF β, VEGF, and inflammatory cytokines • 4-Transient analgesic effect on afferent nerves • 5-Break down calcific deposits (primarily, but not exclusively in tendon)

  15. ESW: Clinical Application Treatment Dose Issues • Applied energy (mJ/mm2) • Number of shocks • Number of treatment session repetitions

  16. ESW: Clinical Application Applied Energy • LOW (up to 0.08mJ/mm2) • MEDIUM (up to 0.28mJ/mm2 ) • HIGH (> 0.28mJ/mm2)

  17. ESW: Clinical Application Shock Number • Shock number usually between 1000 and 2000, • Some research has tried as few as 100-500 • 500 more effective than 100 • 1000-2000shocks/session is most commonly applied range

  18. ESW: Clinical Application Number of Treatment Sessions Some evidence for a single session BUT only for High level treatment – using local anesthesia – not physiotherapy. Most clinical research has used 3–5 sessions at low energy levels, for the majority of patients. There have been no RCT trials yet to determine the maximally effective therapy session number and interval (3days-3weeks).

  19. ESW: Clinical Application • Plantar fasciitis • Achilles tendinopathy • Patellar tendonipathy • Tennis and Golfers elbow (medial & lateral epicondylalgia) • Biceps tendinopathy • Supraspinatus tendinopathy • Trochanteric bursitis

  20. Orthopaedic indications for ESWT (2) Common extensor tendon Supraspinatus tendon Achilles tendon Plantar fascia Patella tendon

  21. Achilles Tendinopathy Achilles tendinopathy • Insertional: within 2 cm of its insertion. • Mid-substance: 2-6 cm proximal to its insertion S/S: Pain, swelling, and impaired performance

  22. ESW: Contraindications, Dangers & Precautions • Lung tissue appears to be damaged and should be avoided • The epiphysis it would make sense to avoid • Patients who are haemophiliac/ on anticoagulant therapy. • Malignancy • Metal implants • Infection in the local area should be treated with strong caution • Joint replacements - come up with a mixed result

  23. ESW: Adverse Events Adverse events are equivalent to those of conventional ESWT – • Transient pain • Subcutaneous hematoma (up to 4%) Local symptoms are much more common in RSWT due to lower penetration energy area. • Local irritation does not appear to be of lasting clinical significance.

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