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Extracorporeal Shockwave Therapy
 Week Topics
PTY1010 1 Introduction to module and EBP

Foundation of 2
3
Clinical reasoning for EPA
E-learning week (Traumatology)
Physiotherapy 4 Hydrotherapy week / Fracture
5 Clinical reasoning tutorial and CNY
6 EPA 1 (Hot/cold/SWD)
7 Tuition free week
8 EPA 2 (Ultrasound, ESWT)
9 and 10 EPA 3 (Electrotherapy)
10 and 11 Massage
12 Practical/Oral Viva exam
15 Retest
Definition
• Electrical energy to mechanical shockwave
• Mechanical pressure disturbance
• Propagates rapidly through a medium
• Large-amplitude compression wave
• Produced by an explosion or by supersonic motion of
a medium
History
1980’s
• Non-invasive treatment for kidney stones
• Its effect on bones, cartilage, tendon, ligament and fascia
were discovered afterwards

1990’s
• Journal papers to show its effects on soft tissue problems

Present
• Publications on this topic regularly increase
Background

Shock Wave Therapy

• Extracorporeal Shock
Wave Lithotripsy ESWL
• Extracorporeal Shockwave
Therapy ESWT
Terminology

Shockwave
therapy

Extracorporeal Extracorporeal
Shockwave Shockwave
Therapy ESWT Lithotripsy SWL

Radial Focused
shockwave shockwave
Terminology

Focused shockwave Radial shockwave

• ?High energy • Low- to medium-energy
• Can be guided by • Generated through the
ultrasound or radiographs acceleration of a projectile
to focus on a specific site.
 Focusing is important to limit the effect to the target
area while
simultaneously reducing side effects outside this area
Basic sciences
Mechanism
Mechanism

Pneumatic
• Generated by air compressors
• Transmit radially, with lower penetration (3 cm)
• Less impact (0.02-0.06 mJ/mm2)
• Limited biological effect
Greve et al., 2009
Mechanism
Electromagnetic
• A metal membrane and an opposing electromagnetic coil
• Electric current passes through a coil
• Strong magnetic field
• Forces the metal membrane away compressing the fluid medium
• Produce a shockwave
• The wave passes through a lens to focus at the desired target
tissue
The waves and energy levels
Energy levels
• High energy
– 0.28 to 0.78mJ/mm2
• Medium energy
– 0.08 to less than 0.28 mJ/mm2
• Low energy
– Less than 0.08 mJ/mm2
Huissetede et al., 2011; Bannuru et al., 2014; Ioppolo et al., 2013
Energy levels
• 1 Pa = 1 N / m2; 1 bar = 100kPa; 1 J = 1 Nm ;
Wave form
• Pressure rises in less than 10 ns
• Wave cycle < 10 ms
Clinical application
 Indications

• Bone healing
• Chronic degenerative soft tissue
pathologies eg.
– Achilles/ Patella/ shoulder tendinopathy
– Tennis elbow
– Plantar fasciitis
• Frozen shoulder
Prentice 2011; Vahdatpour et al., 2014

• Erectile dysfunction
Vardi et al., 2010; Gruenwald et al., 2013
Physiological effects
 Effects
• “Unstable” Cavitation
• Increase local blood flow
– Increase in cellular activity
• Stimulation of an
inflammatory response
– Release of mediators
• Transient analgesic effect on
afferent nerves
• Break down calcified
deposits
Effects
Soft tissue
• Collapse of fluid bubbles creates microscopic high-
energy water jets
• Increase in tissue temperature and damage cells.
Effects
Bone
• Acoustic streaming
• Increase cell permeability
• Increase vascularity and bony regeneration
• Increase stromal cells allow osteogenesis
• Increase growth factor, neovascularization and
protein synthesis
Contraindication
Radial and focused waves with low energy
• Malignant tumor in the treatment area (not as underlying disease)
• Fetus in the treatment area
• Lung tissues to be avoided
• Patients on anitcoagulaant therapy/haemophiliac
• Directly over metal implants
• Epiphyseal plate in children
• Brain or Spine cord in treatment area
• Over Large blood vessels
• Suspected fracture

• Joint replacement (Precaution)

• Local infection (Precaution)
Adverse effects
• Transient pain
• Subcutaneous hematoma (up to 4%)
• Superficial bruising on skin
Treatment Protocol
Treatment Protocol
• Shock number
– 1000 to 2000
• Frequency
– 2 Hz to 10 Hz
• Treatment session
– Average 3 to 5 sessions

• Intensity (Varies a lot!)

– 0.11- 0.22 mJ/mm2 (Ogden et al., 2004; Schmitt et al.,2001)
– 0.1-1.0 mJ/mm2 (Electrotherapy.com)
– 2.0- 4.0 bar

• http://www.electrotherapy.org/
Reference
• http://www.electrotherapy.org/
• http://eswt.net/focused-shock-waves
• http://www.shockwavetherapy.eu/subpage#mechanism-of-action
• https://www.shockwavetherapy.org/the-society/
• https://www.youtube.com/watch?v=mFyZTppAXXY
• https://www.youtube.com/watch?v=Q3fTpz1uIC4
• Haake, M., Böddeker, I., Decker, T., Buch, M., Vogel, M., Labek, G., ... & Betthäuser, A. (2002). Side-effects of
extracorporeal shock wave therapy (ESWT) in the treatment of tennis elbow. Archives of orthopaedic and trauma
surgery, 122(4), 222-228.
• McAteer, J. A., & Evan, A. P. (2008, March). The acute and long-term adverse effects of shock wave lithotripsy.
In Seminars in nephrology (Vol. 28, No. 2, pp. 200-213). WB Saunders.
• Schmitt, J., Haake, M., Tosch, A., Hildebrand, R., Deike, B., & Griss, P. (2001). Low-energy extracorporeal shock-
wave treatment (ESWT) for tendinitis of the supraspinatus. Bone & Joint Journal, 83(6), 873-876.
• Ogden, J. A., Alvarez, R. G., Levitt, R. L., Johnson, J. E., & Marlow, M. E. (2004). Electrohydraulic high-energy shock-
wave treatment for chronic plantar fasciitis. J Bone Joint Surg Am, 86(10), 2216-2228.
• Vardi, Y., Appel, B., Jacob, G., Massarwi, O., & Gruenwald, I. (2010). Can low-intensity extracorporeal shockwave
therapy improve erectile function? A 6-month follow-up pilot study in patients with organic erectile
dysfunction. European urology, 58(2), 243-248.
• Gruenwald, I., Appel, B., Kitrey, N. D., & Vardi, Y. (2013). Shockwave treatment of erectile dysfunction. Therapeutic
advances in urology, 5(2), 95-99.
• Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology:
what is its merit in clinical practice and research?. Br J Sports Med, bjsports-2015.
Reference
• Vahdatpour, B., Taheri, P., Zade, A. Z., & Moradian, S. (2014). Efficacy of extracorporeal shockwave therapy in
frozen shoulder. International journal of preventive medicine, 5(7), 875.
• Prentice, W. (2011). Therapeutic modalities in rehabilitation. McGraw Hill Professional.
• Huisstede, B. M., Gebremariam, L., van der Sande, R., Hay, E. M., & Koes, B. W. (2011). Evidence for
effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff
tendinosis–a systematic review. Manual therapy, 16(5), 419-433.
• Mouzopoulos, G., Stamatakos, M., Mouzopoulos, D., & Tzurbakis, M. (2007). Extracorporeal shock wave
treatment for shoulder calcific tendonitis: a systematic review. Skeletal radiology, 36(9), 803-811.
• Bannuru, R. R., Flavin, N. E., Vaysbrot, E., Harvey, W., & McAlindon, T. (2014). High-Energy Extracorporeal
Shock-Wave Therapy for Treating Chronic Calcific Tendinitis of the ShoulderA Systematic ReviewHigh-Energy
Extracorporeal Shock-Wave Therapy for Shoulder Tendinitis. Annals of internal medicine, 160(8), 542-549.
• Louwerens, J. K., Sierevelt, I. N., van Noort, A., & van den Bekerom, M. P. (2014). Evidence for minimally
invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: a systematic review
and meta-analysis. Journal of Shoulder and Elbow Surgery, 23(8), 1240-1249.
• Ioppolo, F., Tattoli, M., Di Sante, L., Venditto, T., Tognolo, L., Delicata, M., ... & Santilli, V. (2013). Clinical
improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at
6 months' follow-up: a systematic review and meta-analysis. Archives of physical medicine and
rehabilitation, 94(9), 1699-1706.
• Hopkins, C., Fu, S. C., Chua, E., Hu, X., Rolf, C., Mattila, V. M., ... & Chan, K. M. (2016). Critical review on the
socio-economic impact of tendinopathy. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation
and Technology, 4, 9-20.
• Mariotto, S., de Prati, A. C., Cavalieri, E., Amelio, E., Marlinghaus, E., & Suzuki, H. (2009).
Extracorporeal shock wave therapy in inflammatory diseases: molecular mechanism that
triggers anti-inflammatory action. Current medicinal chemistry, 16(19), 2366-2372.
• Waugh, C. M., Morrissey, D., Jones, E., Riley, G. P., Langberg, H., & Screen, H. R. (2015). In vivo
biological response to extracorporeal shockwave therapy in human tendinopathy. Eur Cell
Mater.
• Yu, T., Junger, W. G., Yuan, C., Jin, A., Zhao, Y., Zheng, X., ... & Liu, J. (2010). Shockwaves
increase T-cell proliferation and IL-2 expression through ATP release, P2X7 receptors, and FAK
activation. American Journal of Physiology-Cell Physiology, 298(3), C457-C464.
• Bechara, A., Casabé, A., De Bonis, W., & Ciciclia, P. G. (2016). Twelve-month efficacy and safety
of low-intensity shockwave therapy for erectile dysfunction in patients who do not respond to
phosphodiesterase type 5 inhibitors. Sexual medicine, 4(4), e225-e232.
• https://www.youtube.com/watch?v=8WksGHFL6l4
• https://youtu.be/igrHLPIEJcc?t=16s
• https://www.youtube.com/watch?v=fHp95e-CwWQ
• Greve, J. M. D. A., Grecco, M. V., & Santos-Silva, P. R. (2009). Comparison of radial shockwaves
and conventional physiotherapy for treating plantar fasciitis. Clinics, 64(2), 97-103.
• http://brisbanefootclinic.com.au/shockwave-therapy/