Extracorpal Shock Wave Therapy on Rehabilitation of Tendinopathy
Mao-Hsiung Huang M.D.,Ph.D. Department of PM&R Kaohsiung Medical University Hospital
2017.10.19
Rehabilitation of Tendinopathy
Exercise-based physical therapy Transverse friction massage Modalities Iontophoresis, phonophoresis, ultrasound, low-level laser therapy Shock wave therapy
Shock Wave Therapy
AJSM: 2007;35:374-83
What is a Shock wave ď Ž Shock waves are
acoustic waves with a short pulse of positive pressure followed by a phase of negative pressure ď Ž Shock waves have a very short rise time of only a few nanoseconds
30-60 MP
<50 ns 5-15MP
Effects of Extracorporeal Shock wave Stimulate or reactivate the healing processes
in musculoskeletal tissue. Microdestruction of avascular or minimally vascular tissues, Encourage revasularization and release of local growth factors Recruitment of appropriate stem cells leading to an enhancement of the intrinsic wound healing process.
Mechanism of action for shockwave Mechanical effects Cavitation Radiation force Shear force Transverse friction massage Thermal effects (-)
Proposed Biomechanisms of Therapeutic Effect
ESWT
Mechanical effect
Increasing pressure through the deposit
Deposit fragmentations
Molecular effect
Inflammatory response Neovascularization Leukocyte chemotaxis
Deposit phagocytosis
Antigenic effect
Inhibition of serotonergic activation Denervation of pain receptors Affect dorsal root ganglion neuron
[Mouzopoulos et al, Skeletal Radiology, 2007]
Comparison of ESWT and RSWT
Application of ESWT and RSWT
Comparison of different sources of Shock Wave
J Bone Surg [Br] 2004;86-B165-71.
Energy classification of ESWT
Author
Level
FED range (mj/mm2)
Mainz
Low Medium High
0.08-0.27 0.28-0.59 >0.60
Kassel
Low High
<0.12 >0.12
J Bone Surg [Br] 2004;86-B 165-71
Proposed Cascade of ESWT Biomechanism in Musculoskeletal Tissues
Low Energy ESWT on Nerve Ending
Takahashi. Clin Orthop Relat Res 2006; 443:315-9.
Low Energy ESWT on Nerve Ending
Takahashi. Clin Orthop Relat Res 2006; 443:315-9.
ESWT on Sensory Nerve
Ohtori. Neuroscience Letter 2001;315:57-60
Bimodal Pain relief Response after ESWT (Odgen 2002) ď Ž Pain reduction 0-4 days:
Nerve damage / hyperstimulation analgesia / CGRP
ď Ž Pain reduction after 1
month: Angiogenesis and tissue healing
Medium Energy ESWT for Calcificing Tendinitis
Moretti etal. Knee Surg Sport Traumatol Arthrosc 2005;13:405-10
Medium Energy ESWT for Calcificing Tendinitis
Moretti etal. Knee Surg Sport Traumatol Arthrosc 2005;13:405-10
Different Location Determination for ESWT
(Group I: tender point; Group II: Lithotracl device)
Sabeti-Aschrif, Am J Sport Med 2005;33:1365-8.
Dose dependent of calcific tendinitis
Clinical effects of calcific tendinopathy
3M
Knee OA with cyramella
Shock wave therapy on knee cyamella
Shock wave therapy on knee cyamella
Shock wave therapy on knee cyamella
Shock wave therapy on knee cyamella
Shock wave therapy on knee cyamella
Nuchal ligament calcification
Nuchal ligament calcification
Nuchal ligament calcification
Nuchal ligament calcification
Nuchal ligament calcification
Nuchal ligament calcification
Nuchal ligament calcification
Hypertrophy of burn scar
ESWT for hypertrophy scar
ESWT for hypertrophy scar
Adverse effect of ESWT Low Energy- no damage 0.6 mJ/mm2-peritendinous
inflammation and fibrinoid necrosis (Rompe, JBJS,1998) ＜0.5 mJ/mm2 – no damage 1.2 mJ/mm2 -Damage impairment of tensile strength (Maier, Arch Orthop Traumz Surg, 2002) Mainz
Potential mechanism of beneficial and adverse effects of ESWT
J Bone Surg [Br] 2004;86-B165-71
Local complications
Soft tissue swelling Resolve within 48 hours Cutaneous erosions Reddening of the skin Occurring at 0.04-0.22 mJ/mm2 Pain 0.3 mJ/mm2 is the lowest Hematoma Threshold for vascular damage in Nerve lesion Animals soft tissue Transient bone edema Only two case reports: avoid Humeral head osteonecrosis targeting at the intertubercular groove
High - vs. Low-energy Low-energy
-＜0.1 mJ/mm2 -regarded as a from of hyperstimulation analgesia -local anaesthesia is generally not required High-energy -0.2~0.4 mJ/mm2 -expected to exert a disintegrating effect on the calcium deposits -typically require local anaesthesia [Royal Australasian College of Surgeons , 2003]
Clinical Efficacy Determined by
-Effective total energy of a treatment (single session of high-energy ESWT or multiple sessions of lowenergy) -Guidance method Clinical success rate: 60~80% in uncontrolled prospective trials Disintegration of calcify deposits: 32~77% -May as early as 12 weeks after ESWT -Higher in Gärtner type II than type II Duration of effectiveness: May last 2~3 years