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Extracorporeal shockwave therapy (eswt)

What is ESWT:
Shockwave Therapy is a noninvasive method that uses acoustive waves to treat varies musculoskeletal conditions.
Extracorporeal = outside body.
Shockwave = intense, short energy wave travelling faster than speed of sound.
Well-controlled mechanical insult to tissue.
Fast pain reliever and restore mobility.

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Extracorporeal shockwave therapy (eswt)

  1. 1. EXTRACORPOREAL SHOCKWAVE THERAPY (ESWT) Presenter: Sami Halim ( PT,DPT)
  2. 2. WHAT IS ESWT  Shockwave Therapy is a noninvasive method that uses acoustive waves to treat varies musculoskeletal conditions.  Extracorporeal = outside body.  Shockwave = intense, short energy wave travelling faster than speed of sound.  Well-controlled mechanical insult to tissue.  Fast pain reliever and restore mobility.
  3. 3. HISTORY  In 1983 the first commercial lithotripter, The Dornier Lithotripter  Since 1985 other organs such as the gall bladder, bile duct, pancreas and salivary glands have been treated with shockwave.  During the next 10 years shockwave machines were trialed and have been used to treat orthopaedic disorders, including pseudo-arthroses, osteochondrosis and various tendinopathies (Haupt, 1997).
  4. 4. SHOCKWAVE THEORY  Extracorporeal shockwaves (ESW) are pressure waves generated acoustically.  Shockwaves are different from other acoustic waves because they are at a lower frequency.  There are many examples of these sonic pulse waves in real life. A more day to day version of a shockwave are those created by clapping.  Aeroplane breaking the sound barrier which generates an audible bang and can lead to the breakage of glass even in distant areas.
  5. 5. CONTI….  Acoustive waves create compression and shear loads on the surface of the material.  This rapid interaction between compression and shear forces results in what is commonly referred to as Cavitations.  Cavitations is a formation of vapor bubbles in a molecules. This cavitations damages the affected tissues.
  6. 6. CONTI…
  7. 7. CONTI..  There are 2 fundamentally different types of shockwave (McClure & Merritt, 2003). 1. Focused (Hard shockwave often referred to as lithotripsy) 2. Non-Focused also called Radial or Dispersive (Soft shockwave)  Non-focused or radial or dispersive shockwave which is created by mechanical concussion that creates expanding wave fronts away from the concussion plate (the end of the machine) which travel forward into the body.
  8. 8. BROADER EFFECTS OF ESWT:  Destruction of Tissues  Increase Healing/Blood Supply  Pain Reduction
  9. 9. MEDICAL EFFECTS OF ESWT: New Blood Vessel Formation:  Nutrient blood flow is necessary to start and maintain the repair processes of damaged tissue structure.  The application of acoustic waves creates capillary microruptures in tendon and bone.  Due to microruptures the expression of growth factors such as eNOS, VEGF, PCNS and BMP is significantly increased.  As a result of these processes arterioles are remodeled, stimulated to grow and new ones are formed.  The new blood vessels improve blood supply and oxygenation of the treated area and support faster healing of both the tendon and the bone.
  10. 10. Reversal of Chronic Inflammation:  Mast cells are one of the key components of the inflammatory process. Their activity may be increased by using pervasive acoustic waves.  Mast cell activation is followed by the production of chemokines and cytokines.  These pro-inflammatory compounds first enhance the inflammatory process and in the next step help restore normal healing and regenerative processes.
  11. 11. Stimulation of Collagen Production:  The production of a sufficient amount of collagen is a necessary precondition for the repair processes of the damaged myoskeletal and ligamentous structures  Shockwave therapy accelerates procollagen synthesis. The therapy forces the newly created collagen fibers into a longitudinal structure which makes the newly formed tendon fibers more dense and stiff and creates a firmer structure.
  12. 12. Dissolution of Calcified Fibroblasts:  Calcium build-up is most often a result of micro-tears or other trauma to a tendon. Acoustic waves break up the existing calcifications.  Shockwave therapy starts the biochemical decalcification of the calcium build-up of a toothpaste-like consistency and treats the tendon.  The granular particles of calcium are then removed by the lymphatic system.
  13. 13. Dispersion of Pain Mediator “Substance P”:  Substance P is a neurotransmitter that mediates pain information through C-fibers.  This neuropeptide is generally associated with intense, persistent and chronic pain. It relays pain messages to the central nervous system.  Lowering the concentration of Substance P reduces the stimulation of afferent nociceptive fibers and thus reduces the pain.  Decreasing Substance P, histamines and other nociceptive metabolites also helps inhibit development of inflammatory oedema.  Acoustic waves generated by Shockwave therapy lower the Substance P concentration and trigger pain relief.
  14. 14. Release of Trigger Points:  They are associated with palpable nodules in taut bands of muscle fibers and have extremely contracted sarcomeres.  The dysfunctional sarcomeres contract so tightly that they begin to cut off their own blood supply.  This causes the waste products to build up. Waste product build-up irritates the sensory nerve endings which then causes even more contraction.  This vicious cycle is referred to as “metabolic crisis”. The assumed mechanism of action is that the delivered acoustic energy unblocks the calcium pump and thus reverses the metabolic crisis in the myofilaments and releases the trigger points.
  15. 15. Activation of Osteoblasts: (osteogenesis)  The main effect of shockwave on bone healing is most certainly the activation of osteoblasts through integrin activation and differentiation of mesenchymal stem cells Chen et al. (2004).  Change in levels of Osteocalcin (OC) and bone specific alkaline phosphatase (bALP) following each session of shockwave therapy.  Extracorporeal shockwave promotes bone marrow stromal cell growth.
  16. 16. TREATMENT DOSAGE:
  17. 17. CLINICAL INDICATIONS:  Plantar Fasciitis  Heel spurs/Heel pain  Calcific Tendonitis  Patellar Tendonitis (Jumper’s Knee)  Achilles Tendonitis  Rotator Cuff Tendonitis  Myofascial Trigger Points in muscle  Iliotibial Band Syndrome (IT Band Syndrome)  Tennis Elbow and Golfer’s Elbow  Bursitis  Heterotopic Ossification (Myositis Ossificans) etc…
  18. 18. IS IT SAFE:  Mild side effects reported in studies.  Side effects usually come and go within 3 to 5 days. 1. Redness 2. Swelling 3. Pain (sometime initially) 4. Hematoma
  19. 19. CONTRAINDICATIONS:  Eyes  Major Blood Vessels  Open Wound  Implanted Devices  Brain  Major Nerves  Epiphysis  Infection  Cancer  Pregnancy  Joint replacement  Corticosteriod Injection  Clotting disorders
  20. 20. HOW SUCCESSFUL IS SHOCKWAVE?  Shockwave therapy is one of the most widely researched rehabilitation modalities used in physiotherapy clinics, with increasing numbers of scientific studies added each year.  The majority of research validates the effectiveness of extracorporeal shockwave, and shows successful treatment rates of up to 90%.
  21. 21. RESEARCH: Evidence: Calcific Tendinopathy:  High-Energy Extracorporeal Shock-Wave Therapy for Treating Chronic Calcific Tendinitis of the Shoulder.  Systematic review  Results: High energy ESWT was effective for treating calcific tendinitis .Reduced pain, improved function, resorption of calcifications  Low energy ESWT is less effective ◦ Regardless of energy level, ESWT is not effective in treating non- calcific tendinitis (Bannuru et al., 2014)
  22. 22. REFERENCES  http://www.shockwavetherapy.education/theory/cav itation.htm  http://www.shockwavetherapy.education/theory.htm  https://kreja.eu/img/cms/BTL_udarni_globinski_valo vi_katalog.pdf  http://www.shockwavetherapy.eu/subpage#medical- effects  https://www.yumpu.com/en/document/view/388750 18/understanding-shockwave-therapy-presentation- ortho-providers/4
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What is ESWT: Shockwave Therapy is a noninvasive method that uses acoustive waves to treat varies musculoskeletal conditions. Extracorporeal = outside body. Shockwave = intense, short energy wave travelling faster than speed of sound. Well-controlled mechanical insult to tissue. Fast pain reliever and restore mobility.

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