We currently do not offer this service. This post contains information gathered from research that was done during the process of looking into getting a shockwave therapy machine of our own.
What is Shockwave?
Extracorporeal shockwave therapy (ESWT) was first introduced as a clinical therapy for the disintegration of kidney stones (lithotripsy) in 1982, a practice that remains common today. The kinds of devices that will be discussed further are of lower energy so they do not disintegrate tissue, but rather cause microscopic extracellular responses that lead to tissue regeneration. [1,2] Shockwaves are sound waves that have specific characteristics and create a positive and negative phase. The positive phase generates direct force and the negative phase causes the formation of gas bubbles that implode at high speeds, creating a second wave of shockwaves. [2]
There are currently two distinct forms of ESWT, focused and radial. The waves generated by radial machines do not follow the specific characteristics of true shockwaves and it has been argued that ‘radial pulse therapy’ (RPT) would be a more appropriate term for this modality. However, both forms create cavitation (gas bubbles), and although the current research is variable and scarce, there is presently no evidence to suggest that focused shockwave therapy is superior; with the exception being for treatment of deep conditions such as pseudoarthrosis and necrosis [3,4]
Focused v.s Radial Shockwave Systems
Focused systems have shockwaves generated by either electrohydraulic, electromagnetic, or piezoelectric mechanisms. The shockwaves are created inside the system, then focused into a small, targeted site inside the body using reflectors. [3,5]
Radial systems are generated pneumatically, they use compressed air to shoot a projectile that strikes the applicator. This causes the devices to have their forces focused at the tip of the applicator, where contact with the skin is made, then radiate out to larger areas of the body. [5]
Shockwave v.s Ultrasound Therapy
There are limited studies comparing the two modalities, but, the literature seems to point to radial ESWT as being slightly superior. Plantar fasciitis is a common condition that can be treated by both modalities. Dedes et al [6] and Greve et al [7] both found relative superiority of radial ESWT for plantar fasciitis, it was also found to have a quicker effect after the onset of treatment. On the other hand, Akinoglu et al [8] found that while radial ESWT was more effective in increasing the sense of feeling (proprioception) in the ankle, ultrasound therapy was found to be more effective in reducing pain in plantar fasciitis. A different study looking at heel pain by Chieng et al [9] also found ESWT to be more effective in relieving pain and improving the maximum tolerable duration of standing or walking. Another examining lateral epicondylosis by Yalvaç et al [10] concluded that the two are equally as effective.
Nonetheless, it is important to keep in mind that in the studies above, participants receiving ESWT had treatment once a week, while those receiving ultrasound underwent treatments three times per week for a period of either 3 or 6 weeks. This is reasonable when considering that shockwaves have peak pressures that are approximately 1000 times greater than those of ultrasound waves. [2] All studies found improvements in both pain & functionality using either modality, with mixed results on superiority. Yet, there are advantages for ESWT such as fewer treatments required which can shorten the amount of time and cost required for the same results.
Mechanism
The exact mechanisms of how shockwave therapy functions in the body are unknown; however, there are several experimental studies and clinical trials that have found evidence of the following:
- Mechanical forces from shockwave devices converting into electrical and biochemical messages which in turn lead to cellular responses
- Effectiveness in stimulating growth factors
- Regulation of the inflammatory response related to the innate immune system pathway
- Induction of angiogenesis (formation of new blood vessels)
- Leading to the healing of tendons, muscles, cartilage, bone & skin, fractures, ulcers, and complex lesions
- Enhanced collagen deposition by activating components of the immune system [5]
Indications
Shockwave is used primarily for musculoskeletal conditions, however, it has also been found to be effective in treating other types of conditions as well. Proven treatable conditions include:
- Chronic Tendinopathies
- Plantar fasciitis
- Calcific & non-calcific tendinopathies of the rotator cuff
- Lateral epicondylitis of the elbow (tennis elbow) [5]
- Patellar tentinopathy (jumper’s knee)
- Achilles tendinopathies [11]
- Medial epicondylitis of the elbow (golfers elbow)
- Adductor tendinopathy syndrome
- Pes-Anserine tendinopathy syndrome
- Peroneal tendinopathy
- Foot & ankle tendinopathies [12]
- Bone Pathologies
- Fracture healing
- Non-union & delayed union of long bone fracture
- Osteoarthritis of the knee
- Avascular necrosis of the femoral head
- Spine fusion [11]
- Osteochondritis dissecans (OCD) without articular derangement
- Bone marrow edema
- Osgood Schlatters disease
- Tibial stress syndrome (shin splint)
- Muscle Pathologies
- Myofascial syndrome
- Muscle sprain without discontinuity
- Skin Pathologies
- Delayed or non-healing wounds
- Skin ulcers
- Non-circumferential burn wounds
- Cellulite [12]
Note that this is not a comprehensive list of treatable conditions. Please consult a healthcare provider to ensure that shockwave therapy is right for you.
There is also evidence that suggests ESWT is more appropriate for later stages of tendinopathy (degeneration phase) and when conservative treatments have not worked. This claim is backed by studies that showed no effect from ESWT in the early stages of tendinopathy (disrepair phase). [13]
Contraindications
- For low energy focused and radial shockwaves:
- Malignant tumor in treatment area
- Fetus in treatment area
- For high energy focused shockwaves:
- Malignant tumor in treatment area
- Fetus in treatment area
- Lung tissue in treatment area
- Epiphyseal plate in treatment area
- Brain or spine in treatment area
- Severe coagulopathy [12]
Although soreness, redness and/or swelling are common following treatment, the use of anti-inflammatories (NSAIDs- aspirin, ibuprofen) is often discouraged when undergoing shockwave as they may disrupt the inflammatory pathway that may be responsible for the treatment response. [2]
We currently do not offer this service. This post contains information gathered from research that was done during the process of looking into getting a shockwave therapy machine of our own.
Author: Katrina Kanbergs, BSc. Kin Candidate
Disclaimer
This information is designed to provide education and awareness. This article is not intended as a substitute for the medical advice of doctors and/or healthcare professionals. The reader should always consult their physician and/or healthcare providers in matters relating to their health.
References
[1] Wang, C.J., (2012) Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res, 7(11) doi: 10.1186/1749-799X-7-11
[2] Reilly, J.M., Bluman, E., Tenforde, A.S., (2018) Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions: A Narrative Review. PM&R, 10(12), 1385-1403. doi:10.1016/j.pmrj.2018.05.007
[3] Speed, C.,(2014) A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. British Journal of Sports Medicine ; 48(21),1538-1542. doi: 10.1136/bjsports-2014-094218
[4] Schmitz, C., (2015) Focused and radial extracorporeal shock wave therapy: more similarities than differences. Physiotherapy, 101(1), e1346-e1347. doi: 10.1016/j.physio.2015.03.1279
[5] Carmignano, S. M., (2019) Extracorporeal Shock Wave Therapy in Chronic Wound Care. IntechOpen, doi: 10.5772/intechopen.89592
[6] Dedes, V., Tzirogiannis, K., Polikandrioti, M., Dede, A.M., Nikolaidis, C., Mitseas, A., Panoutsopoulos, G.I., (2019) Radial Extra Corporeal Shockwave Therapy Versus Ultrasound Therapy in the Treatment of Plantar Fasciitis. Acta Inform Med, 27(1), 45-49. doi: 10.5455/aim.2019.27.45-49
[7] Greve, J. M. 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. doi: 10.1590/S1807-59322009000200006
[8] Akinoğlu, B., Köse, N., Kirdi, N., Yakut, Y., (2017) Comparison of the Acute Effect of Radial Shock Wave Therapy and Ultrasound Therapy in the Treatment of Plantar Fasciitis: A Randomized Controlled Study. Pain Medicine, 18(12), 2443-2452. doi:10.1093/pm/pnx113
[9] Cheing, G.L.Y., Chang, H., Lo, S.K., (2007) A comparison of the effectiveness of extracorporeal shock wave and ultrasound therapy in the management of heel pain. Shock Waves, 17, 195-201. doi: 10.1007/s00193-007-0102-1
[10] Yalvaç, B., Mesci, N., Külcü, D.G., Yurdakul, O.V., (2018) Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis. Acta Orthop Traumatol Turc, 52(5), 357-362. doi: 10.1016/j.aott.2018.06.004
[11] Wang, C.J., (2012) Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res, 7(11). doi: 10.1186/1749-799X-7-11
[12] Eid, J. (2016) Consensus Statement on ESWT Indications and Contraindications. International Society for Medical Shockwave Treatment
[13] van der Worp, H., van den Akker-Scheek, I., van Schie, H., Zwerver, J., (2013) ESWT for tendinopathy: technology and clinical implications. Knee surgery, sports traumatology, arthroscopy: official journal of the ESSKA, 21(6), 1451-1458. doi: 10.1007/s00167-012-2009-3
[14] Schmitz, C., Csaszar, N., Milz, S., Schieker, M., Maffulli, N., Rompe, J., Furia, J., (2015). Fig. 1 Working principle of focused and radial extracorporeal shockwave technology [Photograph] Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: A systematic review on studies listed in the PEDro database. British medical bulletin. 116. 10.1093/bmb/ldv047.
[15] Stortz Medical AG (2019) Plantar fasciitis [Photograph] Shockwave Canada. https://shockwavecanada.com/wp-content/uploads/Brochure_MASTERPULS_50-100-200_ultra.pdf
