SHOCKWAVE Diathermy or focused and radial swd.pptx

Types

Focused shockwave therapy (FSWT) and Radial shockwave therapy (RSWT)

1. SHOCKWAVE DIATHERMY S.SRINIVASAN

2. What is shockwave therapy? Shockwave therapy is a non-invasive treatment that stimulates the body’s natural healing process. It can relieve pain and promote healing of injured tendons, ligaments, and other soft tissues. It accomplishes this by releasing growth factors in the injured tissue. Shockwave therapy is sometimes referred to as EPAT or extracorporeal pulse activation technology .

3. Shockwave therapy is a type of regenerative medicine (also known as an Ortho biologic therapy). It is used to treat tendinopathy as well as difficult-to-heal ligament injuries. Some degenerative tendinopathies have an associated buildup of calcium in the tendon. Focused shock waves can break those deposits up.

4. The treatment can also promote healing after orthopedic surgery — for instance, if a hip impingement has damaged tendons and ligaments around the hip. Surgery may correct the hip impingement, but after years of overworking and degeneration because of the impingement, the surrounding tendons often remain painful.

5. HISTORY Extracorporeal Shockwave Therapy (ESWT) otherwise referred to as shockwave therapy, was first introduced into clinical practice in 1982 for the management of urologic conditions . The success of this technology for the treatment of urinary stones quickly made it a first-line, noninvasive, and effective method . Subsequently, ESWT was studied in orthopedics where it was identified that it could loosen the cement in total hip arthroplasty revisions. Further, animal studies conducted in the 1980s revealed that ESWT could augment the bone-cement interface, enhance osteogenic response and improve fracture healing . While shockwave therapy has been shown to be beneficial in fracture healing, most orthopedic research has focused on upper and lower extremity tendinopathies, fasciopathies , and soft tissue conditions

6. PARAMETERS Energy Flux Density (EFD) is the parameter referred to by professionals based on the flow of shockwave energy through an area with perpendicular orientation to the direction of propagation. The unit of measurement is given in mJ /mm2. ESWT has been previously classified based on EFD with low (<0.08mJ/mm2), medium (<0.28 mJ /mm2) and high (<0.60 mJ /mm2) treatment intensities. It should be taken into consideration that there is no consensus in the classification regarding EFD since the literature shows different energy parameters reported in various studies.

7. Despite this observation, clinicians typically resort to energy ranges from 0.001 to 0.4 mJ /mm2. Lower and medium EFD trigger the release of nitric oxide (NO), which is beneficial due to its antalgic, angiogenetic and anti-inflammatory effects in clinical settings. Higher EFD intensity is usually recommended for the treatment of pseudoarthrosis, for example, and yields about 72% success rate

8. Types of ESWT Shockwave therapy is subdivided into two types Focused shockwave therapy (FSWT) and Radial shockwave therapy (RSWT). FSWT features the generation of a pressure field that converges in the adjustable focus at determined depths in specific tissues where maximal pressure is achieved. Focused shockwaves can be generated via three methods: electrohydraulic (EH), electromagnetic (EM) and piezoelectric (PE of waves).

9. Due to the fact that the acoustic impedance of water and biologic tissue is comparable, focused shockwaves are generated in water. Therefore, reflection is limited and propagation of waves into the body is facilitated. The similarity between EH, EM and PE is that they all utilize water for the generation of focused shockwaves. The difference, however, is the moment at which the shockwaves are formed. EH generators, for example, produce shockwaves immediately after the spark gap, whereas EM and PE generators have a slight delay in a matter of nanoseconds by means of flocculation

10. RSWT is described by the diverging pressure field of RSWT devices, which reach maximal pressure at the source instead of selected depths in tissues. Radial shockwaves are not generated in water. Instead, they are generated upon acceleration of a projectile, using compressed air through a tube which has an extremity connected to an applicator. The projectile is accelerated until it collides with the applicator and, subsequently, the pressure wave that is generated is relayed into the body.

11. The fundamental differences between the two types of shockwave therapy, As of this manuscript, are as follows. First and foremost, focused shockwaves reach their maximal energy deeper in body tissues whereas radial shockwaves have a more superficial aspect. McClure and Dorf muller demonstrated that RSWT devices generate pressure fields which extend to 40 mm in water. Conversely, the pressure fields generated via FSWT may penetrate a distance about twice as deep. These observations do depend on the device and the energy settings that are used, but the fact remains that focused shockwaves will still propagate further and have more impact on tissues located deeper in the body.

12. On a different perspective, some research28 points out that it may be equivocal to refer to RSWT as an actual shockwave therapy because, technically, such devices do not generate “real” shockwaves. RSWT does not have the regular physical features of shockwaves, such as short rise time, a high peak pressure and non-linearity.23 This may be attributed to the fact that the speed of sound in tissue is around 1500 m/s, whereas in RSWT the acceleration of the projectile yields proximal speeds of 20 m/s, which is insufficient to generate a real shockwave.27 This is based on the study28 conducted by Chitnis and Cleveland, who found that the rise time of a wave generated from two electrohydraulic FSWT devices was 25–40 ns, whereas for the RSWT device It was 600ns

13. While 25–40 ns is much longer than the usual 5 ns (as mentioned in section 2.1) for the definition of shockwave, the EH-generated waves displayed the physical features of a conventional shockwave, but the same was not true for the radial device in questi

14. Differences between ESWT and Therapeutic Ultrasound Therapeutic ultrasound utilizes high frequency sound waves, while ESWT utilizes lower frequency waves. Ultrasound may produce either thermal or non-thermal effects in tissues, while ESWT does not result in heating effects.

15. Similarities between Therapeutic Ultrasound and ESWT Both modalities employ acoustic waves to produce therapeutic benefits. They both make use of a coupling medium to transmit sound waves to the tissues being treated. They are both non-invasive

16. Principles of Shockwave therapy Extracorporeal Shock Wave Therapy Three different methods: electrohydraulic, electromagnetic, and piezoelectric. Despite their different mechanisms, all three methods use water as a medium to transmit shockwaves, ensuring effective energy transfer to the targeted tissues. Shockwave therapy is widely recognized for its ability to promote tissue regeneration and reduce pain, making it a valuable tool in the treatment of musculoskeletal conditions

17. Physiology of ESWT Shockwaves are sound waves with distinct physical properties, including nonlinearity, high peak pressure followed by low tensile amplitude, a rapid rise time, and a brief duration of approximately 10 milliseconds. They consist of a single pulse, a broad frequency range (0–20 MHz), and a high-pressure amplitude (0–120 MPa). These unique characteristics create both positive and negative phases of the shockwave. The positive phase generates direct mechanical forces on the target tissue, while the negative phase induces cavitation, forming gas bubbles that implode at high velocity. This implosion produces a secondary wave of shockwaves, enhancing the mechanical impact and therapeutic potential of the treatment. Shockwave therapy is widely used in various medical fields, particularly in musculoskeletal disorders, due to its ability to promote tissue repair and pain relief through these dynamic mechanisms. In comparison to ultrasound waves, the shockwave peak pressure is approximately 1000 times greater than the peak pressure of an ultrasound wave

18. Mechanism of Action The effects of ESWT treatment are unknown. However, the proposed mechanisms of action for ESWT include the following: Promote neovascularization at the tendon-bone junction , stimulate proliferation of tenocytes and osteoprogenitor differentiation , Increase leukocyte infiltration , Amplify growth factor and protein synthesis to stimulate collagen synthesis and tissue remodeling

19. INDICATIONS Shockwave therapy is primarily used in the treatment of common musculoskeletal conditions. These include: Upper and lower extremity tendinopathies Greater trochanteric pain syndrome Medial tibial stress syndrome Patellar tendinopathy Plantar fasciopathy . Adhesive capsulitis Non-union of long bone fracture Avascular necrosis of femoral head Osteoarthritis of the knee.

20. Contraindications to ESWT Pregnancy Over major blood vessels and nerves Pacemakers or other implanted devices Open wounds Joint replacements Epiphysis Blood clotting disorders including thrombosis Infection Cancerous tissues A compromised mental status of the patient and/or the inability to cooperate.

21. Potential Side effect Pain Local inflammation Bruising Paresthesia Erythema Fascia/Tendon rupture or soft tissue damage These potential side effects are said to resolve quickly, within a week prior to the following treatment session.

22. Evidence-based According to a study performed by Rompe and coworkers, stretching exercises in combination with radial shock wave therapy is more efficient for the treatment of chronic symptoms of proximal plantar fasciopathy than repetitive radial pressure wave therapy alone. Patients were subjected to three sessions of 2000 radial pressure pulses (EFD = 0.16 mJ /mm 2) in weekly intervals, generated with a ballistic device (air compressor pressure 4 bar; rate 8 Hz) manufactured by Electro Medical Systems.

23. A study to investigate the clinical outcomes of ESWT on calcaneal spurs of 108 patients and its correlation with radiologic changes were reported by Yalcin et al. .All the patients underwent radial pressure wave therapy once a week for 5 weeks (2000 pressure waves starting at an EFD of 0.05 mJ /mm 2 and increasing up to 0.4 mJ /mm 2). After the therapy, approximately 67 % of the patients reported no pain; however, there was no correlation between clinical outcome and radiologic changes.

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