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Shockwave Therapy as a Physiotherapy Treatment


Shockwave therapy (also known a ESWT : Extracorporeal Shockwave Therapy) is used in various medical disciplines including orthopaedics, physiotherapy, urology, sports medicine and veterinary medicine. The use of this therapy for musculoskeletal disorders has been on for over a decade. The success rate of this therapy, according to research, ranges from 65% - 95%.

A shockwave is an acoustic wave which carries high energy to the tissues resulting in accelerated tissue repair and cell growth with minimal scar tissue production.
Shockwaves are high intensity, high frequency, short duration bursts of energy waves that are faster than sound.


The Shockwave Device
The fixed part of the device generates shock waves which are then transmitted by the system’s probe.
The generated waves are introduced into the body through the system’s probe and cover the area to be treated. Mechanical vibrations from the probe produce kinetic energy which is then converted into acoustic energy transmitted to the tissue.


Therapeutic Effects of Shockwave Therapy

1. New blood vessel formation
The application of acoustic waves causes microrupturing of the capillaries in the tendon and bone (which they are directed) thereby remodelling and stimulating the growth of new arterioles. The production of new blood vessels in the tendons and bones result in accelerated healing.

2. Reversal of chronic inflammation
Shockwaves activate mast cells (key components of the inflammatory process) and the production of cytokines which are growth factors secreted by the immune system. This results in first, the enhancement of the inflammatory process, then restoration of normal healing and regenerative processes.

3. Stimulation of Collagen Production
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.

4. Dissolution of Calcified fibroblasts
Shockwaves break up the sticky calcium deposits on tendons and promote the absorption of the calcium granules while treating the tendon.

5. Dispersion of pain mediator "Substance P"
Shockwaves reduce the concentration of "Substance P" (that relates pain messages to the central nervous system) which results in pain relief.

Common Conditions treated by Shockwave Therapy
Plantar Fasciitis
Chronic Tendinitis
Lateral Epicondylitis of the elbow
Patella tendinopathy (jumper's knee)
Achilles tendinopathy
Non union and delayed union fractures
Avascular necrosis
Chronic diabetic foot ulcers
Calcifying tendonitis of the shoulder

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Dosage
Most experts recommend 3-5 treatment sessions, with each session spaced by a week. Application of shockwave lasts 3-5minutes and improvement can be felt by the patient immediately after the treatment. Some may feel sore or experience inflammation within 24hrs of treatment, but that should pass.

Contraindications, Dangers and Precautions

Whilst not intended to constitute a definitive list, there are several areas/pathologies where concern has been expressed with regards the use of shockwave, and until further clarification has been obtained, some of the key issues are identified below. This list is compiled from the best (currently) available evidence and expert advice/opinion. It may be that this is an over conservative approach, but as with many 'new' or 'emerging' therapies, it is normal to err on the side of caution in the initial stages of clinical application.

Lung tissue appears to be damaged unequivocally and should be avoided

The epiphysis has been considered and whilst some experiments demonstrate a detrimental outcome, others do not. Whilst clarification is being obtained, it would make sense to avoid epiphyseal regions

Patients who are haemophiliac or who are on anticoagulant therapy are best not treated with shockwave given that some visible tissue damage (skin petechiae and disruption of the microvasculature) has been noted in several studies.

Malignancy remains on the contraindication list, though, as with other modalities, some experimental work is ongoing whereby shockwave therapies are being employed to try and minimise the growth and spread of malignant tissue. 

Given the unknowns at the moment, it is considered best to avoid such areas.Metal implants appear to be OK with regards bone based treatments, but implanted cardiac stents and implanted heart valves have not been fully evaluated. If however, one is avoiding the lungs, then they should not be exposed anyway.

Infection in the local area should be treated with strong caution given the as yet unknown effect of the therapy in this field.

Joint replacements - interestingly - come up with a mixed result. Some have used the therapy experimentally as a means to help with the removal of prostheses, making extraction easier. Given this, it would seem wise to avoid cemented implants. On the other hand, it is suggested that several researchers have actually used shockwave as a means to stimulate bone growth around an already lose prosthesis (osseous ingrowth). It would seem prudent to avoid the area given the possible loosening effect which, unless desired, would certainly constitute a detrimental outcome.

References
"Extracorporeal Shockwave therapy in Musculoskeletal Disorders", Journal of Orthopaedic Surgery and Research
Shockwavetherapy.au
Electrotherapy.org

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