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Shockwave Therapy For Treatment of Chronic Soft-Tissue Lesions
Shockwave therapy is an emerging treatment for a variety of chronic conditions. Radial pressure waves offer a non invasive treatment solution to long term insertion and soft tissue pathologies.
Production of Mechanical Energy used in SWT
The mechanical energy that is directed to the tissue is generated in one of four ways, depending on the SWT device used. These include electrohydraulic, electromagnetic, piezoelectric, and radial technologies.3 Radial shock waves can be generated either by using a ballistic projectile that is electromagnetically accelerated or by means of a pneumatic system. The projectile is accelerated to a high speed then is suddenly decelerated by a transmitter. The transmitter is held to the area to be treated and transmits the wave outward (radially) into the tissue.
Application of SWT
Shockwave devices deliver 1,500 to 3,000 shocks per session. Each session can be completed in 10 to 15 minutes, with the number of treatment sessions varying from one to six. Focused ESWT requires fewer treatments than RSWT, often only requiring one treatment. The SWT application technique involves placing the applicator directly on the skin over the target tissue. Once in contact, the clinician activates the series of shock waves into the target tissue. During RSWT, or low-to-mediumfocused ESWT, the patient will feel an uncomfortable yet tolerable series of “thumping” sensations. They may also feel post-treatment soreness in the area.
Eighty percent of patients with plantar fasciopathy improve within 12 months with standard conservative care.4 Those with recalcitrant plantar fasciosis are candidates for shockwave therapy. It is the preferred treatment to cortisone injection and surgery; patients can bear weight immediately and return to normal activity quickly. Success rates for the treatment of plantar fasciosis with SWT range from 34% to 88%, with the majority of studies reporting positive effects.5 Chang et al reported pain relief and treatment success using RSW or focused ESWT at the high end of the medium-intensity range (.08 to 0.28 mJ/mm2). For example, 0.16 to 0.25 mJ/mm2 is well tolerated by most without the need for anesthesia. Gerdesmeyer et al6 showed an overall success rate of 61.0% compared to 42.2% in the placebo group with three treatment sessions of RSWT (0.16 mJ/mm²; 2,000 impulses). Similar improvement in functional outcome scores and pain have been reported for both RSWT and focused ESWT, with RSW being a good alternative due to its lower cost.
Rasmussen et al11 compared conservative treatment of chronic Achilles tendinopathy to a second group that received SWT in addition to conservative treatment. Both groups showed improvement. However, the SWT group showed better results at 8- and 12-week follow-ups. The researchers concluded shockwave therapy appears to be a good supplemental treatment for chronic Achilles tendinopathy. These findings support the fact that SWT appears to be optimized when used as a combined therapy. Studies on the Achilles tendons of rabbits and dogs indicate that SWT alleviates pain of chronic Achilles tendinopathy by inducing neovascularization and improved blood supply, which initiates repair and tissue regeneration.
Trigger Point Treatment
The use of SWT to treat trigger points has become increasingly common. A recent study on musicians with shoulder-neck pain demonstrated temporary relief of pain when RSWT to trigger points was used in combination with other rehabilitation interventions.
Ultrasound examination revealed a significant increase in the vascularity of the patellar tendon and decreased patella tendon thickness after SWT compared to conservative treatment.8 Peers et al9 compared functional outcomes for patella tendinosis in a group of patients who received surgery for the condition, compared to a second group that received SWT; they concluded that the outcomes were comparable and that SWT is effective in the treatment of chronic tendinopathy. Zwerver et al10 studied SWT in athletes with chronic patella tendinopathy who continued to participate in their respective sport while using SWT as a stand-alone treatment. No significant differences were noted on the Victorian Institute of Sport Assessment-Patella Questionnaire. However, subjective ratings of the severity of symptoms were better in the SWT group. These findings once again support the concept that SWT is likely to be most effective when combined with other key interventions.
A meta-analysis on SWT for lateral epicondylalgia revealed that six out of 10 studies showed positive outcomes.13 Spacca et al14 reported a decrease in pain, improved function, and an increase of the pain-free grip strength and elbow function after applying 2,000 impulses of RSWT one time per week for 4 weeks. Eighty-seven percent of the treatment group was satisfied with their outcome, whereas only 3% of the control group was satisfied. The authors concluded that RSWT is safe and effective, and should be considered an alternative to surgery.