This document summarizes the author's presentation on shockwave therapy. It discusses different types of shockwaves used in therapy, including focused shockwave therapy (F-ESWT) and radial pulse therapy (RPT). It reviews several studies on the effectiveness of shockwave therapies for various soft tissue conditions. The studies show high-intensity F-ESWT and RPT are generally effective for chronic plantar fasciitis, high-intensity F-ESWT and low-intensity RPT are effective for chronic mid-portion Achilles tendinopathy, and high-intensity F-ESWT is effective for chronic insertional Achilles tendinopathy and calcific rotator cuff tendinopathy. However, the effectiveness depends on
3. Michael Harbo
OSLO
STOCKHOLM
Clinical expert in sports physiotherapy
DENMARK
Aalborg, Denmark
UNITED
KINGDOM
COPENHAGEN
IRELAND
NETHERLANDS
DUBLIN
AMSTERDAM
LONDON
•
PO
BERLIN
GERMANY
Working with shockwave since 2003
BRUSSELS
CHECH REP
BELGIUM
LUXEMBOURG
PRAGUE
•
Text-book author on electro-therapy
AUSTRIA
PARIS
BRATI
VIENNA
SWITZERLAND
SLOVENIA
BERN
•
Associate lector at University College
LJUBLJANA
ZA
FRANCE
CROATIA
ITALY
BOSNIA
HERZ.
Northern Jutland
SARAJEV
MONTENE
PODGORICA
SPAIN
ROME
PORTUGAL
MADRID
LISBON
fredag den 25. oktober 13
7. S U CCESS HA S
M ANY FATHE R S
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8. S UCCESS HAS
MANY FAT HE R S
B UT T HE S E
A RE N OT
TH E S A M E
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9. Focused shockwave
Pressure waves
ESWT - low
RPWT
ESWT - high
Radial Pulse Therapy
f ESWT
rESWT
B UT T HE S E
A RE N OT
TH E S A M E
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10. Focused shockwave
Pressure waves
ESWT - low
RPWT
ESWT - high
Radial Pulse Therapy
f ESWT
rESWT
B UT T HE S E
A RE N OT
TH E S A M E
SHOCKWAVES
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11. Focused shockwave
Pressure waves
ESWT - low
RPWT
ESWT - high
Radial Pulse Therapy
f ESWT
WATER
rESWT
B UT T HE S E
A RE N OT
TH E S A M E
SHOCKWAVES
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14. SHOCKWAVES
ESWT
RPT
20 - 20.000 Hz
Focused
Max 100 MPa
0 - 0,50
2
mJ/mm
Total impulse 1 µs
Time to peek 0.3 – 1 ns
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4 - 15 Hz
Radial
Max 10 MPa
2
0 - 0,3 mJ/mm
Total impulse1000 µs
1000-5000 ns
15. SHOCKWAVES
ESWT
RPT
20 - 20.000 Hz
Focused
Max 100 MPa
0 - 0,50
2
mJ/mm
Total impulse 1 µs
Time to peek 0.3 – 1 ns
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4 - 15 Hz
Radial
Max 10 MPa
2
0 - 0,3 mJ/mm
Total impulse1000 µs
1000-5000 ns
16. SHOCKWAVES
ESWT
RPT
20 - 20.000 Hz
Focused
Max 100 MPa
0 - 0,50
2
mJ/mm
Total impulse 1 µs
Time to peek 0.3 – 1 ns
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4 - 15 Hz
Radial
Max 10 MPa
2
0 - 0,3 mJ/mm
Total impulse1000 µs
1000-5000 ns
17. SHOCKWAVES
ESWT
RPT
20 - 20.000 Hz
Focused
Max 100 MPa
0 - 0,50
2
mJ/mm
Total impulse 1 µs
Time to peek 0.3 – 1 ns
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4 - 15 Hz
Radial
Max 10 MPa
2
0 - 0,3 mJ/mm
Total impulse1000 µs
1000-5000 ns
18. SHOCKWAVES
ESWT
RPT
20 - 20.000 Hz
Focused
Max 100 MPa
0 - 0,50
2
mJ/mm
Total impulse 1 µs
Time to peek 0.3 – 1 ns
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4 - 15 Hz
Radial
Max 10 MPa
2
0 - 0,3 mJ/mm
Total impulse1000 µs
1000-5000 ns
19. B UT D O T H E Y WOR K ?
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20. B UT D O T H E Y WOR K ?
FAI
January 1, 2013
The effectiveness of shock wave therapy on chronic achilles
tendinopathy: a systematic review
Hani Al-Abbad
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21. B UT D O T H E Y WOR K ?
FAI
January 1, 2013
The effectiveness of shock wave therapy on chronic achilles
tendinopathy: a systematic review
Hani Al-Abbad
Based on 6 appropriate studies:
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22. B UT D O T H E Y WOR K ?
FAI
January 1, 2013
The effectiveness of shock wave therapy on chronic achilles
tendinopathy: a systematic review
Hani Al-Abbad
Based on 6 appropriate studies:
“Our review showed satisfactory evidence for
the effectiveness of ESWT in the treatment of
chronic insertional and noninsertional Achilles
tendinopathies”
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23. B UT D O T H E Y WOR K ?
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24. B UT D O T H E Y WOR K ?
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25. B UT D O T H E Y WOR K ?
BJSM
August 5, 2013
A systematic review of shockwave therapies
in soft tissue conditions: focusing on the evidence
Cathy Speed
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26. B UT D O T H E Y WOR K ?
BJSM
August 5, 2013
A systematic review of shockwave therapies
in soft tissue conditions: focusing on the evidence
Cathy Speed
Based on 23 appropriate studies:
fredag den 25. oktober 13
27. B UT D O T H E Y WOR K ?
BJSM
August 5, 2013
A systematic review of shockwave therapies
in soft tissue conditions: focusing on the evidence
Cathy Speed
Based on 23 appropriate studies:
“There is evidence for the benefit of F-ESWT
and of RPT in a number of softtissue
musculoskeletal conditions, and evidence that
both treatment modalities are safe”
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28. BU T F E W T H I N G S A RE O NLY
BLAC K O R WH I T E
The effect seems to be:
•
Modality-dependent
•
Diagnose-dependent
•
Dose-dependent
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29. C H RO N IC P L A N TA R FA SC I TI S
( BE NE F IT AT 1 2 W E E K F O L LO W- UP )
YE S
fredag den 25. oktober 13
NO
30. C H RO N IC P L A N TA R FA SC I TI S
( BE NE F IT AT 1 2 W E E K F O L LO W- UP )
YE S
NO
•
•
Buchbinder, 2002
•
Ogden, 2001
•
Haake, 2003
•
Theodore, 2004
•
Speed, 2002
•
Gollwitzer, 2007
•
Kudo, 2006
•
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Malay, 2006
Gerdesmeyer, 2008
31. C H RO N IC P L A N TA R FA SC I TI S
( BE NE F IT AT 1 2 W E E K F O L LO W- UP )
YE S
NO
M O DA LI TY ?
•
Buchbinder, 2002
Ogden, 2001
•
Haake, 2003
•
Theodore, 2004
•
Speed, 2002
•
Gollwitzer, 2007
•
Kudo, 2006
•
Gerdesmeyer, 2008
•
•
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Malay, 2006
32. C H RO N IC P L A N TA R FA SC I TI S
( BE NE F IT AT 1 2 W E E K F O L LO W- UP )
YE S
NO
M O DA LI TY ?
•
ESWT
ESWT
•
ESWT
•
ESWT
•
ESWT
•
ESWT
•
RPT
•
RPT
•
•
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ESWT
33. C H RO N IC P L A N TA R FA SC I TI S
( BE NE F IT AT 1 2 W E E K F O L LO W- UP )
YE S
NO
I N T E N S I TY ?
•
ESWT
ESWT
•
ESWT
•
ESWT
•
ESWT
•
ESWT
•
RPT
•
RPT
•
•
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ESWT
34. C H RO N IC P L A N TA R FA SC I TI S
( BE NE F IT AT 1 2 W E E K F O L LO W- UP )
YE S
NO
I N T E N S I TY ?
•
ESWT
High
•
ESWT
•
High
•
ESWT
•
High
•
High
•
High
•
•
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High
35. C H RO N IC P L A N TA R FA SC I TI S
( BE NE F IT AT 1 2 W E E K F O L LO W- UP )
YE S
NO
I N T E N S I TY ?
•
Low
High
•
Low
•
High
•
Low
•
High
•
High
•
High
•
•
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High
36. C H RO N IC P L A N TA R FA SC I TI S
( BE NE F IT AT 1 2 W E E K F O L LO W- UP )
YE S
H I G H - E S W T & RPT
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37. CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S
(BENEF IT AT 12 WEEK F OLLOW- UP)
YE S
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NO
38. CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S
(BENEF IT AT 12 WEEK F OLLOW- UP)
YE S
•
•
Vulpiani, 2009
•
(Rompe, 2007)
•
(Lakshmanan, 2004)
•
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Rasmussen, 2008
(Rompe, 2008)
NO
•
Costa, 2005
39. CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S
(BENEF IT AT 12 WEEK F OLLOW- UP)
YE S
•
•
ESWT
•
(RPT)
•
(RPT)
•
fredag den 25. oktober 13
ESWT
(RPT)
NO
•
RPT
40. CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S
(BENEF IT AT 12 WEEK F OLLOW- UP)
YE S
•
•
High
•
(High)
•
(Low)
•
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High
(Low)
NO
•
Low
41. CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S
(BENEF IT AT 12 WEEK F OLLOW- UP)
YE S
H IGH-ESWT
(LOW-R PT )
fredag den 25. oktober 13
42. C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY
( BE NEFIT AT 1 2 WEEK FOLLOW-U P )
YE S
fredag den 25. oktober 13
NO
43. C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY
( BE NEFIT AT 1 2 WEEK FOLLOW-U P )
YE S
•
•
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Furia, 2006
Vulpiani, 2009
NO
44. C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY
( BE NEFIT AT 1 2 WEEK FOLLOW-U P )
YE S
•
ESWT
•
NO
ESWT
No RPT studies met
the inclusion criteria
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45. C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY
( BE NEFIT AT 1 2 WEEK FOLLOW-U P )
YE S
•
•
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ESWT
ESWT
NO
46. C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY
( BE NEFIT AT 1 2 WEEK FOLLOW-U P )
YE S
•
•
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High
High
NO
47. C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY
( BE NEFIT AT 1 2 WEEK FOLLOW-U P )
YE S
HI GH - ES WT
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48. CA LCI FI C R OTATOR C U F F TE N DINOPATHY
( BENEFIT AT 12 WEEK FOL LOW-U P )
YE S
fredag den 25. oktober 13
NO
49. CA LCI FI C R OTATOR C U F F TE N DINOPATHY
( BENEFIT AT 12 WEEK FOL LOW-U P )
YE S
•
•
Albert, 2007
•
fredag den 25. oktober 13
Consentino, 2003
Gerdesmeyer, 2003
NO
50. CA LCI FI C R OTATOR C U F F TE N DINOPATHY
( BENEFIT AT 12 WEEK FOL LOW-U P )
YE S
•
ESWT
•
ESWT
•
NO
ESWT
No RPT studies met
the inclusion criteria
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51. CA LCI FI C R OTATOR C U F F TE N DINOPATHY
( BENEFIT AT 12 WEEK FOL LOW-U P )
YE S
•
•
ESWT
•
fredag den 25. oktober 13
ESWT
ESWT
NO
52. CA LCI FI C R OTATOR C U F F TE N DINOPATHY
( BENEFIT AT 12 WEEK FOL LOW-U P )
YE S
•
•
High
•
fredag den 25. oktober 13
High
High
NO
53. CA LCI FI C R OTATOR C U F F TE N DINOPATHY
( BENEFIT AT 12 WEEK FOL LOW-U P )
YE S
H IGH- ESW T
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55. HIGH-ESWT
CONCLUS IO N
Chronic Plantar fascitis
Chronic mid portion achilles tendinosis
Chronic insertional achilles tendinopathy
Calcific rotator cuff tendinopathy
fredag den 25. oktober 13
56. HIGH-ESWT
CONCLUS IO N
Chronic Plantar fascitis
Chronic mid portion achilles tendinosis
Chronic insertional achilles tendinopathy
Calcific rotator cuff tendinopathy
H I G H - R PT
Chronic Plantar fascitis
fredag den 25. oktober 13
57. HIGH-ESWT
CONCLUS IO N
Chronic Plantar fascitis
Chronic mid portion achilles tendinosis
Chronic insertional achilles tendinopathy
Calcific rotator cuff tendinopathy
H I G H - R PT
Chronic Plantar fascitis
LOW- RPT
Chronic mid portion achilles tendinosis
fredag den 25. oktober 13
59. Calcific rotator cuff tendinopathy
“Effect of ESWT on calcific rotator cuff tendinopathy with
classic signs of impingement”
Harbo & Jakobsen, not published
fredag den 25. oktober 13
60. Calcific rotator cuff tendinopathy
“Effect of ESWT on calcific rotator cuff tendinopathy with
classic signs of impingement”
Harbo & Jakobsen, not published
•
•
N=70
•
1 & 6 months follow-up
•
fredag den 25. oktober 13
Doubleblind-RCT
WORC and Constant & Murley score
61. Calcific rotator cuff tendinopathy
80
ESWT on calcific rotator cuff tendinopathy with
1 & 6 months follow-up
•
WORC and Constant & Murley score
Placebo
•
Active
N=70
Placebo
•
40
Active
Doubleblind-RCT
Placebo
•
Active
Harbo & Jakobsen, not published
Constant & Murley Score
gns of impingement”
0
Pre
fredag den 25. oktober 13
1 mo
6 mo
62. Calcific rotator cuff tendinopathy
A case story
•
•
•
•
fredag den 25. oktober 13
38 year old male referred to our ESWT study
X-ray verified large calcification situated in
supraspinatus
Unable to work and did not want to risk receiving
placebo-treatment
No severe pain, but unable to abduct the shoulder
above 80 degree
70. Calcific rotator cuff tendinopathy
Free painfree ROM
- 1 treatment/week for 3 weeks
- 1 treatment/14 days for 4 weeks
- Control at 12 weeks
fredag den 25. oktober 13
74. TAKE H OME MESS AGE
There are two forms of shockwave and they are DIFFERENT modalities and
should be evaluated separately.
There is strong evidence that F-ESWT is effective in the treatment of plantar
fasciitis and calcific tendinitis, and that low-RPT is effective in plantar
fasciitis.
Where benefit is seen in F-ESWT, it appears to be dose dependent, with
greater success seen with higher dose regimes.
Both modalities are promissing and safe to use - even at
High intensities
fredag den 25. oktober 13
75. TAKE H OME MESS AGE
There are two forms of shockwave and they are DIFFERENT modalities and
should be evaluated separately.
There is strong evidence that F-ESWT is effective in the treatment of plantar
fasciitis and calcific tendinitis, and that low-RPT is effective in plantar
fasciitis.
Where benefit is seen in F-ESWT, it appears to be dose dependent, with
greater success seen with higher dose regimes.
Both modalities are promissing and safe to use - even at
High intensities
fredag den 25. oktober 13
76. TAKE H OME MESS AGE
There are two forms of shockwave and they are DIFFERENT modalities and
should be evaluated separately.
There is strong evidence that F-ESWT is effective in the treatment of plantar
fasciitis and calcific tendinitis, and that low-RPT is effective in plantar
fasciitis.
Where benefit is seen in F-ESWT, it appears to be dose dependent, with
greater success seen with higher dose regimes.
Both modalities are promissing and safe to use - even at
High intensities
fredag den 25. oktober 13
77. TAKE H OME MESS AGE
There are two forms of shockwave and they are DIFFERENT modalities and
should be evaluated separately.
There is strong evidence that F-ESWT is effective in the treatment of plantar
fasciitis and calcific tendinitis, and that low-RPT is effective in plantar
fasciitis.
Where benefit is seen in F-ESWT, it appears to be dose dependent, with
greater success seen with higher dose regimes.
Both modalities are promissing and safe to use - even at
High intensities
fredag den 25. oktober 13
78. It hurts - but it works !
fredag den 25. oktober 13
79. It hurts - but it works !
fredag den 25. oktober 13