ESWT: Extracorporeal Shock Wave Therapy


Extracorporeal Shock Wave Therapy (ESWT) is a popular treatment method used to combat common concerns including heel pain, plantar fasciitis, Achilles tendonitis, tennis elbow, shoulder tendonitis, lateral epicondylitis, and more. It is considered a break through treatment that can make common problems like heel pain virtually obsolete. Many people with chronic pain problems are turning to ESWT to find relief from their pain.


What is ESWT?


ESWT is an FDA approved form of treatment. It is a non-surgical approach to pain relief that is used regularly to cure common problems like plantar fasciitis and Achilles tendonitis. The therapy works by targeting shock waves directly to the area that is experiencing pain. This non-invasive procedure typically lasts less than 30 minutes.


Success Rate


Statistically, over 90 percent of patients that receive this therapy experience a reduction in their pain. In patients that suffered from plantar fasciitis and heel pain related problems, the pain reduction was remarkable. Nearly all patients had successful results with only one treatment of ESWT. For this reason, many people are turning to ESWT to treat their injuries.


Low Risk


One of the main benefits of ESWT is the low risk attached to the procedure. The therapy is treated extracorporeally. Patients receive the therapy outside of their body instead of receiving an invasive surgery. This promotes a faster recovery time, and it also minimizes the side effects from the treatment itself.


Recovering From ESWT


Recovery from ESWT is a gradual process, however the pain will not get worse. In the process of ESWT, damaged tissue cells begin to rebuild. Therefore, healing of the injured area will occur over a few days, weeks or months as these new cells develop. In some rare cases individuals will experience soreness or bruising after the treatment.


Why ESWT?


ESWT is a great option for patients that have chronic pain. Individuals that have tried other options with no results and are still experiencing pain will benefit from ESWT. It is important to try this therapy before the pain gets worse. If the injury gets worse or spreads to other areas of the body, ESWT may not be an option.


ESWT Procedure


Treating chronic pain is relatively simple today with ESWT. This state of the art treatment is a non-surgical, non-invasive option that allows many to cure the pain they suffer from with injuries that are common including, plantar fasciitis, heel pain, Achilles tendonitis, elbow pain, and more.


During The Procedure


This procedure is performed like a normal ultrasound in an effort to locate damaged tissue in the area where pain occurs. Then, once these areas are targeted, a shockwave is sent to stimulate the tissue. This helps enables the body to begin to create new tissue and repair damaged tendons.


This therapy is performed outside of the body (extracorporeally). Therefore, it is considered to be non-invasive and low risk. There are little or no side effects associated with this form of treatment for pain.


Faster Than Outpatient


Typical outpatient procedures last at least half of the day. In addition, individuals have to plan for recovery time. However, ESWT simplifies medical procedures. The entire procedure will last less than 30 minutes. Therefore, it will not take much time or effort; yet, it will be worth the time.


Recovery Time


In addition, usually a patient has to plan for time to recover post-surgery. In most cases, the pain gets worse before it gets better. This is not so with ESWT. Individuals may experience minor pain from the procedure, however it is rare. Then, after ESWT is performed, pain will get better gradually. For most people, it will go away with in a few weeks.


ESWT Recovery


ESWT simplifies the way common problems including heel pain, plantar fasciitis, and Achilles tendonitis are treated today. The procedure offers patients access to a remedy that is not only effective but also quick. In addition, this option is almost always preferred to surgery because it is less invasive, providing for a faster recovery time.


Downsides Of Surgery


Frequently those that suffer from chronic pain need a more extreme remedy than pain medication. Therefore, it is common for someone that suffers from an injury like chronic plantar fasciitis to opt for surgery. However, surgeries for these types of injuries are only 50 percent successful. In addition, they are highly invasive. A surgery takes time and is riskier than other options. Also the recovery time can be substantial.


ESWT Is Low Risk


ESWT is a non-surgical treatment that is less invasive. It is performed outside the body, minimizing risk and abuse that is caused from this therapy. Patients do not have to worry about infections or increased pain from the procedure. And although many view it as a more conservative approach to treating chronic pain, it actually generates a higher success rate. Approximately 80 percent of patients exhibit positive results.


Recovery Time


The procedure lasts less than 30 minutes. Since the duration is brief and the side effects are minimal, patients can expect to return home feeling the same way the did when they came in. The difference is the ESWT will have jumpstarted the healing process in the infected area of their body. Therefore, recovery from ESWT focuses on the time it takes to fully recover from the injury not the procedure.


When To Expect A Full Recovery


Typically this recovery period is gradual. The damaged tissues begin to rebuild themselves after receiving ESWT, and in time the pain begins to decrease. For some, the pain will significantly decrease in a few days. For others, it may take a few months. Whether it is a few days, weeks or months, the results prove that ESWT is a great remedy for today’s top injuries.


ESWT Achilles Tendonitis


Heel pain is a common concern among individuals today, and one common condition that leads to this pain is Achilles Tendonitis. When the foot suffers from Achilles Tendonitis, the Achilles tendon becomes inflamed. This tendon runs from the heel bone to the leg muscles of the foot, and it is the strongest and largest tendon in the body. Because of this tendon, humans have the ability to walk. Therefore, problems with the Achilles tendon can complicate walking and sometimes make it impossible.


Treating Achilles Tendonitis


Achilles tendonitis can be a difficult injury to treat. It is often a chronic problem that will not go away. In this instance, a typical remedy like icing the heel area will only help relieve short-term heel pain. Therefore, many people contemplate more aggressive treatment options. For this reason, several people that suffer from Achilles Tendonitis choose ESWT. It helps relieve the heel pain from their injury.


ESWT


ESWT is great option for a more aggressive form of treatment. Although it is more conservative than surgery, the results are statistically more positive. On average people recover faster and have better results with ESWT than surgery. In addition, the therapy is low risk and has few side effects.


How It Works


The procedure will take less than 30 minutes. An ultrasound will be taken of the heel area to determine where the Achilles tendon has been damaged. Once those target areas have been identified, shock waves will be sent through the skin using the ESWT machine. These shocks stimulate tissue growth surrounding the Achilles tendon and help to repair areas of the Achilles tendon that have been damaged. It is the beginning of a gradual recovery process that frees many people of their pain.


ESWT for Plantar Fasciitis


Plantar fasciitis is the number one problem in podiatrists offices today. Men and women of all ages complain of heel pain that leads to this common foot problem. There are a variety of reasons why someone could have plantar fasciitis. However, all who suffer from this condition put too much stress on their plantar fascia (the thick connective tissue on the sole of the foot). And, when the plantar fascia is stressed and/or inflamed, heel pain results.


Treating Plantar Fasciitis


Because of the numerous plantar fasciitis sufferers, there are several treatment options for this condition. Some of the treatment options are basic stretches and home remedies. In addition, new shoes or inserts are sometimes recommended for heel pain relief. Many people find these treatment options to be effective. However, there are individuals that suffer from chronic plantar fasciitis. Since they deal with chronic pain, they need a more aggressive treatment option. In this case, ESWT is a great alternative.


ESWT


ESWT is a great treatment alternative for the individual who feels like they are out of options. Perhaps they have tried other treatments, yet have not found results. At the same time, surgery seems extreme, highly invasive, and somewhat risky. Fortunately, ESWT offers an aggressive way to combat plantar fasciitis problems while minimizing risks and side effects. It is quick, easy, and relatively painless.


How It Works


The entire procedure lasts less than 30 minutes. Ultrasound technology is used on the sole of the foot to locate areas of the plantar fascia that might be damaged. Once these areas are pinpointed, energy shocks are sent. The shockwaves help stimulate tissue growth, thus repairing the plantar fascia. As the plantar fascia begins to repair itself, the heel pain that is present from plantar fasciitis will decrease. Depending on the person, the pain could be gone in a few days, weeks, or months.


Heel Pain and Heel Spurs


ESWT can be effective on people diagnosed with a heel spur or general heel pain as well. You need to consult a physician to be sure that it will work for you, however many patients find the ESWT procedure as a good treatment for heel pain.


What is Shockwave Biosurgery?

Extracorporeal shockwave therapy (ESWT) is sometimes alternatively known as shockwave biosurgery.



THE BENEFICIAL EFFECTS OF EXTRACORPOREAL SHOCKWAVE THERAPY ARE WIDELY KNOWN. SCIENTISTS RECOGNIZE THAT SHOCKWAVES CAN TRIGGER A VARIETY OF EFFECTIVE ACTIONS


RELEASES MORE SUBSTANCE P


> One of these messenger substances is substance P, a pain mediator and growth factor. On the one hand, the release of substance P by shockwaves has an analgesic effect. On the other, it dilates the blood vessels, stimulates blood circulation and contributes to the formation of new bone tissue. NO (nitric oxide) also has a vasodilatory effect and plays an important role in angiogenesis.


> In short, when applied where pain occurs, we know why shockwaves produce an analgesic effect, increase blood circulation and facilitate the repair process.


INHIBITS THE COX II ENZYME


> By inhibiting inflammatory mediators such as COX II, shockwaves produce an anti-inflammatory effect. This weakens any inflammatory process.


ACTIVATES CELLULAR DEFENSES


> By contributing to the release of free radicals, shockwaves help strengthen the body’s endogenous cellular defense mechanisms to protect it from disease.


HYPERSTIMULATES NERVE FIBRES


> Scientific studies also show that shockwaves act in another way. Over stimulating the nerve fibres blocks an increase in pain stimuli and therefore intensifies the analgesic effect (Gate Control Theory).


 


What Conditions Can Be Treated?

Shockwave Therapy can be used to treat a wide variety of musculoskeletal conditions, in particular, those involving areas where major connective tissue attaches to bone. Common sites that can be successfully treated are:

  • Foot – Plantar Fasciitis, heel spurs & Achilles tendonitis
  • Knee – Patellar tendonitis, jumper's knee & shin pain
  • Elbow – tennis or golfer’s elbow
  • Shoulder – rotator cuff tendonitis & calcification
  • Hip – trochanteric bursitis
  • Muscles – various trigger points throughout the body and muscle tension
  • Bones-Stress fractures, non union's(delayed bone healing)
  • Nerves-Morton's Neuroma

 

What are the Advantages?

Shockwave therapy is a recent development that is used successfully by healthcare providers that specialize in musculoskeletal disorders. As compared to other treatment methods, the advantages are:

  • Quickly reduces pain
  • No medication is needed
  • Avoids surgery and anasthesia
  • No side effects
  • No risk of allergies
  • Accelerates healing
  • Effective for chronic conditions

 

How does shockwave work?

Shockwaves accelerate the healing process by activating the body’s self-healing powers, particularly in cases where the body has been unable to do it on its own.  It stimulates metabolism and enhances blood circulation which enables damaged tissue to regenerate and eventually heal. The treatment relieves pain by producing an analgesic effect on the treatment area. Healing occurs over several treatments by initiating an inflammatory response and ultimately vascularization to the area. The high energy acoustic waves that are transmitted through the surface of the skin are spread radially (spherically) into the body and the body responds with increased metabolic activity around the area of the pain. This stimulates and accelerates the healing process and is especially useful for those suffering from chronic heel, shoulder, knee, achilles, elbow and back pain.

Your therapist will apply shockwaves through a specially designed hand piece that produces strong energy pulses for short periods of time.  The shockwave energy pulses are applied directly to the affected tissue areas in controlled procedure.

Shockwaves have a mechanical effect on the tissue.  Pressure in the front of the shockwave is transmitted into the tissue, creating micro-cavitation bubbles that expand and burst into a resultant force. (see chart A)

This force penetrates tissue and stimulates cells in the body which are responsible for bone (osteoblast) and connective tissue (fibroblast) healing.

Research has also shown that Shockwave also breaks down calcium deposits.

What is the success rate?

After only 2-3 sessions, over 80% of patients report a significant reduction in pain.

  • 90% improvement for plantar fasciitis (Journal of Orthopedic Research, 2005)
  • 91% improvement for calcific tendonitis (Journal of American Medical Association, 2003)
  • 77% improvement for tennis elbow (Journal of Orthopedics, 2005)

How Long Does Treatment Last?

The therapy session takes about 10-15 minutes depending on the disorder that is treated.  In general, 3-5 sessions are necessary at weekly intervals.

Ask your doctor or therapist if your condition can be treated by Shockwave Therapy and book your treatment sessions today at Shelbourne Physiotherapy in Victoria BC!

 Research Articles

The following articles confirm the scientific validity of Shockwave Therapy;

Ultrasound Med Biol. 2012 May;38(5):727-35. Epub  2012 Mar 16.
Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis a prospective randomized controlled study. Liu S, Zhai L, Shi Z, Jing R, Zhao B, Xing G.
Source

Orthopaedic Department, Medical College Affiliated Hospital of Chinese People's Armed Police Force, Tianjin, China.

Abstract

Long bicipital tenosynovitis is regarded as one of the common causes of shoulder pain and dysfunction. The traditional therapeutic approach includes a variety of conservative treatments, but these treatments are not substantiated, owing to the lack of proven clinical efficacy. Radial extracorporeal shock wave therapy (rESWT) uses a pneumatically generated and radially propagating low-energy pressure pulse and has been clinically shown to be a new alternative form of treating refractory soft tissue inflammation. While treating patients suffering from long bicipital tenosynovitis, a randomized, controlled trial was conducted to analyze the effects of radial shock wave therapy on pain and function. Seventy-nine adults with long bicipital tenosynovitis were randomized to receive either active (1500 pulses, 8 Hz, 3 bars) or sham treatment through four sessions that were held once a week. All of these adults were assessed before treatment and at time intervals of 1, 3 and 12 months since the completion of the treatment. The outcomes were measured through the visual analogue scale (VAS) and L'Insalata shoulder questionnaire. Mean VAS in the rESWT group showed significant and sustained reduction from 5.67 ± 1.32 at baseline to 2.58 ± 1.49 at one month, 1.83 ± 1.25 at three months and 1.43 ± 0.94 at 12 months from baseline, whereas the sham group's mean VAS was 6.04 ± 0.97 before treatment and stabilized at 5.57 ± 0.84 at 12 months. Similar trends were found for the function scores. Mean scores were increased after rESWT from 60.57 ± 6.91 at baseline to 79.85 ± 6.59 at 1 month and 83.44 ± 5.21 at 12 months from baseline. Both pain and function scores showed significant differences between the two groups (p < 0.001). The rESWT group consisted of "invalid conservative treatment subgroup" and "none conservative treatment subgroup." Both groups showed good recovery and prognosis. Therefore, we recommend rESWT in treating primary long bicipital tenosynovitis.

 
J Orthop Surg Res. 2012 Mar 20;7:11.
Extracorporeal shockwave therapy in musculoskeletal disorders. Wang CJ.
Source

Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan. [email protected]

Abstract

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

Clin Podiatr Med Surg. 2003 Apr;20(2):323-34.
Extracorporeal shock wave therapy for plantar fasciitis. Perez M, Weiner R, Gilley JC.
Source

Clintonville Foot and Ankle Group, Inc., 3695 N. High Street, Columbus, OH 43214, USA.

Abstract

Shock wave therapy is quickly becoming a mainstay treatment for chronic recalcitrant plantar fasciitis, and many more applications for this therapy may exist. Many advances have been made in regard to this modality of treatment in just a few decades since it was first investigated in the 1950s. Much research has been conducted, revealing the physics and physiologic effect of shock wave therapy. Devices are now approved that produce shock waves for medicinal purposes by one of the three primary methods of shock wave generation. Studies and research are actively being reported and published that demonstrate shock wave therapy success rates comparable to those found in surgical intervention but without the risks inherent in surgery. In conclusion, ESWT has proved to be a viable treatment option for the intervention of chronic recalcitrant plantar fasciitis.

J Orthop Res. 2006 Feb;24(2):115-23.
Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study. Kudo P, Dainty K, Clarfield M, Coughlin L, Lavoie P, Lebrun C.
Source

Fowler Kennedy Sport Medicine Clinic, 3M Centre University of Western Ontario, London, Ontario N6A 3K7, Canada.

Abstract

Despite numerous publications and clinical trials, the results of treatment of recalcitrant chronic plantar fasciitis with extracorporeal shockwave therapy (ESWT) still remain equivocal as to whether or not this treatment provides relief from the pain associated with this condition. The objective of this study was to determine whether extracorporeal shock wave therapy can safely and effectively relieve the pain associated with chronic plantar fasciitis compared to placebo treatment, as demonstrated by pain with walking in the morning. This was set in a multicenter, randomized, placebo-controlled, double-blind, confirmatory clinical study undertaken in four outpatient orthopedic clinics. The patients, 114 adult subjects with chronic plantar fasciitis, recalcitrant to conservative therapies for at least 6 months, were randomized to two groups. Treatment consisted of approximately 3,800 total shock waves (+/-10) reaching an approximated total energy delivery of 1,300 mJ/mm(2) (ED+) in a single session versus placebo treatment. This study demonstrated a statistically significant difference between treatment groups in the change from baseline to 3 months in the primary efficacy outcome of pain during the first few minutes of walking measured by a visual analog scale. There was also a statistically significant difference between treatments in the number of participants whose changes in Visual Analog Scale scores met the study definition of success at both 6 weeks and 3 months posttreatment; and between treatment groups in the change from baseline to 3 months posttreatment in the Roles and Maudsley Score. The results of this study confirm that ESWT administered with the Dornier Epos Ultra is a safe and effective treatment for recalcitrant plantar fasciitis.

Am J Sports Med. 2008 Nov;36(11):2100-9. Epub  2008 Oct 1.
Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, Russlies M, Stienstra J, Scurran B, Fedder K, Diehl P, Lohrer H, Henne M, Gollwitzer H.
Source

Department of Orthopedic and Traumatology, Technical University Munich, Klinikum Rechts der Isar, Germany. [email protected]

Abstract BACKGROUND:

Radial extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis that can be administered to outpatients without anesthesia but has not yet been evaluated in controlled trials.

HYPOTHESIS:

There is no difference in effectiveness between radial extracorporeal shock wave therapy and placebo in the treatment of chronic plantar fasciitis.

STUDY DESIGN:

Randomized, controlled trial; Level of evidence, 1.

METHODS:

Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm(2); 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks' follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Maudsley score, SF-36, and patients' and investigators' global judgment of effectiveness 12 weeks and 12 months after extracorporeal shock wave therapy.

RESULTS:

Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 1-sided). No relevant side effects were observed.

CONCLUSION:

Radial extracorporeal shock wave therapy significantly improves pain, function, and quality of life compared with placebo in patients with recalcitrant plantar fasciitis.

 

Clin Rheumatol. 2012 May;31(5):807-12. Epub  2012 Jan 27. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical and ultrasonographical comparison.
Source

Physical Medicine and Rehabilitation Clinic, Ankara Training and Research Hospital, Ankara, Turkey.

Abstract

The aim of this study was to compare--clinically and ultrasonographically--the therapeutic effects of physical therapy modalities (hot pack, ultrasound therapy, and friction massage), local corticosteroid injection, and extracorporeal shock wave treatment (ESWT) in lateral epicondylitis (LE). Fifty-nine elbows of 59 patients with LE were randomized into three treatment groups receiving either physical therapy, a single corticosteroid injection, or ESWT. Visual analogue scale (VAS) was used to assess pain intensity, Jamar hydraulic dynamometer for grip strength, finger dynamometer for pinch strength (before treatment, on the first, third, and sixth months of treatment). All subjects were also evaluated with ultrasonography before and 6 months after treatment. In all groups, VAS scores of the patients were found to decrease significantly on the first, third, and sixth months of treatment. With respect to grip strength evaluations, the increase after treatment was significant only on the first month in group II; on the first and third months in group I; and on the first, third, and sixth months of treatment in group III. Pinch strength and ultrasonographical findings did not change during follow-up in any group. We imply that physical therapy modalities, corticosteroid injection, and ESWT have favorable effects on pain and grip strength in the early period of LE treatment. The increase in grip strength lasts longer with ESWT. On the other hand, ultrasonographic findings do not change in the first six months of these treatment methods.

Shockwave Therapy for Calcium Deposits in Shoulder

Reference:Adnan Saithna, BMedSci(Hons), MBChB, MRCSEd, et al.
Is Extracorporeal Shockwave Therapy for Calcifying Tendinitis of the Rotator Cuff Associated with a Significant Improvement in the Constant-Murley Score? A Systematic Review.

In Current Orthopaedic Practice. September/October 2009. Vol. 20. No. 5. Pp. 566-571.

What's the best way to treat calcifying tendinitis of the shoulder that doesn't respond to physical therapy, medications, or steroid injections? The authors of this systematic review report that the use of extracorporeal shockwave therapy (ESWT) has proven successful, though we still don't know if it is the best treatment approach. That remains to be determined in future studies.

What is calcifying or calcific tendinitis? It's a degenerative condition affecting the four tendons surrounding the shoulder called the rotator cuff. These include the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. All four muscles can be affected, but usually it's just one of the four. And the tendons are listed here in declining order of frequency (i.e., supraspinatus is affected most often and subscapularis least often).

Calcium crystals called calcium pyrophosphate are deposited in the tendons. No one knows where these crystals come from exactly. But once the tendons start to degenerate, the crystals are released into the soft tissues as the tendon fibrils break down. Research shows that the calcium crystals help the tendon degenerate. The tendons harden and symptoms of impingement can develop. With impingement, there is shoulder pain when the arm is raised overhead or to the side above shoulder level. The stiff tendon doesn't move and glide as it should and it gets pinched between the bony structures of the shoulder. Sometimes the person with this problem can move the arm through the pain all the way overhead. But other people have limited motion that leads to decreased function.

By sorting through five years of data from recently published studies, researchers from the Department of Trauma and Orthopaedic Surgery in England were able to confirm that all studies showed improvement after treating calcifying tendinitis of the rotator cuff with extracorporeal shockwave therapy (ESWT). ESWT is the use of sound waves to create enough energy to disintegrate the calcium deposits. It has been used with good results for other problems like gallstones and kidney stones. Once the calcium crystals have been broken up, it appears that the body absorbs them because X-rays show they disappear.

Most of the studies included patients with Types I and II calcification. There are three types of calcifying tendinitis diagnosed by X-rays. Type I has deposits that have clear outlines. A line can be drawn around the dense deposits to show exactly where they are, their size, and their shape. Type II disease has a clear outline but tends to be spread out more through the tissue and harder to see as a distinct shape. Type III lesions look cloudy without a specific form, shape, or outline.

All studies used a scoring system called the Constant-Murley score to measure results before and after treatment. Having one test used by everyone made it possible to compare the outcomes from one study to the next -- even when the studies weren't all conducted exactly the same way. The authors point out that this advantage was also a disadvantage. With only one measure of results was used, it's impossible to know if other test measures might have shown a different result (better or worse). They suggest that future studies use other scoring systems for a comparison.

But for now, it looks like extracorporeal shockwave therapy is safe and effective for this potentially disabling condition. Significant improvement in motion, pain, strength, and function was consistently reported in all studies included in the review. Improvements were reported using both high-energy and low-energy shockwave therapy but high-energy had the best results. Low-energy therapy was better than no treatment or sham (placebo) groups.

Low-Energy Extracorporeal Shock Wave Therapy as a Treatment for Greater Trochanteric Pain Syndrome

The American Journal of Sports Medicine, Vol. X, No. X
John P. Furia, MD, Jan D. Rompe, MD, and Nicola Maffulli, MD, MS, PhD, FRCS (Orth), FFSEM (UK)From SUN Orthopedics and Sports Medicine, Lewisburg, Pennsylvania, OrthoTrauma Evaluation Center, Mainz, Germany, Centre for Sports and Exercise, Barts and the London School of Medicine and Dentistry, London, United Kingdom

Background: Greater trochanteric pain syndrome is often a manifestation of underlying gluteal tendinopathy. Extracorporeal shock wave therapy is effective in numerous types of tendinopathies.

Hypothesis: Shock wave therapy is an effective treatment for chronic greater trochanteric pain syndrome.

Study Design: Case control study; Level of evidence, 3.

Methods: Thirty-three patients with chronic greater trochanteric pain syndrome received low-energy shock wave therapy (2000 shocks; 4 bars of pressure, equal to 0.18 mJ/mm2; total energy flux density, 360 mJ/mm2). Thirty-three patients with chronic greater trochanteric pain syndrome were not treated with shock wave therapy but received additional forms of nonoperative therapy (control). All shock wave therapy procedures were performed without anesthesia. Evaluation was by change in visual analog score, Harris hip score, and Roles and Maudsley score.

Results: Mean pretreatment visual analog scores for the control and shock wave therapy groups were 8.5 and 8.5, respectively. One, 3, and 12 months after treatment, the mean visual analog score for the control and shock wave therapy groups were 7.6 and 5.1 (P < .001), 7 and 3.7 (P < .001), and 6.3 and 2.7 (P < .001), respectively. One, 3, and 12 months after treatment, mean Harris hip scores for the control and shock wave therapy groups were 54.4 and 69.8 (P < .001), 56.9 and 74.8 (P < .001), and 57.6 and 79.9 (P < .001), respectively. At final follow-up,  the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 10 and 0 (P < .001), 16 and 12 (P < .001), 4 and 13 (P < .001), and 3 and 8 (P < .001), respectively. Chi-square analysis showed the percentage of patients with excellent (1) or good (2) Roles and Maudsley scores (ie, successful results) 12 months after treatment was statistically greater in the shock wave therapy than in the control group (P < .001).

Conclusion: Shock wave therapy is an effective treatment for greater trochanteric pain syndrome.

Keywords: extracorporeal shock wave therapy; hip; subgluteus bursa; bursitis

 

Evidence to Support Shock Wave Therapy for Plantar Fasciitis

Plantar Fascitis is a painful condition affecting the bottom of the foot. It is a common cause of heel pain and is sometimes called a heel spur. Plantar fasciitis is the correct term to use when there is active inflammation. Acute plantar fasciitis is defined as inflammation of the origin of the plantar fascia and fascial structures around the area. Plantar fasciitis is usually just on one side. In about 30 per cent of all cases, both feet are affected.

Treatment is usually with conservative (nonoperative) care. This could include stretching, wearing a splint at night, the use of antiinflammatory medications, and/or a special arch support to help reduce the pressure on the fascia.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks. It is not known exactly why it works for plantar fasciitis. It's possible that the shock waves disrupt the plantar fascial tissue enough to start a healing response. The resulting release of local growth factors and stem cells causes an increase in blood flow to the area. Recent studies indicate that this form of treatment can help ease pain, while improving range of motion and function.

There are different types of shock wave therapy. In this study, researchers from Taiwan conduct a systematic review and meta-analysis comparing the effectiveness of two major types of shock wave therapy. The most common type is called focused shock wave therapy (FSW). A newer, alternative form called radial shock wave therapy (RSW) was also evaluated.

Focused shock wave (FSW) therapy is just as it sounds: the energy wave is directed at a specific area. FSW concentrates the wave field whereas radial shock wave (RSW) disperses the energy over a wider range. With RSW, it is not necessary to find the painful spots before applying the energy wave.

A particular area of interest in this study was to see the value in using different intensity levels, which represent energy flow through the tissue. Turning the intensity up may provide more pain relief but could also temporarily increase pain, local swelling, and tenderness. Studies have not been done to determine the most optimal intensity to use when treating plantar fasciitis with shock wave therapy.

Focus shock wave therapy can be delivered in three intensities: low, medium, and high. Patients receiving FSW were divided into three groups based on the intensity of wave delivery. Patients receiving RSW made up the fourth group. Results were measured based on pain reduction and overall success of the treatment. The goal was to see if one type of shock therapy was superior to the others in treating plantar fasciitis.

What did they find? Well, first of all, any type of shock wave therapy yielded better results than a "sham" or placebo (pretend) treatment. The best results were gained using radial shock wave (RSW) therapy. Focused shock wave (FSW) gave the best results when used at the highest energy density tolerated by the patient in the medium intensity range.

For those who use this modality to treat plantar fasciitis, the authors say don't go out and purchase a radial shock wave machine if you already have a focused shock wave device. Anyone just considering purchasing this equipment is advised to select radial shock wave therapy. It costs less and gives better results with fewer potential side effects.

Reference:
Ke-Vin Chang, MD, et al. Comparative Effectiveness of Focused Shock Wave Therapy of Different Intensity Levels and Radial Shock Wave Therapy for Treating Plantar Fasciitis: A Systematic Review and Network Meta-Analysis. In The American Journal of Sports Medicine. July 2012. Vol. 93. No. 7. Pp. 1259-1268.

Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis

J Bone Joint Surg AM, 2005 Jun:87(6):1297-304

Pettrone FA, McCall BR.

Source
Commonwealth Orthopaedics, 1635 North George Mason Drive, Suite 310, Arlington, VA 22205, USA.

Abstract

BACKGROUND:
The use of extracorporeal shock wave therapy for the treatment of lateral epicondylitis is controversial. The purpose of this study was to evaluate the use of extracorporeal shock wave therapy without local anesthesia to treat chronic lateral epicondylitis.
METHODS:
One hundred and fourteen patients with a minimum six-month history of lateral epicondylitis that was unresponsive to conventional therapy were randomized into double-blind active treatment and placebo groups. The protocol consisted of three weekly treatments of either low-dose shock wave therapy without anesthetic or a sham treatment. Patients had a physical examination, including provocation testing and dynamometry, at one, four, eight, and twelve weeks and at six and twelve months after treatment. Radiographs, laboratory studies, and electrocardiograms were also evaluated prior to participation and at twelve weeks. A visual analog scale was used to evaluate pain, and an upper extremity functional scale was used to assess function. Crossover to active treatment was initiated for nonresponsive patients who had received the placebo and met the inclusion criteria after twelve weeks.
RESULTS:
A total of 108 of the 114 randomized patients completed all treatments and the twelve weeks of follow-up required by the protocol. Sixty-one patients completed one year of follow-up, whereas thirty-four patients crossed over to receive active treatment. A significant difference (p = 0.001) in pain reduction was observed at twelve weeks in the intent-to-treat cohort, with an improvement in the pain score of at least 50% seen in 61% (thirty-four) of the fifty-six patients in the active treatment group who were treated according to protocol compared with 29% (seventeen) of the fifty-eight subjects in the placebo group. This improvement persisted in those followed to one year. Functional activity scores, activity-specific evaluation, and the overall impression of the disease state all showed significant improvement as well (p < 0.05). Crossover patients also showed significant improvement after twelve weeks of active treatment, with 56% (nineteen of thirty-four) achieving an improvement in the pain score of at least 50% (p < 0.0001).
CONCLUSIONS:
These results demonstrate that low-dose shock wave therapy without anesthetic is a safe and effective treatment for chronic lateral epicondylitis.

Repetitive low-energy shock wave application without local anesthesia is more efficient than repetitive low-energy shock wave application with local anesthesia in the treatment of chronic plantar fasciitis


Rompe JD, Meurer A, Nafe B, Hofmann A, Gerdesmeyer L.

Background:
It remains unclear whether application of local anesthesia (LA) interferes with clinical efficacy of extracorporeal shock wave therapy (ESWT) for chronic plantar fasciitis.
Aims: To evaluate the effect of local anesthesia on the clinical outcome after repetitive low-energy ESWT for chronic plantar fasciitis.
Methods:
Eighty-six patients with chronic plantar fasciitis were randomly assigned to receive either low-energy ESWT without LA, given weekly for three weeks (Group I, n=45; 3 x 2000 pulses, total energy flux density per shock 0.09 mJ/mm2) or identical ESWT with LA (Group II, n=41). Primary outcome measure was: Reduction of pain from baseline to month 3 post-treatment in a pain numeric rating scale [0-10 points] during first steps in the morning, evaluated by an independent blinded observer. Calculations were based on intention-to-treat.
Results:
No difference was found between the groups at baseline. At 3 months, the average pain score was 2.2+/-2.0 points for patients of Group I, and 4.1+/-1.5 points for patients of Group II. The mean between-group difference was 1.9 points (95% CI: [1.1-2.7 points]; P<.001). Significantly more patients of Group I achieved 50% reduction of pain compared to Group II (67% vs 29%, P<.001).
Conclusions: ESWT as applied should be done without LA in patients suffering from chronic heel pain. LA applied prior treatment reduced the efficiency of low-energy ESWT.

 


Arch Phys Med Rehabil. 2013 Mar 13. pii: S0003-9993(13)00205-0. doi: 10.1016/j.apmr.2013.01.030. [Epub ahead of print]

Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months follow-up. A systematic review and meta-analysis.

Ioppolo F, Tattoli M, Di Sante L, Venditto T, Tognolo L, Delicata M, Rizzo RS, Di Tanna G, Valter S.

Source: Physical Medicine and Rehabilitation Unit, Azienda Policlinico Umberto I, Rome, Italy. Electronic address: [email protected]

Abstract

OBJECTIVE: To evaluate the effect of the Shock wave therapy (SWT) on functional improvements and reduction of pain, and what is rate of disappearance of calcifications after therapy at 6 month follow up.

DATA SOURCES: Articles were searched from the COCHRANE LIBRARY, MEDLINE, EMBASE, CINAHL and OVID DATABASE.

STUDY SELECTION:We included randomized controlled trials from 1992 to 2011 and their quality was assessed using the PEDro scale.

DATA EXTRACTION: Studies were evaluated by two independent reviewers for their methodological quality. If disagreement arose the plan was that it would be settled by a third reviewer. Then data were extracted and cross-checked for accuracy. The reviewers were not blinded to the authors of the articles.

DATA SYNTHESIS: In studies of Hearnden, Hsu, Cacchio and Cosentino the resorption of calcifications was evaluate using meta-analysis because in them there were two groups of treatment, while the studies of Peters and Gerdesmeyer were analyzed descriptively because they considered three groups of treatment. Fixed and random effects models were used to meta-analyze total and partial resorption ratios and to assess heterogeneity the I2 statistics were calculated.

CONCLUSIONS: We found a clinical improvement with a pooled Total Resorption Ratio of 27.19 (95% CI: 7.20-102.67) and a pooled Partial Resorption Ratio of 16.22 (95% CI: 3.33-79.01). SWT increases shoulder function, reduces pain, and it is effective in dissolving calcifications. These results were maintained over the following 6 months.

Am J Phys Med Rehabil. 2013 Apr 2.

Effectiveness of Extracorporeal Shock Wave Therapy in Chronic Plantar Fasciitis: A Meta-analysis.

Source: Dizon JN, Gonzalez-Suarez C, Zamora MT, Gambito ED.

From the Department of Physical Medicine and Rehabilitation, University of Santo Tomas Hospital, Manila, Philippines.

Abstract                                          

The objective of this study was to evaluate the effectiveness of extracorporeal shock wave therapy (ESWT) in treating chronic plantar fasciitis. An online database search was conducted for studies using ESWT in managing chronic plantar fasciitis. Eleven high-quality randomized controlled trials were included in the meta-analysis and showed that ESWT was more effective in reducing morning pain (weighted mean difference, -0.77 [95% confidence interval {CI}, -1.30 to -0.25]; odds ratio, 0.65 [95% CI, 0.42-1.00]). Moderate-intensity ESWT was more effective in decreasing overall and activity pain (weighted mean difference, -6.6 [95% CI, -6.74 to -6.46], and weighted mean difference, 0.47 (95% CI, 0.30-0.74). Both moderate- and high-intensity ESWT were more effective in improving functional outcome, with odds ratios of 0.51 (95% CI, 0.30-0.84) and 0.47 (95% CI, 0.29-0.75). The adverse effects that were seen more in ESWT were pain on the calcaneal area and calcaneal erythema. This study concludes that moderate- and high-intensity ESWT were effective in the treatment of chronic plantar fasciitis.

Radial extracorporeal shock wave therapy improves recalcitrant plantar fasciitis symptoms.

OrthoEvidence Advanced Clinical Evidence Report. In: Ortho Evidence. Created Oct 01, 2011. Last modified Oct 01, 2012. Retrieved Jul 26, 2013 from http://www.myorthoevidence.com/?section=15&id=2807.

Radial Extracorporeal Shock Wave Therapy Is Safe and Effective in the Treatment of Chronic Recalcitrant Plantar Fasciitis

Results of a Confirmatory Randomized Placebo-Controlled Multicenter Study

Ludger Gerdesmeyer,MD, PhD, Carol Frey, MD, Johannes Vester, PhD,Markus Maier, PhD, Lowell Weil Jr, DPM, Lowell Weil Sr,DPM, Martin Russlies, PhD,John Stienstra,DPM, Barry Scurran, DPM, Keith Fedder, MD, Peter Diehl, MD,Heinz Lohrer, MD, Mark Henne, MD, and Hans Gollwitzer, MDFrom the Department of Orthopedic and Traumatology, Technical University Munich, KlinikumRechts der Isar, Germany, the Department of Joint Arthroplasty and Clinical Science, MareClinic, Kiel, Germany, Orthopaedic Foot and Ankle Center, Manhattan Beach, California, DVData Analyses and Study Planning, Biometrics in Medicine, Gauting, Germany, the Departmentof Orthopedics, Ludwig Maximilian University, Munich, Germany, the Weil Foot and Ankle Institute, Des Plaines, Illinois, University Schleswig Holstein, Campus Lübeck, Lübeck,Germany, the Department of Podiatry, The Permanente Medical Group Inc, Union City,California, the Department of Orthopedics, University Rostock, Rostock, Germany, and the Institute of Sportsmedicine, Frankfurt am Main, Germany

Background: Radial extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis that can be administered to outpatients without anesthesia but has not yet been evaluated in controlled trials.

Hypothesis: There is no difference in effectiveness between radial extracorporeal shock wave therapy and placebo in the treatment of chronic plantar fasciitis.

Study Design: Randomized, controlled trial; Level of evidence, 1.

Methods: Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm2; 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks’ follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Maudsley score, SF-36, and patients’ and investigators’ global judgment of effectiveness 12 weeks and 12 months after extracorporeal shock wave therapy.

Results: Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 1- sided). No relevant side effects were observed.

Conclusion: Radial extracorporeal shock wave therapy significantly improves pain, function, and quality of life compared with placebo in patients with recalcitrant plantar fasciitis.

Keywords: heel pain; plantar fasciitis; shock wave; lithotripsy; radial extracorporeal shock wave therapy

The American Journal of Sports Medicine, Vol. X, No. X

Focus
Shock wave therapy

M. Gleitz, U. Dreisilker, R. Rädel

Orthopedic trigger point shock wave therapy with focused and radial shock waves: a review of the current situation

Orthopedic Surgery, Dr. Gleitz, Luxemburg Introduction

Myofascial pain syndromes are among the most frequent orthopedic disorders. However, efforts to treat these syndromes often show limited success. This is confirmed by the multitude of competing therapy options available today.
According to the theory established by Travell and Simons in their Trigger Point Manual (1992), muscular trigger points are one of the main causes of myofascial pain. Clinical observations and experimental examinations conducted by Travell and Simons have corroborated this theory, demonstrating that muscular trigger points cause diverse functional disorders. These findings coincide with the information provided by patients on pain development and progression. Despite the impressively detailed description of muscle- associated pain syndromes in the Trigger Point Manual (1992), trigger point therapy is still only rarely used in orthopedic practice.

The role of trigger points in causing pain and discomfort is evidenced by the clinical symptoms they may generate: formation of muscle knots with local and referred pain, muscular taut bands, twitch response, reduced range of motion (ROM) of joints, formation of satellite trigger points, development of pseudoradicular dysesthesia and vegetative accompanying reactions.
According to Simons' "integrated hypothesis of trigger point formation" (1996), trigger points are produced by muscular motor end-plate dysfunction which may be caused by various mechanisms, such as acute mechanical overstrain, including trauma, chronic overstrain caused by monotony of motion (repetitive strain injury), poor posture, cold, emotional distress, or result from articular, neurogenic, visceral, hormonal or remote muscular disorders.
The increased calcium release resulting from the above lesions causes a permanent contracture of the actin/myosin filaments (abnormally contracted sarcomeres) under the dysfunctional end-plate and thus leads to increased energy consumption. At the same time, the capillary compression caused by the contraction knots produces local ischemia. The concurrence of these two factors causes a local energy crisis. Local ischemia induces the release of bradykinine in the tissue and of other substances sensitizing muscle nociceptors and increases the tenderness to pressure of the trigger points (allodynia, hyperalgesia). Ischemia causes additional motor end-plate dysfunction and thus creates a vicious circle. Muscles affected by trigger points exhibit changed properties. Apart from the typical contractures, these muscles are characterized by a reduced development of muscular force, delayed relaxation after activity, tendency to spasm and decreased fine motor skills (coordination). These conditions explain the muscles' susceptibility to additional lesions (muscle strain, torn fibers, etc.).
Trigger points cause alterations in the nervous system that contribute to the chronification of pain. These alterations include peripheral sensitization of muscle nociceptors, increased number of nociceptors, activation of the axon reflex, central sensitization (synaptic transmission) and failure of inhibiting interneurons of the supraspinal descending antinociceptive system (8).
If trigger points continue to exist over a prolonged period of time, they may activate satellite trigger points in other muscles. These satellite trigger points will develop their own pain patterns and functional disorders. This will eventually induce myopathic chain reactions (2)

with complex pain patterns and secondary structural alterations in the form of insertional tendinopathies (3).
The typical referred pain caused by trigger points is explained on the basis of the "convergence projection theory" (13). This theory postulates that the information from diverse peripheral receptors in various tissue regions is centrally transmitted through a common segmental dorsal horn neuron, which causes a misperception of pain in the patient. If doctors use an approach that is entirely based on classical neurological innervation patterns, this phenomenon makes it extremely difficult to localize the pain origin.

Muscular trigger points require specific treatment owing to their low self-healing capacity. One of the most effective therapy procedures is the application of strong mechanical pressure to the muscle knots (gelotripsy) followed by muscle stretching (17). The following reasons for the efficacy of this therapy approach are discussed: resolution of permanent actin/myosin contractures, improvement of local circulation (reactive hyperemia) along with the elimination of the ischemia-induced energy crisis (8) and reduction in the concentration of vasoneuroactive substances.

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Summary
Key words: ESWT – trigger points – myofascial pain syndrome
Orthopedic trigger point shock wave therapy with focused and radial shock waves

The trigger point therapy of Travell and Simons is the starting point for the diagnosis and treatment of myofascial pain syndromes. As trigger points are difficult to localize and trigger point therapy has only limited efficiency, this therapy option is rarely used in practice.
Shock wave application to trigger points represents a new therapy approach in trigger point treatment. The combined use of radial and focused shock waves allows effective local trigger point treatment as well as shock wave application to a wider muscle surface area. Focused shock waves can be used to induce referred pain for precise trigger point localization.

The experience gathered by the authors has shown that a wide range of functional disorders can be treated with trigger point shock wave therapy. The therapy success is based on recognizing muscular trigger points as the origin of pain, which sets this therapy apart from conventional treatment methods.

No scientific evidence is available to date explaining the precise mode of action of shock waves applied to muscular trigger points.

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Trigger point shock wave therapy

Application of shock waves to muscles

Since the mid-1990s, various publications have discussed the possibility of muscle treatment with low-energy focused shock waves (4, 5, 7, 14) as an alternative to manual therapy. The common result of the treatments conducted is a reduction of muscle tone along with a diminished extent of muscle shortening.

Since the late 1990s, muscular trigger points have also been treated with radial shock waves (rESWT) with a tissue penetration depth of 20 to 25 mm. While no scientific evidence is available to date explaining the exact mechanism of radial shock waves, extensive molecular and biochemical research has been conducted into the mode of action of focused shock waves (6, 18). In fact, focused shock waves induce a reduction of nociceptive fibers, whereas radial shock waves seem to have a counter-irritation and pain modulating effect

through GABAergic interneurons in the dorsal horn. In addition to this action, the pressure and vibrations of radial shock waves improve blood circulation and lymphatic drainage.

Indications and contraindications

Trigger point shock wave therapy can be used to treat all acute and chronic myofascial disorders, provided that no primary disease is present that causes the muscular trigger points and prevents their elimination. In the latter case, trigger points and entire trigger point chains must be seen as part of complex disease patterns such as visceral and psychic diseases, craniomandibular dysfunctions or foot deformations with proprioceptive control disorders. Such conditions should be treated by conducting a causal therapy of the primary disease on the one hand and by eliminating the trigger point syndromes on the other hand. Trigger point therapy is most successful if the primary disease causing the trigger point symptoms can be entirely cured or if its intensity can at least be minimized. Despite causal therapy, trigger points are frequently found to persist or to develop independently. This condition, which is referred to as autonomous trigger point syndrome, can be well treated with trigger point shock wave therapy.

One example for this phenomenon is pseudosciatica after successful discectomy. The trigger points in the gluteal muscles, external rotators (e.g. piriformis muscle) and quadratus lumborum muscle that were activated by the original nerve compression continue to persist despite the fact that the root compression has been eliminated. Successful resolution of these trigger points is only possible by means of trigger point therapy.

Examples of poor indications for trigger point therapy are genuine radicular lesions or advanced spinal or foraminal stenosis in the lower lumbar segments, also with secondary trigger points in the gluteal or hip muscles. Although trigger point therapy of these conditions frequently provides alleviation of pain, this effect will only be of short duration owing to the dominant nature of the nerve compression.
Trigger point therapy is not successful in the treatment of the following disorders: all types of rheumatism with inflammatory activity, severe fibromyalgia and severe vegetative dystonia. General contraindications for trigger point therapy include malignant tumors, primary myopathies, serious rheumatic diseases (e.g. rheumatic polymyalgia) or treatment areas above vulnerable structures. During shock wave therapy, it is crucial that pulmonary tissue is not within the target area of focused shock waves.
Relative contraindications include pregnancy and anticoagulant therapy.

Radial or focused shock waves?

The combined use of focused and radial shock waves is one of the recent developments in trigger point therapy. With this approach, focused shock waves are used to treat both tendon insertions and muscles.
The application of focused shock waves to tendon insertions is recommended whenever muscle shortening caused by trigger points has resulted in secondary insertional tendinopathies. In these cases, treatment of the muscular trigger points alone would not be sufficient to cure the disease as the tendon irritation is often responsible for the dominant pain symptoms and would persist as an independent cause of pain even after successful muscular trigger point therapy.

Focused shock waves applied to muscles are used for diagnostic and therapeutic purposes. On the one hand, they ensure precise localization of the trigger points as the typical referred pain can be induced more reliably than during manual examination. On the other hand, focused shock waves are used for the local treatment of individual trigger points. Thanks to the minimal irritation they cause, focused shock waves can also be used for the trigger point therapy of extremely painful muscles.

Radial shock waves are used for the local treatment of muscular trigger point areas and, subsequently, for smoothing the residual muscle. This method allows large muscle regions to be treated with radial shock waves.

When treating extremely painful myofascial syndromes, only focused shock waves should be used during the initial therapy sessions. Treatment can then be continued with radial shock waves at low therapy pressure (1.6 – 1.8 bar).
Promising experience has been gathered recently in the use of defocused shock waves for the treatment of trigger points or insertional tendinopathies. "Defocused" means that the generated waves are applied to the tissue not in a single spot but over a wider surface area.

Therapy planning

The muscles to be treated are selected on the basis of the following criteria: patient's indication of pain, diagnosis of muscle knots (manually or with radial shock waves), possible provocation of referred pain by palpation pressure or with focused shock waves and, where possible, ROM testing to identify the muscles affected by reductions in the range of motion. The anamnesis and description of the pain with respect to the pain location and referral are of special importance. Detailed knowledge of muscle-specific pain patterns, which deviate entirely from classical neurological innervation patterns, allows early identification of the muscles involved in the pain syndromes. Descriptions of pain provided by patients, which do not make sense under neurological aspects, prove astonishingly coherent and informative when considered under trigger point aspects, all the more so because trigger points can also be responsible for dysesthesia, coordination disorders and loss of strength.
Knowledge of the muscle-specific pain referral described by Travell and Simons (1992) represents an indispensable requirement for every therapist. Increasing experience in trigger point therapy, especially in the use of focused shock waves, has shown that pain referral patterns and the location of muscle knots vary in each patient and need to be identified by accurate examination.

Localization of trigger points

The induced referred pain is a major criterion for the selection of the therapy region. Strong manual pressure is exerted on the muscle knots to cause referred pain. Focused shock waves can be applied to induce referred pain more easily and accurately. Depending on the muscle thickness and depth of the trigger point areas, focused shock waves with variable penetration depth are applied at an energy level of between 0.05 and 0.25 mJ/mm2.

Radial shock waves are less suitable for the localization of trigger points on the basis of referred pain. Radial shock waves are rather used to identify indurations inside the muscles. This is done by moving the applicator over a large muscle area during the therapy.

Therapy procedure

The trigger points to be treated are selected according to the criteria of short-term or long- term reduction of the pain symptoms. Therapy is started by treating the active trigger points which are responsible for spontaneous current pain or pain on exertion.
This is followed by the treatment of satellite trigger points in the area of pain referral. Similarly to secondary trigger points in the functional muscle chains of antagonists and synergists, satellite trigger points are responsible for the chronification process if they persist for a prolonged period of time.

Insertional tendonitis, which Travell and Simons (1992) describe as peripheral trigger points, should be given special attention. These trigger points must be treated with focused shock waves. However, contrary to the treatment of muscular trigger points, a reduction in pain is only perceived several weeks after the therapy. This is due to the slowness of the induced physiological repair mechanisms. In this context, the energy flux density is of major importance. Experience has shown that shock waves should be applied at a low energy level in order not to affect the cell recovery potential, that is the useful neurogenic immediate tissue response. Since treatment is performed on a biological system, the therapy intervals between the individual sessions should not be too short (at least 1 to 2 weeks) and the

number of therapy sessions should be limited. It is also crucial that no local anesthetic be used prior to shock wave application (12).

Accompanying therapies

In principle, no accompanying therapies are required to achieve the desired therapy success. However, shock wave therapy can be supported by trigger point stretching in fiber direction. In the presence of severe joint blockage, the blockage may loosen as a result of muscle relaxation after shock wave therapy. If this is not the case, manual therapy can be performed to eliminate the blockage after the first two or three trigger point therapy sessions and after muscle tension has started to decrease. Additional therapies, such as massaging, should not be used.

Muscle strengthening therapy can be performed one to two days after the trigger point therapy. However, it is crucial that this therapy not be performed with maximum force or at the point of maximum muscle shortening.
In the treatment of chronic pain syndromes, ibuprofen or paracetamol should be administered at the beginning of the trigger point therapy to relieve the pain.

Treatment parameters and duration

The energy flux density of focused shock waves used in muscular trigger point therapy is between 0.05 and 0.25 mJ/mm2. Higher energy levels should not be used to avoid tissue damage (11). Judging by the latest scientific research results, the shock wave frequency applied to the trigger point should not exceed 4 Hz.

The energy flux density (mJ/mm2) is selected on the basis of the thickness and depth of the muscle and the patient's indication of pain during localization of the trigger points and provocation of referred pain. The energy flux density should be selected in such a way that the pain induced by the shock waves can still be well tolerated by the patient. Generally speaking, the energy level can be increased after each therapy session as the pain perceived during shock wave application gradually decreases if the therapy progresses smoothly.

The same applies to radial shock waves. The therapy pressure of radial shock waves varies between 1.6 and 4 bar, depending on the shock transmitter size and the patient's indication of pain. Shock transmitters with a small surface should be used with extreme caution owing to the high peak pressures they may generate. Judging by our experience, such shock transmitters are generally not required for the muscles to be treated. The pressure applied should be adequate for the tissue properties to avoid hematomas. The shock wave frequency is 10 to 15 Hz, where the 15 Hz frequency is generally perceived as causing less pain. This effect may be attributable to the physiological intrinsic muscle oscillation stimulated by the radial shock waves.

In the combined use of focused and radial shock waves in trigger point therapy, the trigger points are first treated locally, applying 200 to 400 focused shock waves.
This step is followed by muscle smoothing of the agonists, antagonists and synergists with the radial shock wave transmitter, applying 3000 to 4000 radial shock waves.

If muscles are treated with radial shock waves alone, the trigger point area is treated locally with 500 to 1000 shock waves and without applying manual pressure. This step is then followed by muscle smoothing with up to 4000 shock waves at a frequency of 15 Hz, in accordance with the stretch-and-spray technique developed by Travell and Simons (1992).

Treatment frequency

A therapy frequency of one session per week has shown to be ideal for most patients. These intervals enable the muscles to recover from the irritation, which may initially persist for up to three days. Shorter intervals might cause additional muscle irritation before the irritation from the previous session has actually disappeared and thus increase pain. Insertional tendonitis should not be treated at shorter intervals in order not to affect the aforementioned

regeneration potential that results from the local neurogenic tissue response. Pain modulation aspects, too, suggest that the treatment intervals in trigger point shock wave therapy, similarly to acupuncture, should not be too short. The following general principle applies: longer therapy intervals and lower treatment intensities should be used for more serious and chronic pain syndromes.