antoni morral. professor of physical therapy. school of health science blanquerna, universitat ramon...
DESCRIPTION
Shock WaveTRANSCRIPT
11/10/2013
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Antoni Morral Fernández Facultat de Ciencies de la Salut Blanquerna. Universitat Ramon Llull.
Centre Salut i Esport. Santa Perpetua de Mogoda. Barcelona.
Facultat de Ciències de la Salut Blanquerna. Universitat Ramon Llull. Barcelona.
Santa Perpètua de Mogoda
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Amateur athletes
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Man, 40-50 years Long Distance Runner with Chronic Achilles tendinopathy (insertional or non-insertional)
Common patient in our center
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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“worker elbow” = “codo de currante”
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
First patients in 1999
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Athletic horses
Shock wave
Change of paradigm Antoni Morral. FCS Blanquerna.
Universitat Ramon Llull. Antoni Morral. FCS Blanquerna.
Universitat Ramon Llull.
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Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
1 MPa = 10 bar
Rassweiler JJ, Knoll T, Köhrmann KU,. Shock wave technology and application: an update. Eur Urol. 2011 May;59(5):784-96.Review.
A shock wave is an acoustic pulse, with a high peak pressure and a short life cycle.
Shock wave. Physical characteristics
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Methods of shock wave generation
Electrohydraulic Piezoelectric Electromagnetic Pneumatic
Ogden JA, Tóth-Kischkat A, Schultheiss R Principles of shock wave therapy. Clin Orthop Relat Res. 2001 Jun;(387):8-17.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
1. Focus
Focused Radial
Focus
Differences
hard shockwave soft shockwave
2. Focus
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Device: Piezo Clast. Electro Medical System (EMS). Nyon . Switzerland
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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Pain Therapy
mJ/mm2
Lithotripsy
Osteotherapy
0 0,2 0,4 0,6 0,8 1,0 1,2
Repair Potential of cells
low medium high
Source: Rompe,‘‘Extrakorporale Stosswellentherapie“
Energy flow density
Energy flow density & Therapeutic objectives
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Cellular Mechanotransduction
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Mechanotransduction is cellular signal transduction in response to mechanical stimuli.
Mechanical cues modulate almost all aspects of cell function, including:
Growth
Differentiation
Migration
Gene expression
Protein synthesis
Apoptosis Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Force transmission between the extracellular matrix (ECM) and the nucleus
Jaalouk DE, Lammerding J. Mechanotransduction gone awry. Nat Rev Mol CellBiol. 2009 Jan;10(1):63-73. Review. Antoni Morral. FCS Blanquerna.
Universitat Ramon Llull.
•Stimulates tissue regeneration •Enhances angiogenesis •Inhibits nociceptors
Biological Effects of Shock Waves
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
“The evidence from in vitro and animals studies”
There are many studies studies about cell biological effects of mechanical stimulations generated by shock wave.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
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Shock waves: mechanisms of action
Tobalem M, Wettstein R, Pittet-Cuénod B, Vigato E, Machens HG, Lohmeyer JA, Rezaeian F, Harder Y. Local shockwave-induced capillary recruitment improves survival of musculocutaneous flaps. J Surg Res. 2013 Oct;184(2):1196-204.
Yang G, Luo C, Yan X, Cheng L, Chai Y. Extracorporeal shock wave treatment improves incisional wound healing in diabetic rats. Tohoku J Exp Med. 2011;225(4):285-92.
Tepeköylü C, Wang FS, Kozaryn R, Albrecht-Schgoer K, Theurl M, Schaden W, Ke HJ, Yang Y, Kirchmair R, Grimm M, Wang CJ, Holfeld J. Shock wave treatment induces angiogenesis and mobilizes endogenous CD31/CD34-positive endothelial cells in a hindlimb ischemia model: Implications for angiogenesis and vasculogenesis. J Thorac Cardiovasc Surg. 2013 Oct;146(4):971-8.
Cárcamo JJ, Aliaga AE, Clavijo RE, Brañes MR, Campos-Vallette MM. Raman study of the shockwave effect on collagens. Spectrochim Acta A Mol Biomol Spectrosc. 2012 Feb;86:360-5.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Shock wave produces effects on gap junctional communication and the activation of signaling cascades associated with cell proliferation and differentiation. Ha CH, et al. Extracorporeal shock wave stimulates expression of the angiogenic genes via mechanosensory complex in endothelial cells: Mimetic effect of fluid shear stress in endothelial cells. Int J Cardiol. 2013 Jul 31. Holfeld J, et al. Shockwave Therapy Differentially Stimulates Endothelial Cells: Implications on the Control of Inflammation via Toll-Like Receptor 3. Inflammation. 2013 Aug 15. Suhr F, et al. Cell biological effects of mechanical stimulations generated by focused extracorporeal shock wave applications on cultured human bone marrow stromal cells. Stem Cell Res. 2013 Sep;11(2):951-64.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Berta L, Fazzari A, Ficco AM, Enrica PM, Catalano MG, Frairia R. Extracorporeal shock waves enhance normal fibroblast proliferation in vitro and activate mRNA expression for TGF-beta1 and for collagen types I and III. ActaOrthop. 2009 Oct;80(5):612-7.
3 hours 5 hours 0 hours
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Vetrano M, d'Alessandro F, Torrisi MR, Ferretti A, Vulpiani MC, Visco V. Extracorporeal shock wave therapy promotes cell proliferation and collagen synthesis of primary cultured human tenocytes. Knee Surg Sports Traumatol Arthrosc. 2011 May 27.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Figure 2: Cell proliferation was assessed by immunofluorescense with the Ki67 antibody
Raabe O et al. Effect of extracorporeal shock wave on proliferation and differentiation of equine adipose tissue-derived mesenchymal stem cells in vitro. Am J Stem Cells. 2013 Mar 8;2(1):62-73.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Leone L, Vetrano M, Ranieri D, Raffa S, Vulpiani MC, Ferretti A, Torrisi MR, Visco V. Extracorporeal Shock Wave Treatment (ESWT) improves in vitro functional activities of ruptured human tendon-derived tenocytes. PLoS One.2012;7(11):e49759.
Cell migration was evaluated by measuring the repopulation of the cleared area
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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SHOCK WAVE &
ANALGESIA
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
To investigate the analgesic properties of shock wave application, we analyzed whether it
produces morphologic changes in cutaneous nerve fibres.
There was nearly complete degeneration of epidermal nerve fibres in the shock wave-
treated skin (1000 SW x 0.08 mJ/mm²), as indicated by the loss of immunoreactivity for PGP
9.5 or CGRP. Reinnervation of the epidermis occurred 2 weeks after treatment.
Ohtori et al. 2001; Neurosci Letter 315:57
Depletes nociceptive nerve endings reversibly
from PGP 9.5 and from CGRP
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
We questioned whether repeated shock wave application provides a cumulative effect on nerve
fibers compared with the effect of one application. 1000 SW x 0.08 mJ/mm² were applied to
the foot pad of 32 rats. After 14 days, 16 rats received a second application.
During the first 4 weeks, there was nearly complete degeneration of epidermal nerve fibers in
both groups. By the end of 6 weeks, reinnervation of the epidermis began in the single-
treatment group. Reinnervation occurred slower in the repeated-treatment group. These
data show that a second application has a cumulative effect on nerve fibers. Our data
suggest multiple applications of low-energy shock waves might a provide longer-lasting
antinociceptive effect. Takahashi et al. 2006; CORR 443:315
Induces a longer lasting depletion from PGP 9.5 and
CGRP when applied repetitively
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
ESWT and selective nerve destruction
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
VETERINARY REGULATIONS 12th Edition, effective 5 April 2010, updated 1 January 2011.
“Shock Wave therapy and cryo-therapy are not permitted during competition and for a period of 5 days prior to the first Horse Inspection. Cooling with ice and water is permissible to above 0° C is acceptable. Cooling with machines that can cool below 0 degrees C are not permitted unless the machine can be locked out of the lower temperatures by the Veterinary Delegate.”
Fédération Equestre Internationale
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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Bias Bias Bias
Bias
Bias
Bias
Adapted from: Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996 Jan 13;312(7023):71-2. Howick J et al. The Oxford 2011 Table of Evidence. Oxford Centre for Evidence-Based Medicine.
Level of scientific evidence on therapeutic questions
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Levels of evidence: 1.- Strong: Consistent findings among multiple hight-quality RCTs. 2.- Moderate: Consistent findings among multiple low-quality RCTs and/or CCTs and/or one hight-quality RCT. 3.- Limited: One low-quality RCT and/or CCT. 4.- Conflicting: Inconsistents findings among multiple trials (RCTs and/or CCTs). 5.- No evidence from trials: No RCTs or CCTs.
van Tulder M, Furlan A, Bombardier C, Bouter L. Updated method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group. Spine 2003; 28: 1290–1299.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Systematic review Meta-analysis Randomized controlled trials
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Speed C. A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. Br J Sports Med. 2013 Aug 5.
•23 RCTs. •There is evidence that Focused SW is effective in the treatment of plantar fasciitis, calcific tendinitis, and that Radial SW is effective in plantar fasciitis. •Both treatment modalities are safe.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Treatment protocol:
3 sessions Interval between sessions: 1-2 weeks
Low energy (< 0,20 mJ/mm2) 2000 pulses
2-8 Hz
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Inclusion criteria
Established diagnosis of chronic tendinopathy for at least 6 months before treatment and failure of nonoperative management.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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Shoulder
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
CONCLUSION: The results of the meta-analysis provide strong evidence that HESWT was effective in the treatment of recalcitrant plantar fasciitis when compared with placebo.
Meta-analysis of high-energy (>0.2 mJ/mm2) extracorporeal shock wave therapy in recalcitrant plantar fasciitis
Zhiyun L, Tao J, Zengwu S. Meta-analysis of high-energy extracorporeal shock wave therapy in recalcitrant plantar fasciitis. Swiss Med Wkly. 2013 Jul 7;143
5 RCTs
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Huisstede BM, Gebremariam L, van der Sande R, Hay EM, Koes BW.
Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT)
to treat calcific and non-calcific rotator cuff tendinosis - A systematic review.
Man Ther. 2011 Mar 9.
17 RCTs (11 calcific, 6 non-calcific)
No evidence for non-calcific.
Lee SY, Cheng B, Grimmer-Somers K. The midterm effectiveness of extracorporeal shockwave therapy in the management of chronic calcific shoulder. A systematic review. tendinitis. J Shoulder Elbow Surg. 2011 Jan 11.
There was consistent evidence of midterm effectiveness of ESWT in reducing pain and improving shoulder function for patients with chronic calcified tendinitis. ESWT is a potential alternative to surgery with minimal side effects. 9 RCTs
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Storheim K, Gjersing L, Bølstad K, Risberg MA.
[Extracorporeal shock wavetherapy (ESWT) and radial extracorporeal
shock wave therapy (rESWT) in chronic musculoskeletal pain].
Tidsskr Nor Laegeforen. 2010 Dec 2;130(23):2360-4.
Systematic Review. Norwegian.
N= 49 RCT. SW-Focused:
Only had a positive effect in chronic rotator
cuffsyndrome with calcium deposits and was not effective
in the absence of calcium deposits.
N= 5 RCT. SW-Radial:
Positive results in chronic rotator cuff
syndrome with calcium deposits.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Plantar fasciopathy
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP. Extracorporeal Shock Wave Therapy Is Effective In Treating Chronic Plantar Fasciitis: A Meta-analysis of RCTs. Clin Orthop Relat Res. 2013 Jun 28.
CONCLUSIONS: ESWT is a safe and effective treatment of chronic plantar fasciitis refractory to nonoperative treatments. Improved pain scores with the use of ESWT were evident 3 months after treatment. 7 RCTs (Studies without local anesthesia)
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Dizon JN, Gonzalez-Suarez C, Zamora MT, Gambito ED. Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis. Am J Phys Med Rehabil. 2013 Jul;92(7):606-20.
11 RCT,s This study concludes that moderate- and high-intensity ESWT were effective in the treatment of chronic plantar fasciitis.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Chang KV, Chen SY, Chen WS, Tu YK, Chien KL. 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. Arch Phys Med Rehabil. 2012 Jul;93(7):1259-68.
Conclusions:
Focused SW and Radial SW are effective treatment. N= 12 trials comprising 1431 participants
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Achilles tendinopathy
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Al-Abbad H, Simon JV. The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int. 2013 Jan;34(1):33-41.
CONCLUSION: Overall, our review showed satisfactory evidence for the effectiveness of low-energy ESWT in the treatment of chronic insertional and noninsertional Achilles tendinopathies at a minimum 3 months' follow-up before considering surgery if other conservative management fails. However, combining ESWT with eccentric loading appears to show superior results.
Chronic insertional and noninsertional Achilles tendinopathies. 4 RCTs
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN. Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1345-55.
Extracorporeal shockwave therapy (ESWT) was superior to both wait-and-see and an eccentric training regime. 14 RCTs (Surgery, LASER, SW, EE…)
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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Rowe V, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D. Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Sports Med. 2012 Nov 1;42(11):941-67. 47 Clinical Trial
Evidence was strong for eccentric loading exercises and extracorporeal shockwave therapy.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Sussmilch-Leitch SP, Collins NJ, Warden SJ, Crossley KM. Physical therapies for Achilles tendinopathy: systematic review and meta-analysis. J Foot Ankle Res. 2012 Jul 2;5(1):15.
“Shock wave therapy may represent an effective alternative”
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Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Elbow
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Shock Wave: limited/conflicting evidence for effectiveness or evidence of no difference in effect was found.
Dingemanse R, Randsdorp M, Koes BW, Huisstede BM. Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review. Br J Sports Med. 2013 Jan 18.
20 RCTs
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Medial Tibial Stress Syndrome
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Winters M, Eskes M, Weir A, Moen MH, Backx FJ, Bakker EW. Treatment of Medial Tibial Stress Syndrome: A Systematic Review. Sports Med. 2013 Aug 27. 11 RCTs.
CONCLUSION: None of the studies are sufficiently free from methodological bias to recommend any of the treatments investigated. Of those examined, ESWT appears to have the most promise. (Level III)
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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Patellar tendinopathy
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy--a systematic review of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc. 2012 Aug;20(8):1632-46.
Strong evidence was found for the use of eccentric training treat patellar tendinopathy. Limited evidence was found for surgery, sclerosing injections, and shockwave therapy, must be investigated further before recommendations can be made regarding their use.
13 Clinical Trial
Greater trochanteric pain syndrome
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the greater trochanteric pain syndrome: a systematic review. Br Med Bull. 2012 Jun;102:115-31.
Low-to-moderate quality of the 14 studies. Radial shock wave therapy and home training approach provide beneficial effect over months, with almost 80% success rate at 15 months. CONCLUSION: The effectiveness of the various treatment modalities needs to be tested in carefully conducted RCTs.
Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011 Sep;21(5):447-53.
24 articles: Level I: 2 Level II: 1 Level III: 1 Level IV: 20
Two comparative studies (levels II and III) found Radial SW to be superior to other non-operative modalities
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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External validity of clinical trials
and transferability of their results to medical practice
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
In an RCT:
Internal validity refers to the comparability between the intervention (I) and the control group (C), and to the care for minimizing the risk of bias
External validity refers to the availability of information to guide the applicability of the trial results to the target population in a specific setting
I. group C. group
Trial results
Target population and setting
External validity, applicability
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Eficàcia: Efficacy, Efectivitat: Effectiveness Eficiència: Efficiency
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
P.I.C.O.T. Krupski TL, Dahm P, Fesperman SF, Schardt CM. How to perform a literature search. J Urol. 2008 Apr;179(4):1264-70.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
P: Patients I: Intervention C: Comparison O: Outcome T: Time
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Zwerver J, Hartgens F, Verhagen E, van der Worp H, Diercks RL. No Effect of Extracorporeal Shockwave
Therapy on Patellar Tendinopathy in Jumping Athletes During the Competitive Season:
A Randomized Clinical Trial. Am J Sports Med. 2011 Feb 1.
SW as a solitary treatment during the competitive season has no benefit over
placebo treatment in the management of actively competing jumping athletes with
patellar tendinopathy who have symptoms for less than 12 months.
STUDY DESIGN: RCT; Level of evidence, 1
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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A model of tendinopathy differentiates between: •Reactive tendinopathy (Pacients aged from 15-25 years)
•Dysrepair tendinopathy (Pacients aged from 20-35 years)
•Degenerative tendinopathy (Pacients aged from 30-60 years)
Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009 Jun;43(6):409-16. Zwerver J, Hartgens F, Verhagen E, van der Worp H, van den Akker-Scheek I,
Diercks RL. No effect of extracorporeal shockwave therapy on patellar tendinopathy in jumping athletes during the competitive season: a randomized clinical trial. Am J Sports Med. 2011 Jun;39(6):1191-9.
SHOCK WAVE
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Rompe JD, Cacchio A, Weil L Jr, Furia JP, Haist J, Reiners V, Schmitz C, Maffulli N. Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy. J Bone Joint Surg Am. 2010 Nov 3;92(15):2514-22.
(in weeks)
SHOCK WAVE
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. J Bone Joint Surg Am. 2008 Jan;90(1):52-61
SHOCK WAVE
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
It seems thus possible that Shock Wave is not an effective treatment modality for the early stages of tendinopathy.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Inclusion criteria
Established diagnosis of chronic tendinopathy for at least 6 months before treatment and failure of nonoperative management.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
11/10/2013
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Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009 Sep;37(9):1855-67 Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Decision-making
Best available research evidence
Population characteristics, needs, values, and preferences
Resources, including practitioner expertise
Satterfield JM, Spring B, Brownson RC, Mullen EJ, Walker BB,Whitlock EP. Toward a transdisciplinary model of evidence-based practice. Milbank Q. 2009 Jun;87(2):368-90.
Environment and organizational context
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
time
intensity
We must have patience, patience, patience…
Return to competition
Shock wave therapy
velocity
strength
plyometrics
Individual graded running programme
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Charles Robert Darwin (1809-1882)
Adaptation theory, is an organism's ability to adapt to changes in its environment and adjust accordingly over time.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Jean-Baptiste Lamarck (1744 -1829)
Use and disuse – Individuals lose characteristics they do not require (or use) and develop characteristics that are useful.
Lamarck's theory can be described in one sentence:
The function creates the organ.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003 Dec 20;327(7429):1459-61.
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Archibald Leman Cochrane (1909–1988) Scottish doctor and pioneer of evidence based medicine.
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.
Medicus curat, natura sanat The physician treats, nature cures
Be honest to your patients Shock wave is your second line of defense
Patience: 3-4 months
Thank you very much for your kind attention
Antoni Morral. FCS Blanquerna. Universitat Ramon Llull.