michael harbo. clinical expert in sports physiotherapy

RCT IN SHOCKWAVE FROM THEORY TO PRACSIS

Michael Harbo

Clinical expert in sports physiotherapy

fredag den 25. oktober 13

Michael Harbo



Michael Harbo


Aalborg, Denmark

DUBLIN

IRELAND

UNITEDKINGDOM

LONDON

PORTUGAL

LISBON

SPAIN

MADRID

FRANCE

PARIS

ROME

ITALY

BELGIUM

LUXEMBOURG

BRUSSELS

NETHERLANDS

AMSTERDAM

GERMANY

BERLIN

DENMARK

COPENHAGEN

OSLO

STOCKHOLM

LITHUANIA

POLAND

SWITZERLAND

BERN

AUSTRIA

VIENNA

BRATISLAVA

CHECH REP

PRAGUE

BUDAPEST

ALBANIA

TIRANA

MONTENEGRO

PODGORICA

BOSNIA HERZ.

SARAJEVO

CROATIA

ZAGREB

SLOVENIA

LJUBLJANA

• Working with shockwave since 2003

• Text-book author on electro-therapy

• Associate lector at University College Northern Jutland


ESWT - highPressure waves

RPWT

rESWTFocused shockwave

Radial pulse therapy

Extracorporal shockwave

f ESWTESWT - low

RPT


ESWT - highPressure waves

RPWT

rESWTFocused shockwave

Radial pulse therapy

SHOCKWAVESExtracorporal

shockwave

f ESWTESWT - low

RPT


SUCCESS HAS MANY FATHERS


SUCCESS HAS MANY FATHERS

BUT THESE ARE NOT

THE SAME


BUT THESE ARE NOT

THE SAME

Focused shockwave

ESWT - high

ESWT - lowPressure waves

f ESWT

RPWTRadial Pulse Therapy

rESWT


BUT THESE ARE NOT

THE SAME

Focused shockwave

ESWT - high


f ESWT


rESWT

SHOCKWAVESfredag den 25. oktober 13

BUT THESE ARE NOT

THE SAME

Focused shockwave

ESWT - high


f ESWT


rESWT

SHOCKWAVES

WATER


SHOCKWAVESfredag den 25. oktober 13

SHOCKWAVES


SHOCKWAVES RPT

4 - 15 Hz Radial Max 10 MPa 0 - 0,3 mJ/mm2

Total impulse1000 µs 1000-5000 ns

ESWT 20 - 20.000 Hz

Focused

Max 100 MPa

0 - 0,50 mJ/mm2

Total impulse 1 µs

Time to peek 0.3 – 1 ns fredag den 25. oktober 13

BUT DO THEY WORK ?


BUT DO THEY WORK ?

The effectiveness of shock wave therapy on chronic achilles tendinopathy: a systematic review

January 1, 2013FAI

Hani Al-Abbad


BUT DO THEY WORK ?


January 1, 2013FAI

Hani Al-Abbad

Based on 6 appropriate studies:


BUT DO THEY WORK ?


January 1, 2013FAI

Hani Al-Abbad


“Our review showed satisfactory evidence for the effectiveness of ESWT in the treatment of chronic insertional and noninsertional Achilles tendinopathies”


BUT DO THEY WORK ?


BUT DO THEY WORK ?

A systematic review of shockwave therapiesin soft tissue conditions: focusing on the evidence

August 5, 2013BJSM

Cathy Speed


BUT DO THEY WORK ?


August 5, 2013BJSM

Cathy Speed



BUT DO THEY WORK ?


August 5, 2013BJSM

Cathy Speed


“There is evidence for the benefit of F-ESWT and of RPT in a number of softtissue musculoskeletal conditions, and evidence that both treatment modalities are safe”


BUT FEW THINGS ARE ONLY BLACK OR WHITE

• Modality-dependent

• Diagnose-dependent

• Dose-dependent

The effect seems to be:


CHRONIC PLANTAR FASCITIS

(BENEFIT AT 12 WEEK FOLLOW-UP)

YES NO




• Malay, 2006

• Ogden, 2001

• Theodore, 2004

• Gollwitzer, 2007

• Kudo, 2006

• Gerdesmeyer, 2008

YES NO

• Buchbinder, 2002

• Haake, 2003

• Speed, 2002




• Malay, 2006

• Ogden, 2001

• Theodore, 2004

• Gollwitzer, 2007

• Kudo, 2006


YES NO

• Buchbinder, 2002

• Haake, 2003

• Speed, 2002

MODALITY ?




YES NO

• ESWT

• ESWT

• ESWT

• ESWT

• RPT

• RPT

• ESWT

• ESWT

• ESWT

MODALITY ?




YES NO

• ESWT

• ESWT

• ESWT

• ESWT

• RPT

• RPT

• ESWT

• ESWT

• ESWT

INTENSITY ?




YES NO

• ESWT

• ESWT

• ESWT

• High

• High

• High

• High

• High

• High

INTENSITY ?




YES NO

• High

• High

• High

• High

• High

• High

• Low

• Low

• Low

INTENSITY ?




YES

HIGH-ESWT & RPT


CHRONIC MID PORTION ACHILLES TENDINOSIS(BENEFIT AT 12 WEEK FOLLOW-UP)

YES NO



• Rasmussen, 2008

• Vulpiani, 2009

• (Rompe, 2007)

• (Lakshmanan, 2004)

• (Rompe, 2008)

YES NO

• Costa, 2005



YES NO

• ESWT

• ESWT

• (RPT)

• (RPT)

• (RPT)

• RPT



YES NO

• High

• High

• (High)

• (Low)

• (Low)

• Low



YESHIGH-ESWT(LOW-RPT)


CHRONIC INSERTIONAL ACHILLES TENDINOPATHY(BENEFIT AT 12 WEEK FOLLOW-UP)

YES NO



• Furia, 2006

• Vulpiani, 2009

YES NO



YES NO

• ESWT

• ESWT

No RPT studies met the inclusion criteria



YES NO

• ESWT

• ESWT



YES NO

• High

• High



YES

HIGH-ESWT


CALCIFIC ROTATOR CUFF TENDINOPATHY


YES NO




• Consentino, 2003

• Albert, 2007


YES NO




YES NO

• ESWT

• ESWT

• ESWTNo RPT studies met the inclusion criteria




YES NO

• ESWT

• ESWT

• ESWT




YES NO

• High

• High

• High




YES

HIGH-ESWT


CONCLUSION


HIGH-ESWTChronic Plantar fascitis

Chronic mid portion achilles tendinosis

Chronic insertional achilles tendinopathy

Calcific rotator cuff tendinopathy

CONCLUSION






CONCLUSION

HIGH-RPTChronic Plantar fascitis






LOW-RPTChronic mid portion achilles tendinosis

CONCLUSION

HIGH-RPTChronic Plantar fascitis



“Effect of ESWT on calcific rotator cuff tendinopathy with classic signs of impingement”

Harbo & Jakobsen, not published





• Doubleblind-RCT

• N=70

• 1 & 6 months follow-up

• WORC and Constant & Murley score



0

40

80

Cons

tant

& M

urle

y Sc

ore

Pre 1 mo 6 moA

ctiv

e

Act

ive

Act

ive

Plac

ebo

Plac

ebo

Plac

ebo



• Doubleblind-RCT

• N=70

• 1 & 6 months follow-up

• WORC and Constant & Murley score


A case story

• 38 year old male referred to our ESWT study • X-ray verified large calcification situated in

supraspinatus• Unable to work and did not want to risk receiving

placebo-treatment • No severe pain, but unable to abduct the shoulder

above 80 degree



A case story



A case story

Initial treatment3 sessions of high-ESWT

(1500 impulses of 0.4 mJ/mm



No ROM incresement- 2 treatments more are given ...




ROM increased to 140 degree- no treatment given for 4 weeks



Free painfree ROM - 1 treatment/week for 3 weeks- 1 treatment/14 days for 4 weeks- Control at 12 weeks


TAKE HOME MESSAGE


TAKE HOME MESSAGEThere are two forms of shockwave and they are DIFFERENT modalities and should be evaluated separately.

There is strong evidence that F-ESWT is effective in the treatment of plantar fasciitis and calcific tendinitis, and that low-RPT is effective in plantar fasciitis.

Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes.

Both modalities are promissing and safe to use - even at High intensities

There are two forms of shockwave and they are DIFFERENT modalities and should be evaluated separately.

There is strong evidence that F-ESWT is effective in the treatment of plantar fasciitis and calcific tendinitis, and that low-RPT is effective in plantar fasciitis.

Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes.

Both modalities are promissing and safe to use - even at High intensities


It hurts - but it works !


RPT example


THANK YOU


michael harbo. clinical expert in sports physiotherapy

Health & Medicine