IN NATURE. What are SW?

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1 EXTRACORPOREAL SHOCK WAVE THERAPY (ESWT) Theory & Clinical Applications Examples of therapies performed with Duolith SD1 Vet, a new system by Storz Medical AG Stefano Tassan, Med Vet, Equicenter stefanotassan@tiscali.it Ing. Gianni Luongo, Storz Medical Italia g.luongo@storzmedicalitalia.it

2 EQUICENTER 7 Veterinary Surgeons, 24/7

3 What are ESW? are mechanical waves are sound waves (expanding faster then the speed of sound) require an elastic medium for propagation like Water Air Tissue feature a steep pressure rise are not electro-magnetic waves

4 IN NATURE What are SW?

5 MAN MADE What are SW?

6 MAN INDUCED! What are SW?

7 Pressure Shock Wave Characteristics IMPORTANT PARAMETERS Energy: mj Energy Flux Density: mj/mm 2 P(t) 10ns 100 MPa (= 1000 bar) 300 ns High peak pressure Steep rise Short time duration Low tensile wave components V = 1500 m/s in water 10 MPa Time

8 MECHANISM 3 mechanisms - electrohydraulic Electrohydraulic ellipsoid - piezoelectric - electromagnetic Piezo-electric sphere Electro-magnetic flat coil/lens Electro-magnetic cylinder coil/ paraboloid

9 Shock Waves vs. Pressure Waves Physicists make a difference between pressure waves and shock waves Physicians prefere to call pressure waves Radial shock waves What is the difference?

10 Pressure Wave Therapy Impact of elastic bodies

11 Pressure Shock Waves vs. Pressure Waves physical differences Shock Wave (electro-magnetic) Pressure Wave (ballistic) bar 1-10 bar (100:1) 0.3 μs ms (1:1000) Time Time

12 COMPARISON Shock waves Different techniques Pressure: bar Duration: 0.3 μs Precise focus Superficial and in depth Concentrated, localized Pressure waves different waves 1-10 bar 0.5 ms unfocussed superficial radially divergent

made by a ballistic pressure generator, pressure on the

13 COMPARISON ESWT: shock waves generated outside the body focused on a specific side: peak energy RSWT: pressure waves made by a ballistic pressure generator, pressure on the skin, transmitted radially, energy decreasing square of the distance

14 Effect of Pressure Waves affect superficial tissue increase circulation and metabolism reduce pain have an effect on superficial nerves may cause superficial hematoma Interesting tool in medicine

15 PHYSICAL EFFECTS Travel trough tissues and effect occurs with change of acoustic impedance: eg: soft tissue bone interface Mechanical effect: 1. generate forces at interface transmitted Shock wave 2. generate cavitation if > 0,1 mj/mm 2 3. generate micro- Jets

BIOLOGICAL EFFECTS Urologists consider ESWT a force to break stones Orthopaedics have used this force to break sclerotic bone But other actions for blood increase, osteogenesis and anti inflammatory

16 BIOLOGICAL EFFECTS Urologists consider ESWT a force to break stones Orthopaedics have used this force to break sclerotic bone But other actions for blood increase, osteogenesis and anti inflammatory effect Nitric oxide produced directly and NO synthase NO is the first step in GFs production Nitric Oxide mediates anti inflammatory action of ESWT A.R. Ciampa et al, Fed. of European Biochemical Societies, 2005

17 SHOCK WAVES: IN VIVO EFFECTS Reduce pain: iperpolarization, endorphine, gate control Short term analgesic effect of extracorporeal shock wave therapy in horses with proximal palmar metacarpal/plantarplantar metatarsal pain. Imboden et al. Vet J 2007, Dec 7 FEI: no tx 5 days before competition! Increase cellular permeability, NO production Antinflammatory: wash out, NO ( wash out, NO (modulation) Increase in TGF-B1, VEGF, FGF Neovascularisation at bone-tendon junction Recruitement of progenitive cells? Effects of Extracorporeal Shock Wave Therapy on bone McClure SR, Vansickle D, White MR; Vet Surgery 33:40-48, 2004

18 SHOCK WAVES: IN VIVO EFFECTS

(enthesiopathies) Calcification (metaplasia) in tendon/ ligament

19 CLINICAL CASES Stimulation of bone formation or remodelling Treatment of insertional desmitis and tendinitis (enthesiopathies) Calcification (metaplasia) in tendon/ ligament Extracorporeal Shock Wave Therapy: What? Why? Safety? S. McClure Iowa State University

20 Clipping (n. 40 blade) Patient Preparation Washing (hot water and soap) Acoustic gel 2-5 Tx, 5-15 days intervalls E Flux Density: 0,2-0,50,5 mj/mm 2 No local analgesia, sedation (required for difficult horses)

21 Bayern, F, 11 ESWT F SL, F, 11 yo, Dressage, Gran Prix Recurrent lameness1/5 RF Sound after a single day of rest, back on work uneven in a few training sessions Positive sub carpal block E. Sanzogni

22 ESWT F SL D. Zani Magnetic resonance imaging features of proximal metacarpal and metatarsal injuries in the horses. Brokken et al. Vet Rad & Ultrsd, Vol 48, N. 6, 2007

23 ESWT F SL ECHOGRAPHIE PRATIQUE DES TENDONS FLECHISSEURS CHEZ LE CHEVAL. COMMENT VISUALISER L INSERTION PROXIMALE DU LIGAMENT SUSPENSEUR DU BOULET : UNE TECHNIQUE MODIFIEE Michel Hoegaerts, BEPS 2007 Proc D. Zani

24 ESWT F SL 3 tx, 10 days apart, US at 60 days Treatment of chronic or recurrent proximal suspensory desmitis using radial pressure wave therapy. Crowe, O., Dyson, S., Wright, I., Schramme, M., Smith R. Equine vet. J. 36: , 2004.

25 ESWT F MC3 QH, 5 yo, G, Reining RF lameness, sudden onset 3/5, worse in circles at corresponding rein Extremely sore palpating the middle third SL 50% improvement L4 P NB Blocks sound H 4 P Neg fetlock IA

26 ESWT F MC3

27 ESWT F MC3

28 5 tx every 7 days ESWT F MC3 Clearly improved after the third tx Effect of ESWT on mineral apposition rate in healing equine third metacarpal bone. Hubert, J.D., Proc. 9th Int. WEVA Congr., 2006

29 DIP COLLATERAL LIGAMENT German warmblood, 9 yo, SJ Acute lameness, 4/5 No fracture, foot block postive

30 DIP COLLATERAL LIGAMENT 30 days rest, mild improvement Same lameness at ridden walk J.M. Denoix Osseus abnomalities associated with collateral desmopathy of the distal interphalangeal joint: part1 S.G. Dakin, S.J. Dyson, R.C. Murray, C. Tranquille; Equine Vet. J

31 DIP COLLATERAL LIGAMENT 3 tx every 10 days 4 weeks controlled exercise Osseus abnomalities associated with collateral desmopathy of the distal interphalangeal joint: part 2: Treatment and outcome S.G. Dakin, S.J. Dyson, R.C. Murray, R. Newton; Equine Vet. J

32 10 yo, German SJ DSIL 2-3/5 RF, 100 % sound LD NB, DIP B, NB B

33 DSIL MRI D. Zani D. Zani D. De Zani, S. Vignati ESWT for Treatment of Navicular Syndrome S. McClure et al, Proc. 50 AAEP Convention, 2004

34 H PSD 11 yo Dressage Westfalen 2/5 lame LH Blocks sound sub-tarsal

35 H PSD Review of results of treatment of proximal suspensory desmopathy with ESWT. C. J. Lischer, Proc. BEVA Congr. 2005

36 SL Distal enthesiopathy The effect of focused extracorporeal shock wave therapy on collagen matrix and gene expression in normal tendons and ligaments G. Bosch et al, EVJ, 2009, 41

37 YE OLDE CHAMPION! 23 yo Standardbred Trotter Stallion Win in carreer > Still covering every second day Unable to stand on a phantom C. Rognoni, C. LoGalbo

38 YE OLDE CHAMPION!

39 YE OLDE CHAMPION! Tx every 10 days the whole season

40 Poor Performance

41 Poor Performance I.S., 9 yo, Dressage, Gran Prix Stiffness in half pass and pirouettes at right canter SI joints already injected Improves with L sub tarsal block

42 Poor Performance X-rays & standard Ultrasound

43 Poor Performance E Flow Aloka At rest 20 min exercise

44 STORZ DUOLITH VET Portability, low weight probe (600 g) Low noise Focal area clinically optimized Low energy at skin High energy modulation Long handpiece live > shocks Economics, low handpiece cost Future investigation on wound healing Well Tollerated Shockwave therapy: Is there an application to enhance wound healing in horses? A. J. Dart, A. S. Bischofberger, Equine vet. Educ. (2010) 22 (2) 73-76

45 Stefano Tassan Gianni Luongo Special thanks to all at Equicenter

Extracorporeal Shock Wave Therapy (ESWT) Jeff Blea, DVM Von Bluecher, Blea, Hunkin, Inc. Equine Medicine and Surgery Sierra Madre, CA

Extracorporeal Shock Wave Therapy (ESWT) Jeff Blea, DVM Von Bluecher, Blea, Hunkin, Inc. Equine Medicine and Surgery Sierra Madre, CA History Shock waves used in human medicine as early as 1980s: Break