Lööklaineravi kasutus tendinopaatiate ravis. Extracorporeal Shockwave Therapy for Tendinopaties

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1 LÖÖKLAINETERAAPIA Lööklaineravi kasutus tendinopaatiate ravis Extracorporeal Shockwave Therapy for Tendinopaties Tõnis Mandel taastusarst SA Tartu Ülikooli Kliinikum Spordimeditsiini ja taastusravi kliinik Spordimeditsiini osakond Tõnis Mandel Tartu Ülikooli Kliinikum Spordimeditsiini osakond

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4 Young therapy method 1980 the first patient with a kidney stone was treated in Munich with a prototype machine called Dornier Lithotripter HM the first commercial lithotripter (HM3, Dornier, Fig.3) was installed in Stuttgart/Germany 1988 the first shock wave treatment of non-union in human was successfully performed in Bochum/Germany first reports about shock wave therapy on tendinitis calcarea 1999 Radial shockwave principle introduced

5 International Society for Medical Shockwave Treatment

6 ISMST consensus statement Terms and Definitions The Managing Board of the ISMST (International Society for Medical Shockwave Treatment) has decided to publish the following statement regarding the following terms. Focused or defocused extracorporeal shockwaves Generation: Piezoelectric, electromagnetic, electrohydraulic Indications: See ISMST-website1 Application: Trained physicians Radial extracorporeal shockwaves Generation: Air pressure Indications: Superficial tendinopathies and muscle pathologies (ISMST-website1) Application: Trained physicians; after diagnosis of physician trained physiotherapist, technician and nurses may perform ESWT Linz, January 14th, 2011

7 Shockwave The opportunity to transmit mechanical energy from the place of generation to distant areas

8 Shockwave technologies ESWT extracorporal shock wave therapy FESWT focused ESWT RESWT radial ESWT = EPWT (E pressure WT) ESWL extracorporal shock wave lithotripsy

9 Shockwave technologies

10 Radial SW device

11 Focused SW device

12 Radial vs focused ESWT reswt feswt

13 Radial vs focused ESWT FESWT bar pressure 1-10 bar RESWT 0,2 mikr s time 0,2 0,5 ms <10 ns rise time 3,5 mikrosek schock wave pressure wave Different waves but same indications and similar outcome

14 feswt versus reswt Deep focus Pressure wave

15 FSWT RSWT

16 SHOCKWAVE ENERGY Energy flux density - maximum amount of acoustical energy, which is transmitted through an area of 1 mm2 per pulse (mj/mm2) SW treatment on the basis of the EFD: low (<0.08 mj/mm2), medium (<0.28 mj/mm2) high (<0.60 mj/mm2) Rompe JD, Kirkpatrick CJ, Küllmer K, Schwitalle M, Krischek O J Bone Joint Surg Br May; 80(3):

17 SHOCKWAVE ENERGY RSWT Working pressure (bar) 1,5 2,0 2,5 3,0 3,5 4,0 FSWT Energy flux density (mj/mm2) 0,03 0,06 0,11 0,13 0,16 0,18

18 SHOCKWAVE ENERGY

19 SHOCKWAVE ENERGY

20 SW effects Immediate : - Local increase of microcirculation - Immediate myorelaxation - Immediate and strong analgesia Long term: Mechanodransduction > regeneration of tendon

21 Mechanodransduction Shockwave -> mechanodransduction Mechanodransduction cells convert mechanical signals into biochemical responces.

22 Mechanodransduction

23 Basic treatment principles Diagnostic Ultrasound and SWT guidance is recommended No consensus of treatment protocols Sessions: 3-6 Frequency of the sessions- every 7 days Final clinical assesment 2 months from the end of the therapy Mechanical (un)loading important. No sport? Stretching is recommended NO use of anesthesia or analgetics NO NSAID between sessions NO corticosteroids within last 6 weeks before tratment, during treatment and 2 months after treatment The success rate ranges from 60% to 80% in epicondylitis, plantar fasciitis, cuff tendinitis, trocanteritis, Achilles tendinitis or jumper s knee.

24 Treatment Three commonly used methods of localization: 1. Anatomic focusing wave is directed at an anatomic location determined by palpation and anatomical landmarks. 2. Image-guided focusing via guided ultrasound (calcification, thickened region of tendon). 3. Clinical focusing shock waves are directed to the most painful area with the aid of patient feedback. * Extracorporeal Schock Wave Therapy in the Treatment of Chronic Tendinopathies. Perspectives on Modern Orthopaedics, Andrew Sems, J Am Acad Orthop Surg 2006; 14:

25 ISMST Recommendations for the use of ESWT Approved standard indications Chronic tendinopathies: Plantar fasciitis with or without heel spur Achilles tendon Radial epicondylopathy (tennis elbow) Rotator cuff with or without calcification Patella tendon Greater trochanteric pain syndrome

26 Contraindications ABSOLUTE Pregnancy Abdominal or frontal pelvic application RELATIVE Pharmacotherapy by corticosteroids within last 6 weeks Sensational deficite in the treated area Blood coagulation disorders, anticoagulation treatment Application in the area of varices Direct application above internal organs, head, gonads,nervs Acute infectious disease

27 Possible temporary side effects Temporary hyper/hypo- sensitivity Erythema Haematoma Oedema Most of the patients never experience any of these side effects

28 BASIC INDICATIONS

29 Shoulder tendinopathy Diagnostic US always before prescription of SW Calcification Tendinosis SSP; ISP; SSC; BBCL Efficacy of ESWT in calcifying shoulder tendonitis was proved in 70% patients Cosentino R et al., Ann Rheum Dis, 2003

30 Shoulder tendinopathy SSP tendinosis SSP Calcification

31 Shoulder tendinopathy Recommended parameters: - RSWT: 2-3 bars, 2500 pulses, frequency 8-12 Hz, 4-8 sessions - FSWT: 0,18-0,32 mj/mm2; 4-6 Hz; pulses; 4-8 sessions ROM improvement during treatment Final assesment 2 months from the end of the therapy

32 Epicondylitis lateralis et medialis Dgn: clinical palpation > tendon + muscle Minor US changes Palpation with applicator Sensitive area, not easy to treat Results at one year are 62% excellent to good and 38% fair to poor Muscles Ligaments Tendons J Jan-Mar; 2(1): 33 37

33 Epicondylitis lateralis et medialis Treat painful points and muscle RSWT: 2-3 bar; Hz; x; 5-8 sessions FSWT: 0,15-0,35 mj/mm2; 4-6 Hz; x; interval days, 3-5 sessions

34 Plantar fasciitis Best dgn for ESWT treatment SW is best treatment for this dgn DGN: palpation, anamnesis US: to rule out rupture insoles Success rates of 70.7% at 3 months and 77.2% at 12 months j.jfas Source: PubMed

35 Plantar fasciitis RSWT: 2-3 bar; Hz; x; 3-5 sessions FSWT: 0,2-0,3 mj/mm2; 4Hz; ; days interval; 1-3 sessions Treat most painful spot (attachment to calcaneus) Smooth intrinsic foot and calf muscles with RSW

36 Achilles tendinopathy Diagnostic US always - location (enthesis;lover, middle, upper 1/3) - enlargement, neovascularisation, calcification, fluid - partial rupture Treat location of patology Satisfactory results : % of cases at two-months follow-up, % at medium-term Follow-Up (FU) (6 to 12 months), - 76% at long FU (13 to 24 months) Muscles Ligaments Tendons J Jan-Mar; 2(1): 33 37

37 Achilles tendinopathy Achilles tendinosis: -Fusiform swelling -hypoechoic -neovascularisation

38 Achilles enthesitis: Achilles tendinopathy

39 Achilles tendinopathy RSWT: 2-3 bar; Hz; x; weekly; 3-5 sessions FSWT: 0,2-0,3 mj/mm2; 4 Hz; x; weekly; 4-6 sessions

40 Spondyloarthropathies In case ESWT treatment of plantar fasciitis or achilles enthesitis is not successful Think about Spondyloarthropathies

41 Spondyloarthropathies

42 Patella tendinopaty Tendinosis diagnostic US Satisfactory results were reported in 73.5% of cases Muscles Ligaments Tendons J Jan-Mar; 2(1): 33 37

43 Patella tendinopathy RSWT: 1,8-2,2 bar; Hz; pulses; days interval; 5 sessions FSWT: 0, mj/mm2; 4-6 Hz; pulses; days interval; 5 sessions

44 Greater trochanteric pain syndrome Insertion tendopathy Lateral position; hip 70 flexion, 30 adduction, internal rotation RSWT: 2,8-3,5 bar; 15-20Hz; x; 6-8 sessions FSWT 0,15-0,3 mj/mm2; 4-5 Hz; x; 5 sessions

45 More indications Common empirically-tested clinical uses Tendinopathy: Ulnar epicondylopathy Adductor syndrome Pes anserinus syndrome Peroneal tendon syndrome Muscular pathologies: Myofascial syndrome (fibromyalgia excluded) Injury without discontinuity Impaired wound healing Burn injuries Salivary stones

46 Exceptional indications/expert indications Spasticity Early stage osteochondritis dissecans (OD) pre-skeletal maturity Apophysitis (Osgood Schlatter disease) Peyronie s disease (IPP-induratio penis plastica) Uses under experimental conditions Myocardial ischemia (extracorporeal/endocorporeal) Peripheral nerve lesions Abacterial prostatitis Periodontal disease Osteoarthritis

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