Kevin Jones Medical Services Director

Transcription

1 Kevin Jones Medical Services Director

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3 MSK 2016 Extra Corporeal Shockwave Therapy

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5 Shock!

6 Some Examples Of A Shockwave

7 Atomic Bomb

8 John Non Neumann 1945 Mathematician. Invented the WWII 1945 Atomic Bomb Defined the direct and indirect effect of shockwaves. Effect between compressed and undisturbed air. Object to be supersonic to create shockwave (Sonic) 768mph /343.2 m/s in air at sea level 20 centigrade. 3316mph / 1482 m/s in water at 20 centigrade.

9 History & Background

10 Dr Frank Rieber

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12 1951

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14 Yutkin et al 1950

15 Chaussy, Eisenberger & Forssman 1974

16 In vitro and In Vivo Experiements

17 The Early HM1 1980

18 Human Model

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20 1951

21 Types Of Shockwave Generator Electrohydraulic HM1(1980) & HM3 (1983) Piezoelectric Array Single & Dual Electromagnetic Coil with Lens. Electromagnetic Cylindrical Coil.

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23 Test stone

24 Renal ESWL

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26 Latest Lithotripter

27 Dual Layer technology

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29 MSK ESWT

30 ESWT Technology

31 Radial Pressure Devices

32 Radial Pressure Devices

33 Radial Pressure Properties

34 Focussed Shockwave Devices

35 Focussed Shockwave Properties

36 Plug & Play Transducers

37 Linear & Cylindrical Transducers

38 Penetration depth The Piezo shockwave technology uses interchangeable gel pads which contact the patient to ensure that the shockwave penetrates precisely to the desired depth with as little scattering as possible. These gel pads are used as spacers and change the penetration depth in increments of 5 mm.

39 Energy % v Depth

40 Ultrasound Biphasic Low bar pressure 0.5 bar Focussed Shockwave Up to 1000 times more pressure than ultrasound Low to High Energy pressure Short duration Focussed and depths from skin surface to 20cm. Radial Pressure Wave Low energy pressure Superfical depth 5mm

41 ESWT Biological Effects

42 Mechanotransduction Mechanical Stressors causing a biological effect

43 Increased fibroblast proliferation and Differentiation by activation of gene expression for transforming Growth factor TGF-1 with an effect on collagen type I & lll. Tenocytes are elongated fibroblast cells in tendons. ESWT Angiogenesis Stage - Week 1 to 4 Certain healing expressions called enos, VEGF and PCNA all increase. Revascularisation - PCNA Markers remain up to week 12. This period allows new blood vessels to be created and grow forming new tissue growth. Important NOT to review patient outcomes until week 12. Effect continues up to 6 months.

44 ENOS - Endothelial Nitric Oxide Synthase Important cellular signalling molecule and involved with angiogenesis.

45 VEGF Vessel Endothelial Growth Factor is a signal protein responsible for new blood vessel formation and restoring oxygen supply to tissues.

46 PCNA - Proliferating Cell Nuclear Antigen is a protein that acts as a processivity factor for DNA polymerase ε in eukaryotic cells. Within the nucleus and involved with repair of DNA.

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48 Other Biological Effects Inhibits inflammatory mediators such as COX II Hyperstimulation of nerve endings, increasing analgesic effect (Melzak & Wall Gate control theory) Substance P increase? Increase in free radicals.

49 NICE Approved ESWT Indications Calcific Tendinitis of the shoulder 2003 Refractory Achilles Tendinopathy 2009 Refractory Plantar Fasciitis 2009 Refractory Lateral Epicondylitis 2009 Refractory Trochanteric Pain Syndrome 2011

50 Calcified Tendinitis of Shoulder

51 Achilles Tendinopathy

52 Plantar Fasciitis

53 Lateral Epicondyitis

54 Trochanteric Hip Syndrome

55 Treatment Protocol 3 6 treatment sessions. Frequency of treatment once every 1-2 weeks 2000 shockwaves Energy flux density of mj/mm2 Repetition rate 5-6 Hz Depth of focus 10-40mm Review at 3 months. No Local anaesthetic Proceed with physiotherapy/eccentric loading and Orthotics.

56 Post treatment patient care Proceed with Loading/ stretching exercises Patients not to take anti-inflammatories No sport for 4 weeks Use of orthotics should be encouraged Inflammatory response seen about 2-3 days Post ESWT.

57 Contraindications Anticoagulant Therapy Patients <18 years old Patients had steroid injection <3 months. Pregnancy Focus to air filled such as lung fields and bowel. Brain Spinal cord Full muscle/tendon ruptures (grade 3) Localised malignancy.

58 Other Orthopaedic indications Medial Epicondylitis Infrapatellar Tendinitis Medial Tibial stress syndrome Popliteal tendinitis Myofascia Pain Syndrome Pseudathrosis Myositis Ossificans (Little evidence)

59 Non or Delayed Union

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63 Clinical & Technical Considerations Optimum focal energy for safety and efficacy. Optimal focal area dependant on technology. Shockwave repetition rate 5-6HZ Versus 15-20hz Insertion plus trigger points causing referred pain Patient positioning utilising limb Extension Optimum number of treatment sessions Therapy technique for transducer Focussing upon correct area. Focussed v Radial

64 Complications A Study performed that included world wide literature on complications related to ESWT did not find any substantial adverse side effects from shockwave therapy (Siebert 1996)

65 Evidence Issues More high quality level 1 research. Greater understanding of the technical differences in technology and limitations Heterogeneity of evidence Greater Author understanding when writing papers regardless of type including Systematic reviews. Papers need to be more pragmatic and include Operator dependency.

66 Other Indications Renal Stones Pancreatic stones Peyronies Disease Erectile Dysfunction Diabetic Ulcers & Wound healing Spasticity Salivary tones Peripheral Arterial Disease. Pre surgical Conditioning Cellulite

67 ESWT For Wound Healing

68 ESWT for Wound Healing July 30 th 2014 September 10 th 2014 October 17 th 2014

69 Post Surgery Wound

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71 Thank You