Antoni Morral: Professor of Physical Therapy. School of Health Science Blanquerna, Universitat Ramon...

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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.


Amateur athletes


Man, 40-50 years Long Distance Runner with Chronic Achilles tendinopathy (insertional or non-insertional)

Common patient in our center


http://www.mediomaratonmadrid.es/mmm2011/wp-content/uploads/MMM004.jpg

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“worker elbow” = “codo de currante”


First patients in 1999



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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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


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.


1. Focus

Focused Radial

Focus

Differences

hard shockwave soft shockwave

2. Focus


Device: Piezo Clast. Electro Medical System (EMS). Nyon . Switzerland


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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


Cellular Mechanotransduction


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


“The evidence from in vitro and animals studies”

There are many studies studies about cell biological effects of mechanical stimulations generated by shock wave.


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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.


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.


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


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.


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.


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


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SHOCK WAVE &

ANALGESIA


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


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


ESWT and selective nerve destruction


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



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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


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.


Systematic review Meta-analysis Randomized controlled trials


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.


Treatment protocol:

3 sessions Interval between sessions: 1-2 weeks

Low energy (< 0,20 mJ/mm2) 2000 pulses

2-8 Hz


Inclusion criteria

Established diagnosis of chronic tendinopathy for at least 6 months before treatment and failure of nonoperative management.


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Shoulder


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


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


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.


Plantar fasciopathy


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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)


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.


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


Achilles tendinopathy


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


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…)


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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.


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”

Qqqq qqqqq


Elbow


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


Medial Tibial Stress Syndrome


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)


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Patellar tendinopathy


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


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


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External validity of clinical trials

and transferability of their results to medical practice


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


Eficàcia: Efficacy, Efectivitat: Effectiveness Eficiència: Efficiency


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.


P: Patients I: Intervention C: Comparison O: Outcome T: Time


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


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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


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


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


It seems thus possible that Shock Wave is not an effective treatment modality for the early stages of tendinopathy.


Inclusion criteria

Established diagnosis of chronic tendinopathy for at least 6 months before treatment and failure of nonoperative management.


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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


time

intensity

We must have patience, patience, patience…

Return to competition

Shock wave therapy

velocity

strength

plyometrics

Individual graded running programme


Charles Robert Darwin (1809-1882)

Adaptation theory, is an organism's ability to adapt to changes in its environment and adjust accordingly over time.


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.


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.


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

[email protected]

Thank you very much for your kind attention


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Antoni Morral: Professor of Physical Therapy. School of Health Science Blanquerna, Universitat Ramon...

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