Antoni Morral. Professor of Physical Therapy. School of Health Science Blanquerna, Universitat Ramon Llull, Barcelona, Spain.

11/10/2013

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



Common patient
in our center

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


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11/10/2013

“worker elbow” = “codo de currante”


First patients in 1999


Athletic horses


Shock wave

Change of paradigm


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11/10/2013

Shock wave. Physical characteristics

1 MPa = 10 bar

A shock wave is an acoustic pulse, with a high peak
pressure and a short life cycle.
Rassweiler JJ, Knoll T, Köhrmann KU,.
Shock wave technology and application: an update. Eur Urol.
2011 May;59(5):784-96.Review.


Differences

Methods of shock wave generation
Focused

1. Focus

Electrohydraulic

Piezoelectric

Electromagnetic

Radial

2. Focus

Focus

Pneumatic
 hard shockwave

 soft shockwave

Ogden JA, Tóth-Kischkat A, Schultheiss R
Principles of shock wave therapy. Clin Orthop Relat Res. 2001 Jun;(387):8-17.


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

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11/10/2013

Energy flow density & Therapeutic objectives
Repair Potential of cells

low
0

medium
0,2

0,4

Energy flow density

high
0,6

0,8

1,0

1,2
mJ/mm2

Cellular
Mechanotransduction

Pain Therapy
Lithotripsy
Osteotherapy
Source: Rompe,‘‘Extrakorporale Stosswellentherapie“


Mechanotransduction is cellular signal transduction in
response to mechanical stimuli.


Force transmission between
the extracellular matrix (ECM) and the nucleus

Mechanical cues modulate almost all aspects
of cell function, including:
Growth
Differentiation
Migration
Gene expression
Protein synthesis
Apoptosis

Biological Effects of Shock Waves
•Stimulates tissue regeneration
•Enhances angiogenesis
•Inhibits nociceptors


Jaalouk DE, Lammerding J. Mechanotransduction gone awry.
Nat Rev Mol CellBiol. 2009 Jan;10(1):63-73. Review.

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

“The evidence
from in vitro and
animals studies”

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11/10/2013

Shock waves: mechanisms of action
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.
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.


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.


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.

0 hours

5 hours

3 hours

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.


Cell migration was evaluated by measuring the repopulation of the cleared area

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.

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11/10/2013

Depletes nociceptive nerve endings reversibly
from PGP 9.5 and from CGRP

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 wavetreated 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


ESWT and selective nerve destruction
Induces a longer lasting depletion from PGP 9.5 and
CGRP when applied repetitively
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 singletreatment 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



Fédération Equestre Internationale

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.”


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11/10/2013

Level of scientific evidence on therapeutic questions
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.

Systematic review

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.

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.

Meta-analysis
Randomized controlled trials

•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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11/10/2013

Meta-analysis of high-energy (>0.2 mJ/mm2)
extracorporeal shock wave therapy in recalcitrant plantar fasciitis

Shoulder
5 RCTs
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.
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

17 RCTs (11 calcific, 6 non-calcific)
No evidence for non-calcific.

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.


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

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.


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

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.



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11/10/2013

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)

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.


This study concludes that
moderate- and highintensity ESWT were
effective in the treatment
of chronic plantar fasciitis.

11 RCT,s

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.


Conclusions:

Focused SW and
Radial SW are effective treatment.

Achilles tendinopathy

N= 12 trials comprising 1431 participants

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.


CONCLUSION:
Overall, our review showed satisfactory evidence for the effectiveness of lowenergy 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.


Extracorporeal shockwave therapy (ESWT) was superior to both wait-and-see and an
eccentric training regime. 14 RCTs (Surgery, LASER, SW, EE…)

Chronic insertional and
noninsertional Achilles
tendinopathies. 4 RCTs

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.

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.

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11/10/2013

Evidence was strong for eccentric loading exercises
and extracorporeal shockwave therapy.

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 Antoni Morral. FCS Blanquerna.

Elbow

“Shock wave therapy may represent an effective alternative”

Qq Sussmilch-Leitch SP, Collins NJ, Warden SJ, Crossley KM. Physical therapies for Achilles
qq
tendinopathy: systematic review and meta-analysis. J Foot Ankle Res. 2012 Jul 2;5(1):15.
qqq
qq

Shock Wave: limited/conflicting
evidence for effectiveness
or evidence of no difference in effect was found.

20 RCTs

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.

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)

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.

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11/10/2013

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.

Patellar tendinopathy

13 Clinical Trial
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.


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.

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.


Two comparative studies (levels II and III) found Radial SW
to be superior to other non-operative modalities

24 articles:
Level I: 2
Level II: 1
Level III: 1
Level IV: 20

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.

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11/10/2013

In an RCT:
External validity
of clinical trials
and transferability of their results
to medical practice

 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


Eficàcia: Efficacy,
Efectivitat: Effectiveness
Eficiència: Efficiency

I. group

C. group

Trial results
External validity,
applicability
Target population
and setting


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.



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.

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

STUDY DESIGN:
RCT; Level of evidence, 1

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.

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11/10/2013

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.

SHOCK WAVE

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.

(in weeks)

SHOCK WAVE
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.

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


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

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


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11/10/2013

Best available
research evidence

Environment and
organizational context

Decision-making
Population
characteristics,
needs, values,
and preferences

Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med. 2009 Sep;37(9):1855-67

Individual graded running programme
Return to
competition

plyometrics

Resources, including
practitioner expertise

Satterfield JM, Spring B, Brownson RC, Mullen EJ, Walker BB,Whitlock EP.
Toward a transdisciplinary model of evidence-based practice.
Antoni Morral. FCS
Milbank Q. 2009 Jun;87(2):368-90. Blanquerna.

Charles Robert Darwin (1809-1882)

We must have patience,
patience, patience…
velocity

intensity

strength

time

Shock wave
therapy


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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11/10/2013

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


Thank you very much for your kind attention
antonimf@blanquerna.url.edu


15

Antoni Morral. Professor of Physical Therapy. School of Health Science Blanquerna, Universitat Ramon Llull, Barcelona, Spain.

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Antoni Morral. Professor of Physical Therapy. School of Health Science Blanquerna, Universitat Ramon Llull, Barcelona, Spain.