Michael Harbo. Clinical Expert in Sports Physiotherapy.
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Michael Harbo. Clinical Expert in Sports Physiotherapy.

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RCT in shock wave. From theory to practical

RCT in shock wave. From theory to practical

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Michael Harbo. Clinical Expert in Sports Physiotherapy. Michael Harbo. Clinical Expert in Sports Physiotherapy. Presentation Transcript

  • R CT IN S H OCKWAVE F RO M T H E O RY TO P RACSIS Michael Harbo Clinical expert in sports physiotherapy fredag den 25. oktober 13
  • Michael Harbo Clinical expert in sports physiotherapy fredag den 25. oktober 13
  • Michael Harbo OSLO STOCKHOLM Clinical expert in sports physiotherapy DENMARK Aalborg, Denmark UNITED KINGDOM COPENHAGEN IRELAND NETHERLANDS DUBLIN AMSTERDAM LONDON • PO BERLIN GERMANY Working with shockwave since 2003 BRUSSELS CHECH REP BELGIUM LUXEMBOURG PRAGUE • Text-book author on electro-therapy AUSTRIA PARIS BRATI VIENNA SWITZERLAND SLOVENIA BERN • Associate lector at University College LJUBLJANA ZA FRANCE CROATIA ITALY BOSNIA HERZ. Northern Jutland SARAJEV MONTENE PODGORICA SPAIN ROME PORTUGAL MADRID LISBON fredag den 25. oktober 13
  • fredag den 25. oktober 13
  • Pressur e RPT i gh -h T SW E RPW T ow l T SW E Extracorporal shockwave f ESWT Ra dial pu lse the rapy Focused shockwave fredag den 25. oktober 13 waves E r T W S
  • Pressur e RPT i gh -h T SW E waves Extracorporal shockwave RPW T SHOCKWAVES f ESWT ow Ra l T SW E dial pu lse the rapy Focused shockwave fredag den 25. oktober 13 E r T W S
  • S U CCESS HA S M ANY FATHE R S fredag den 25. oktober 13
  • S UCCESS HAS MANY FAT HE R S B UT T HE S E A RE N OT TH E S A M E fredag den 25. oktober 13
  • Focused shockwave Pressure waves ESWT - low RPWT ESWT - high Radial Pulse Therapy f ESWT rESWT B UT T HE S E A RE N OT TH E S A M E fredag den 25. oktober 13
  • Focused shockwave Pressure waves ESWT - low RPWT ESWT - high Radial Pulse Therapy f ESWT rESWT B UT T HE S E A RE N OT TH E S A M E SHOCKWAVES fredag den 25. oktober 13
  • Focused shockwave Pressure waves ESWT - low RPWT ESWT - high Radial Pulse Therapy f ESWT WATER rESWT B UT T HE S E A RE N OT TH E S A M E SHOCKWAVES fredag den 25. oktober 13
  • SHOCKWAVES fredag den 25. oktober 13
  • SHOCKWAVES fredag den 25. oktober 13
  • SHOCKWAVES ESWT RPT 20 - 20.000 Hz Focused Max 100 MPa 0 - 0,50 2 mJ/mm Total impulse 1 µs Time to peek 0.3 – 1 ns fredag den 25. oktober 13 4 - 15 Hz Radial Max 10 MPa 2 0 - 0,3 mJ/mm Total impulse1000 µs 1000-5000 ns
  • SHOCKWAVES ESWT RPT 20 - 20.000 Hz Focused Max 100 MPa 0 - 0,50 2 mJ/mm Total impulse 1 µs Time to peek 0.3 – 1 ns fredag den 25. oktober 13 4 - 15 Hz Radial Max 10 MPa 2 0 - 0,3 mJ/mm Total impulse1000 µs 1000-5000 ns
  • SHOCKWAVES ESWT RPT 20 - 20.000 Hz Focused Max 100 MPa 0 - 0,50 2 mJ/mm Total impulse 1 µs Time to peek 0.3 – 1 ns fredag den 25. oktober 13 4 - 15 Hz Radial Max 10 MPa 2 0 - 0,3 mJ/mm Total impulse1000 µs 1000-5000 ns
  • SHOCKWAVES ESWT RPT 20 - 20.000 Hz Focused Max 100 MPa 0 - 0,50 2 mJ/mm Total impulse 1 µs Time to peek 0.3 – 1 ns fredag den 25. oktober 13 4 - 15 Hz Radial Max 10 MPa 2 0 - 0,3 mJ/mm Total impulse1000 µs 1000-5000 ns
  • SHOCKWAVES ESWT RPT 20 - 20.000 Hz Focused Max 100 MPa 0 - 0,50 2 mJ/mm Total impulse 1 µs Time to peek 0.3 – 1 ns fredag den 25. oktober 13 4 - 15 Hz Radial Max 10 MPa 2 0 - 0,3 mJ/mm Total impulse1000 µs 1000-5000 ns
  • B UT D O T H E Y WOR K ? fredag den 25. oktober 13
  • B UT D O T H E Y WOR K ? FAI January 1, 2013 The effectiveness of shock wave therapy on chronic achilles tendinopathy: a systematic review Hani Al-Abbad fredag den 25. oktober 13
  • B UT D O T H E Y WOR K ? FAI January 1, 2013 The effectiveness of shock wave therapy on chronic achilles tendinopathy: a systematic review Hani Al-Abbad Based on 6 appropriate studies: fredag den 25. oktober 13
  • B UT D O T H E Y WOR K ? FAI January 1, 2013 The effectiveness of shock wave therapy on chronic achilles tendinopathy: a systematic review Hani Al-Abbad Based on 6 appropriate studies: “Our review showed satisfactory evidence for the effectiveness of ESWT in the treatment of chronic insertional and noninsertional Achilles tendinopathies” fredag den 25. oktober 13
  • B UT D O T H E Y WOR K ? fredag den 25. oktober 13
  • B UT D O T H E Y WOR K ? fredag den 25. oktober 13
  • B UT D O T H E Y WOR K ? BJSM August 5, 2013 A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence Cathy Speed fredag den 25. oktober 13
  • B UT D O T H E Y WOR K ? BJSM August 5, 2013 A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence Cathy Speed Based on 23 appropriate studies: fredag den 25. oktober 13
  • B UT D O T H E Y WOR K ? BJSM August 5, 2013 A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence Cathy Speed Based on 23 appropriate studies: “There is evidence for the benefit of F-ESWT and of RPT in a number of softtissue musculoskeletal conditions, and evidence that both treatment modalities are safe” fredag den 25. oktober 13
  • BU T F E W T H I N G S A RE O NLY BLAC K O R WH I T E The effect seems to be: • Modality-dependent • Diagnose-dependent • Dose-dependent fredag den 25. oktober 13
  • C H RO N IC P L A N TA R FA SC I TI S ( BE NE F IT AT 1 2 W E E K F O L LO W- UP ) YE S fredag den 25. oktober 13 NO
  • C H RO N IC P L A N TA R FA SC I TI S ( BE NE F IT AT 1 2 W E E K F O L LO W- UP ) YE S NO • • Buchbinder, 2002 • Ogden, 2001 • Haake, 2003 • Theodore, 2004 • Speed, 2002 • Gollwitzer, 2007 • Kudo, 2006 • fredag den 25. oktober 13 Malay, 2006 Gerdesmeyer, 2008
  • C H RO N IC P L A N TA R FA SC I TI S ( BE NE F IT AT 1 2 W E E K F O L LO W- UP ) YE S NO M O DA LI TY ? • Buchbinder, 2002 Ogden, 2001 • Haake, 2003 • Theodore, 2004 • Speed, 2002 • Gollwitzer, 2007 • Kudo, 2006 • Gerdesmeyer, 2008 • • fredag den 25. oktober 13 Malay, 2006
  • C H RO N IC P L A N TA R FA SC I TI S ( BE NE F IT AT 1 2 W E E K F O L LO W- UP ) YE S NO M O DA LI TY ? • ESWT ESWT • ESWT • ESWT • ESWT • ESWT • RPT • RPT • • fredag den 25. oktober 13 ESWT
  • C H RO N IC P L A N TA R FA SC I TI S ( BE NE F IT AT 1 2 W E E K F O L LO W- UP ) YE S NO I N T E N S I TY ? • ESWT ESWT • ESWT • ESWT • ESWT • ESWT • RPT • RPT • • fredag den 25. oktober 13 ESWT
  • C H RO N IC P L A N TA R FA SC I TI S ( BE NE F IT AT 1 2 W E E K F O L LO W- UP ) YE S NO I N T E N S I TY ? • ESWT High • ESWT • High • ESWT • High • High • High • • fredag den 25. oktober 13 High
  • C H RO N IC P L A N TA R FA SC I TI S ( BE NE F IT AT 1 2 W E E K F O L LO W- UP ) YE S NO I N T E N S I TY ? • Low High • Low • High • Low • High • High • High • • fredag den 25. oktober 13 High
  • C H RO N IC P L A N TA R FA SC I TI S ( BE NE F IT AT 1 2 W E E K F O L LO W- UP ) YE S H I G H - E S W T & RPT fredag den 25. oktober 13
  • CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S (BENEF IT AT 12 WEEK F OLLOW- UP) YE S fredag den 25. oktober 13 NO
  • CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S (BENEF IT AT 12 WEEK F OLLOW- UP) YE S • • Vulpiani, 2009 • (Rompe, 2007) • (Lakshmanan, 2004) • fredag den 25. oktober 13 Rasmussen, 2008 (Rompe, 2008) NO • Costa, 2005
  • CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S (BENEF IT AT 12 WEEK F OLLOW- UP) YE S • • ESWT • (RPT) • (RPT) • fredag den 25. oktober 13 ESWT (RPT) NO • RPT
  • CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S (BENEF IT AT 12 WEEK F OLLOW- UP) YE S • • High • (High) • (Low) • fredag den 25. oktober 13 High (Low) NO • Low
  • CHR ON IC MID P O RT I O N AC H I L L ES TEND I NO S I S (BENEF IT AT 12 WEEK F OLLOW- UP) YE S H IGH-ESWT (LOW-R PT ) fredag den 25. oktober 13
  • C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY ( BE NEFIT AT 1 2 WEEK FOLLOW-U P ) YE S fredag den 25. oktober 13 NO
  • C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY ( BE NEFIT AT 1 2 WEEK FOLLOW-U P ) YE S • • fredag den 25. oktober 13 Furia, 2006 Vulpiani, 2009 NO
  • C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY ( BE NEFIT AT 1 2 WEEK FOLLOW-U P ) YE S • ESWT • NO ESWT No RPT studies met the inclusion criteria fredag den 25. oktober 13
  • C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY ( BE NEFIT AT 1 2 WEEK FOLLOW-U P ) YE S • • fredag den 25. oktober 13 ESWT ESWT NO
  • C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY ( BE NEFIT AT 1 2 WEEK FOLLOW-U P ) YE S • • fredag den 25. oktober 13 High High NO
  • C H R ON I C I N SERTI ONA L AC HI L L ES TEN DIN OPATHY ( BE NEFIT AT 1 2 WEEK FOLLOW-U P ) YE S HI GH - ES WT fredag den 25. oktober 13
  • CA LCI FI C R OTATOR C U F F TE N DINOPATHY ( BENEFIT AT 12 WEEK FOL LOW-U P ) YE S fredag den 25. oktober 13 NO
  • CA LCI FI C R OTATOR C U F F TE N DINOPATHY ( BENEFIT AT 12 WEEK FOL LOW-U P ) YE S • • Albert, 2007 • fredag den 25. oktober 13 Consentino, 2003 Gerdesmeyer, 2003 NO
  • CA LCI FI C R OTATOR C U F F TE N DINOPATHY ( BENEFIT AT 12 WEEK FOL LOW-U P ) YE S • ESWT • ESWT • NO ESWT No RPT studies met the inclusion criteria fredag den 25. oktober 13
  • CA LCI FI C R OTATOR C U F F TE N DINOPATHY ( BENEFIT AT 12 WEEK FOL LOW-U P ) YE S • • ESWT • fredag den 25. oktober 13 ESWT ESWT NO
  • CA LCI FI C R OTATOR C U F F TE N DINOPATHY ( BENEFIT AT 12 WEEK FOL LOW-U P ) YE S • • High • fredag den 25. oktober 13 High High NO
  • CA LCI FI C R OTATOR C U F F TE N DINOPATHY ( BENEFIT AT 12 WEEK FOL LOW-U P ) YE S H IGH- ESW T fredag den 25. oktober 13
  • CONCLUS IO N fredag den 25. oktober 13
  • HIGH-ESWT CONCLUS IO N Chronic Plantar fascitis Chronic mid portion achilles tendinosis Chronic insertional achilles tendinopathy Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  • HIGH-ESWT CONCLUS IO N Chronic Plantar fascitis Chronic mid portion achilles tendinosis Chronic insertional achilles tendinopathy Calcific rotator cuff tendinopathy H I G H - R PT Chronic Plantar fascitis fredag den 25. oktober 13
  • HIGH-ESWT CONCLUS IO N Chronic Plantar fascitis Chronic mid portion achilles tendinosis Chronic insertional achilles tendinopathy Calcific rotator cuff tendinopathy H I G H - R PT Chronic Plantar fascitis LOW- RPT Chronic mid portion achilles tendinosis fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy “Effect of ESWT on calcific rotator cuff tendinopathy with classic signs of impingement” Harbo & Jakobsen, not published fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy “Effect of ESWT on calcific rotator cuff tendinopathy with classic signs of impingement” Harbo & Jakobsen, not published • • N=70 • 1 & 6 months follow-up • fredag den 25. oktober 13 Doubleblind-RCT WORC and Constant & Murley score
  • Calcific rotator cuff tendinopathy 80 ESWT on calcific rotator cuff tendinopathy with 1 & 6 months follow-up • WORC and Constant & Murley score Placebo • Active N=70 Placebo • 40 Active Doubleblind-RCT Placebo • Active Harbo & Jakobsen, not published Constant & Murley Score gns of impingement” 0 Pre fredag den 25. oktober 13 1 mo 6 mo
  • Calcific rotator cuff tendinopathy A case story • • • • fredag den 25. oktober 13 38 year old male referred to our ESWT study X-ray verified large calcification situated in supraspinatus Unable to work and did not want to risk receiving placebo-treatment No severe pain, but unable to abduct the shoulder above 80 degree
  • Calcific rotator cuff tendinopathy A case story fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy A case story Initial treatment 3 sessions of high-ESWT (1500 impulses of 0.4 mJ/mm fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy No ROM incresement - 2 treatments more are given ... fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy ROM increased to 140 degree - no treatment given for 4 weeks fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy Free painfree ROM - 1 treatment/week for 3 weeks - 1 treatment/14 days for 4 weeks - Control at 12 weeks fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  • Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  • TAKE H OME MESS AGE fredag den 25. oktober 13
  • TAKE H OME MESS AGE There are two forms of shockwave and they are DIFFERENT modalities and should be evaluated separately. There is strong evidence that F-ESWT is effective in the treatment of plantar fasciitis and calcific tendinitis, and that low-RPT is effective in plantar fasciitis. Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. Both modalities are promissing and safe to use - even at High intensities fredag den 25. oktober 13
  • TAKE H OME MESS AGE There are two forms of shockwave and they are DIFFERENT modalities and should be evaluated separately. There is strong evidence that F-ESWT is effective in the treatment of plantar fasciitis and calcific tendinitis, and that low-RPT is effective in plantar fasciitis. Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. Both modalities are promissing and safe to use - even at High intensities fredag den 25. oktober 13
  • TAKE H OME MESS AGE There are two forms of shockwave and they are DIFFERENT modalities and should be evaluated separately. There is strong evidence that F-ESWT is effective in the treatment of plantar fasciitis and calcific tendinitis, and that low-RPT is effective in plantar fasciitis. Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. Both modalities are promissing and safe to use - even at High intensities fredag den 25. oktober 13
  • TAKE H OME MESS AGE There are two forms of shockwave and they are DIFFERENT modalities and should be evaluated separately. There is strong evidence that F-ESWT is effective in the treatment of plantar fasciitis and calcific tendinitis, and that low-RPT is effective in plantar fasciitis. Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. Both modalities are promissing and safe to use - even at High intensities fredag den 25. oktober 13
  • It hurts - but it works ! fredag den 25. oktober 13
  • It hurts - but it works ! fredag den 25. oktober 13
  • RPT example fredag den 25. oktober 13
  • T H AN K YOU fredag den 25. oktober 13