Michael Harbo. Clinical Expert in Sports Physiotherapy.

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RCT in shock wave. From theory to practical

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Michael Harbo. Clinical Expert in Sports Physiotherapy.

  1. 1. 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
  2. 2. Michael Harbo Clinical expert in sports physiotherapy fredag den 25. oktober 13
  3. 3. 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
  4. 4. fredag den 25. oktober 13
  5. 5. 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
  6. 6. 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
  7. 7. S U CCESS HA S M ANY FATHE R S fredag den 25. oktober 13
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. SHOCKWAVES fredag den 25. oktober 13
  13. 13. SHOCKWAVES fredag den 25. oktober 13
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. B UT D O T H E Y WOR K ? fredag den 25. oktober 13
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. B UT D O T H E Y WOR K ? fredag den 25. oktober 13
  24. 24. B UT D O T H E Y WOR K ? fredag den 25. oktober 13
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. 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
  54. 54. CONCLUS IO N fredag den 25. oktober 13
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. Calcific rotator cuff tendinopathy A case story fredag den 25. oktober 13
  64. 64. 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
  65. 65. Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  66. 66. Calcific rotator cuff tendinopathy No ROM incresement - 2 treatments more are given ... fredag den 25. oktober 13
  67. 67. Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  68. 68. Calcific rotator cuff tendinopathy ROM increased to 140 degree - no treatment given for 4 weeks fredag den 25. oktober 13
  69. 69. Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  70. 70. 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
  71. 71. Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  72. 72. Calcific rotator cuff tendinopathy fredag den 25. oktober 13
  73. 73. TAKE H OME MESS AGE fredag den 25. oktober 13
  74. 74. 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
  75. 75. 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
  76. 76. 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
  77. 77. 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
  78. 78. It hurts - but it works ! fredag den 25. oktober 13
  79. 79. It hurts - but it works ! fredag den 25. oktober 13
  80. 80. RPT example fredag den 25. oktober 13
  81. 81. T H AN K YOU fredag den 25. oktober 13

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