2. Contents
2
1. Introduction
2. Shockwave Therapy Methods
3. Generation Of Focused Shock
Waves
4. Difference Between ESWT and
RSWT
5. Mechanism Of Action
6. Mechanism Of Action Of RWST
7. Advantages of RWST
8. RSWT with the enPuls Version 2.0
9. Preparation
10. Basic Rules
11. Dosing
12. Application methods
13. Recommendation For Chronic Soft
Tissues
14. Indications
15. Contraindications
16. Cautions
17. Treatment Protocol
18. References
3. Introduction
• Shockwaves are mechanical pressure waves that
work on the tissue.
• widely used to treat musculoskeletal problems.
• Originally → non-invasive disintegration of
kidney stones.
• Shockwave therapy has since also been used
successfully in orthopaedics.
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5. Objectives
• Pain relief
• Elimination of the cause of the pain
• Effect on muscle tone
• Stimulation of cell metabolism
• Activation of regeneration processes
• Improvement of muscle trophic level
• Stimulation of vascular renewal
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Introduction (Contd.,)
7. Shockwave therapy methods (Contd.,)
Extracorporeal Shockwave Therapy (ESWT) - 1990s,
• chronic pain management, impaired bone healing and other disorders.
• electrohydraulic or piezoelectric pressure pulses are generated –
so-called shockwaves.
• also known as focused shockwave therapy
• curve is a steep slope of the order of 10 ns
• pressure up to 140 MPa then to 10 MPa
• depth of up to 140 mm.
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8. Radial Shockwave Therapy (RSWT)
• ESWT is referred to as RSWT,
• An electromagnetic generator
• Rise time of the pressure pulse is longer than with ESWT.
• maximum pressure is around 15 MPa
• penetrate approximately 35-40 mm.
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Shockwave therapy methods (Contd.,)
9. • At 40 cm → wavelength is much longer than diameter of the
applicator heads, resulting in divergent, on-focused wave propagation
• Amount of energy → controlled with different acceleration of
projectile
• effective amount of energy → considerably by additional factors, such
as contact area and contact pressure, etc.
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Shockwave therapy methods (Contd.,)
13. Difference Between ESWT and RSWT
• wave speeds → ESWT > RSWT
• ESWT waves are not long and not less intense like RSWT.
• ESWT → more of an acoustic wave with a very high pressured
amplitude with short intense pulses while RSWT → more of a
pressure wave.
• RSWT → put right onto skin itself and waves of pressure are created
along skin surfaces.
• ESWT → waves and force is transferred to skin and tissues without
effect, and is focused at a specific desired depth.
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14. Difference Between ESWT and RSWT (Contd.,)
• RSWT → pressure waves are generated by repeatedly bouncing upon
skin with, creating pressure waves through body.
• RSWT → waves disperses through to tissue beneath.
• ESWT → treating deep tissue injuries.
• RSWT → treating superficial injuries.
• ESWT→ may be required to undergo anesthesia when undergoing
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15. Mechanism Of Action
• Kinetic energy of projectile, created by compressed air → transmit at
end of applicator → into tissue.
• Pulses of acoustic energy are focused on target tissues by the
applicator of the shockwave therapy machine (handpiece) .
• It cause localized microtrauma that stimulates the bodies natural
healing processes.
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16. • It stimulate angiogenesis / neovascularization (new blood
vessels) and neurogenesis(new nerve cells).
• Microtrauma increases local circulation and enhances
break down of calcifications (calcium build-up).
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Mechanism Of Action (Contd.,)
17. Mechanism Of Action Of RWST
• RWST → release as Hormones, trigger various pain
inhibiting and stimulating reactions in body.
• Results in a reduction in pain, expansion of blood vessels,
and, as a result, improved blood flow and tissue healing.
•Inhibition of the COX II enzyme (cyclooxygenase)
•Activation of cellular defenses
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18. •Inhibition of the COX II enzyme (cyclooxygenase)
• Inflammatory mediators such as COX II can be
inhibited by radial shockwaves.
• This attenuates inflammatory processes (anti-
inflammatory effect).
• Activation of cellular defenses
• Radial shockwaves trigger the release of free radicals.
• Hence this strengthens the body’s cellular defense
mechanisms.
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Mechanism Of Action Of RWST (Contd.,)
19. Advantages of RWST
• Increasing significance for treatment of superficial orthopaedic
conditions. Therapeutic outcome → very good in 70% of cases
• This is essentially due to:
ovirtually same therapeutic outcome as with ESWT
oRSWT treatment costs less than ESWT
• According to studies, a positive reaction (pain relief / improved
function) has been recorded in over 80% of patients (painful plantar
fasciitis)
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21. RSWT with the enPuls Version 2.0 (Contd.,)
Parameter
• Shock energy of 90 and 120 mJ
• Frequencies of around 10 Hz.
• Small, light, fully mobile device
• Long life-span of the hand piece (guaranteed at least 2,000,000 pulses)
Energy
• Energy levels at the applicator tip: 60 mJ, 90 mJ, 120 mJ and 185 mJ,
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24. Preparation
• patients → safe, comfortable position for treatment.
• Therapist → can easily reach affected area in an upright
position and handpiece →vertically.
• When treating muscles and joints, prepare the area or
muscles and move or stretch in a pain-free region in
advance.
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25. Basic Rules
• In case of pain/trigger points → Pinpoint the treatment area and
detect point with the greatest sensitivity
• Create a virtual grid over the treatment area
• Position the handpiece at right angles and apply its own weight
• Apply moderate pressure
• Contact gel is used in silicone cap
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26. • Handpiece can be held in one hand and the second hand can be used to
hold the treatment area
• Start with the most sensitive point
• Every point in the grid must be treated with the number of pulses
stipulated in the protocol.
• If possible, start with the most sensitive point.
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Basic Rules (Contd.,)
28. Dosing
• start with the large applicator head to a smaller surface
area.
• energy level and frequency can be changed for dosing
purposes.
• If treatment intensity has to be reduced on tolerance, this
should initially be done via the frequency.
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30. Application methods (Contd.,)
Static
• Handpiece is applied to one point and only vertically with
contact pressure.
• a method of procedure based on experience and common
sense when treating localised problems (pain point, trigger
point).
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31. Semi-static
• The handpiece remains on the point and also treated by
moving the handpiece evenly, working outwards from the
vertical position.
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Application methods (Contd.,)
32. Dynamic
• Handpiece is moved with head and by applying contact
pressure over the structure to be treated, without
interrupting the pulse sequence.
• This method is used to treat soft tissue areas (muscles) and
tendons.
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Application methods (Contd.,)
33. Combined Therapy
• In particularly painful situations or if the patient is
sensitive, Cryo 6 can alternatively be applied prior to
treatment in order to reduce the pain.
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Application methods (Contd.,)
34. Recommendation For Chronic Soft Tissues
• 3-5 treatments be taken at weekly intervals.
• body will require 3-4 weeks to go through the healing
phase.
• Treatments last approximately 5 minutes
• The area treated may have a throbbing discomfort for up to
48 hours after treatment which is expected due to the
inflammatory response created.
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35. Indications
• Myofascial trigger points
• Calcific tendonitis of the shoulder
• Radial and ulnar epicondylitis
• Plantar fasciitis / heel spores
• Deep back pain / lumbago
• Trochanteric bursitis
• Achillodynia
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36. Contraindications
• Vascular diseases
• Local infections
• Malignant or benign tumours
• Cartilage surfaces or near the small facet joints
• Pacemakers or analgesic pumps
• Metal implants for fractures, muscle pulls or tears
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A computerized pump
attached to the IV lets
release pain medicine
by pressing a handheld
button.
37. • Recent cortisone injection within 6 weeks
• Blood thinning medication (i.e., Heparin or Coumadin)
• Large nerves or vessels close to the area being treated
• Pregnancy
• Diseases with vasomotor impairment
• fibromyalgia
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Contraindications (Contd.,)
38. Caution
• impaired aesthesia
• severe autonomic disorders
• influence of drugs and/or alcohol
• applied to the head,
• above the lungs,
• over the abdomen and
• epiphyseal plates of children
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