You may have heard the buzz or the rumblings on the grapevine about Shockwave Therapy, but what on earth is it? How can it help you? Is it a ‘proper’ treatment? Lets de-mystify!
History
Shockwave Therapy, known in the trade as Extracorporeal Shockwave Therapy (EWST) is a treatment used in physical therapy, orthopaedics, cardiology and urology, which is where the practice first started. EWST is not a new treatment – one of the earliest uses was in Urology and the treatment of kidney stones. Whilst blasting away these kidney stones, people were inadvertently being cured of musculoskeletal conditions too.
In recent years, it has been shown to be beneficial for an increasingly broad number of conditions and has been used by a number of high profile sportsmen, women and teams, creating a much larger awareness of the benefits it can provide.
What does it actually do?
Shockwave Therapy is based on a wave of energy generated outside the body giving the therapy the extracorporeal (outside of the body) part of its name. Now think of a jacuzzi. The bubbles created are also outside the body but when you focus the jets on a certain area of the body, the effect can be felt below the surface of the skin. The stronger the jet, the deeper the effect. The Shockwave Therapy machine works in a similar way to the jacuzzi. A wave of energy is created in the handset of the machine and delivered to the target area of the body.
During the treatment micro traumas are occurring within the tissue around the target area, which increases blood flow to that area and speeds up the healing process in that area. There is also the stimulation of the body’s inflammatory response to a chronic injury.
The shockwave treatment creates something called cavitation bubbles within the tissues, and these bubbles expand and burst. The bursting of these bubbles is important in causing soft tissues to repair and the irritation created when the bubbles burst helps break down topologies and sometimes calcium deposits.
The compression phase penetrates the skin and weakens in the tissue. A tensile phase generates cavitation bubbles. These bubbles collapse, causing secondary shock waves.
More energy is more effective in the treatment of these conditions but that can be more painful but systems like the EMS Swiss DolorClast and the Evo Blue handset is very effective at producing efficient energy to the right spot with no loss of energy within the handset or the superficial tissue prior to reaching the injured tissue. There are a number of other machines on the market that cannot supply the required energy to the tissue due to loss of energy within the handset.
What can Shockwave Therapy treat?
In the UK, official clinical guidance is issued by NICE (National Institute for Health & Clinical Excellence) and they make recommendations on treatments that have been evidenced and backed by clinical research. There are 6 conditions that have NICE guidelines, although there are many more conditions that can be treated with Shockwave Therapy.
Conditions with NICE guidelines:
Subacromial Pain Syndrome
Also known as Rotator Cuff Disease this condition is often caused by trauma, inflammation or deterioration. It is often seen in throwing sports, golf, volleyball, and gymnastics, and is one of the most common shoulder conditions seen.
Lateral Epicondylitis
Better known as Tennis Elbow, although it isn’t often seen in tennis players! It is a tendinopathy of the extensor mechanism of the wrist – the hinging action which brings the wrist upwards towards the ceiling. It isn’t usually an inflammatory disorder – it is usually caused by regular overloading causing micro traumas, which then lead to tendon deterioration over time.
Greater Trochanteric Pain Syndrome
Often called hip bursitis but actually affects the whole of the trochanter area and not just the trochanteric bursa. The pain is in and around the greater trochanter (the little bony bump on the side of the thigh). It is a complex area and as there are 5 muscles that attach at this point, it is prone to degeneration.
Achilles Tendinopathy
Usually not the result of one specific injury, but more often the result of repetitive strains over a long period of time or a sudden increase in activity. The strain can also be caused by tight calf muscles or poor foot biomechanics. It can affect a wide range of people from the very sporty at one end of the spectrum to those with high BMI at the other end. It can affect the area where the tendon attaches to the bone – known as insertional tendinopathy, or it can be further up the calf – mid-portion tendinopathy.
Plantar fasciopathy
More commonly known as plantar fasciitis, this condition is the most well known to be successfully managed using Shockwave Therapy. The pain is usually felt at the medial tubercle of the calcaneous and is felt along the soft tissue of the arch to the base of the toes. It is not always caused by problems in the foot, but can be the result of factors through the joints above the foot and ankle. Plantar fasciopathy can cause significant pain and discomfort and can have a huge impact on mobility levels, which can cause even more problems.
Typical symptoms are pain first thing in the morning that eases after the foot has ‘warmed up’, and pain on rising after periods of rest during the day. Correcting the biomechanics of the foot using custom foot orthotics is often required initially, and then Shockwave Therapy is used to treat the fasciopathy. The complex nature of the biomechanics of the foot makes it a very difficult area to treat but the results are amongst the most successful of any Shockwave Therapy treatment.
Other conditions
The ISMST (International Society for Medical Shockwave Treatment) maintains a list of recommendations for the use of Shockwave Therapy in medical conditions. Although they are not on the NICE list they have been gathered by the leading experts in the field of Shockwave Therapy and they may benefit from the treatment.
Chronic Tendiopathies:
– Plantar Fascia (with or without a heel spur)
– Achilles Tendon
– Lateral Epicondylitis (tennis elbow)
– Rotator cuff (with or without calcification)
– Patella Tendon
– Greater Trochanteric Pain Syndrome
Impaired bone healing function:
– Delayed Bone Healing
– Stress Fractures
– Early stage of avascular bone necrosis
Urology:
– Lithotripsy (breaking down kidney stones)
Muscular pathologies:
– Myofascial syndrome (fibromyalgia excluded)
There are a number of peer-reviewed resources that evidence the benefits Shockwave Therapy can have on other conditions, and this includes PEDro, a database of over 34,000 evidence-based studies that is a project of the Centre of Evidence-Based Physiotherapy.
– Hamstring Tendiopathies
– Knee Pain
– Osteoarthritis
– Carpal Tunnel Syndrome
– Dupuytrens Contracture
– De Quervain Disease
– Trigger Finger
– Idiopathic Low Back Pain
– Myofascial Pain Relief
So what can I expect?
With a condition that is correctly diagnosed patients can expect the appropriate treatment recommendation and then symptoms to be greatly improved. Progression may take time, and this will vary from patient and condition. The clinical studies report a success rate above 75%. Though it’s not popular to attribute a percentage to treatment success, it is statistically far more likely that you will have a more beneficial outcome from Shockwave Therapy than from surgery.
During each session we deliver a set number of Shockwave impulses to deliver energy to the site of the injury. Typically, your first treatment may be 30 minutes as we explain the process and you experience the delivery for the first time. Most people find the treatment a little uncomfortable until we deliver about 500 impulses; then there’s a release of a pain and growth mediator called
substance P. This is similar to the effect you get from eating a hot chilli pepper – at first your mouth is on fire, and then it feels numb, almost as if you have got used to it.
There is no medication or injections associated with the procedure, there is no need for numbing agents or anaesthetics, and this greatly reduces the risk of side effects. Unfortunately, it’s not uncommon to see tendons rupture as the result of injections. This can set back recovery by many weeks or months, so a treatment with almost no side effects is a huge benefit to your overall health.
You will be asked to stop any non-steroidal anti-inflammatory medications for 14 days prior to the course of treatment. If medication is needed then paracetamol and codeine could be considered.
In terms of overall healing, it may take up to 6 months to fully recover, however most patients notice a positive improvement between the 2- 3rd treatment. With a course of treatment lasting up to 6 sessions for the more recalcitrant (non-responding to treatment) conditions, we’ll often see people asking for the last few sessions to be accelerated as they feel the benefits and want to complete the course as soon as possible. More often than not, three treatments seem to be the sweet spot, delivering the right amount of power to generate the required effect in the body. As the area heals, many patients report an ongoing sensation of healing between treatments.
Does Shockwave Therapy hurt?
Shockwave Therapy is probably best described as uncomfortable. This of course is very subjective and will vary from person to person. The great news is that improvements in technology and delivery practices means it becoming more comfortable all the time.
Most treatments are short and the best advice is to manage the discomfort through focus and breathing, allowing you to receive the full treatment wherever possible. Higher power and longer duration will deliver more benefit but at the end of the day you should work with a practitioner who is aware of your tolerance, but is certain enough in their work to deliver the most effective treatment that will give you the outcome you’re looking for.
The immediate discomfort of the procedure will subside as soon as the treatment is complete. Some patients experience residual tenderness after the treatment and it may produce some minor skin bruising, reddening or swelling around the contact point. This typically settles down within 36-48 hours and has usually gone completely before the next treatment. For most people, the benefits outweigh the discomfort and as soon as they start to feel the improvement, they are keen to finish the course of treatment.
Why might Shockwave Not Be For Me (Contraindications)?
Shockwave is unsuitable in the following circumstances:
– If you are pregnant
– If you have a blood clotting disorder (including thrombosis)
– If you are taking oral anti-coagulants
– If you have received a Steroid injection within 6 weeks
– If you have a Pacemaker fitted
– If tumours are present at the treatment site
– If you have an infection or skin abrasion at the treatment site
– If you are Under 18 (except in the treatment of Osgood-Schlatter disease).
– Any treatment over an air-filled area such as the lungs or guts is also not possible
Most people think the only option to deal with ongoing tendon or joint pain is surgery or living with the symptoms. The good news is, there is an alternative and Shockwave therapy may be your solution to becoming pain free.
