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PHYSICS

E S W T - S H O C K - W A V E D E V I C E I N P H Y S I O T H E R A P Y

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Shock-wave is defined as an acoustic wave, which is made by high pressure peak, adjustable in alimited frequency range. On the wave side, the positive pressure increases in a short time from the valueof the room temperature so that of maximum pressure. After that, a generally shorter stage follows atnegative pressure

Range: p < 0.001 _bar (breath)p > 1000 _bar (jet)

Shock Wave Therapy from 1 to 5 bar

Mechanical energy density

I DISPOSITIVI LARGE FOCUS


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A shock-wave is made by■ Rapid increase in pressure

■ Short last

■ Adjustment of frequency range

■ High pressure peak

■ Pause of negative pressure

■ Patented LARGE FOCUS emission mode

■ Patented CONTROLLED UNFOCUSED emission mode

PECULIARITIES


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PECULIARITIES

■ Capability to deliver high mechanical energy

■ Short pulse width

■ Capability of transmitting into the tissue

■ Wide range of adjustable intensity

■ Constant delivery of energy density

■ Certain placement of the focused shock-waves

■ Long life of applicators and probe

■ Few and cheap maintenance

■ Patient’s comfort

PECULIARITIES – CAPABALITY DO DELIVER HIGH MECHANICAL ENERGY


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■ Capability to deliver high mechanical energy

● Energy is represented by the force bringing the pressure impulses into the body

● The effects are strictly connected to the intensity

● Too much low intensity doesn’t provoke any effect

● Too much high intensity may provoke damages and/or pain

PECULIARITIES – SHORT PULSE WIDTH


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■ Short pulse width

● Shorter is the pulse width, higher is the pressure (intensity) the operator may deliver to the tissue without collateral effects and painful

PECULIARITIES – CAPABILITY OF TRANSMITTING INTO THE TISSUE


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■ Capability of transmitting into the tissue

● Shock-wave therapy is based on the capability of delivering short pressure impulses into the cellular tissues, giving rise to the therapeutic effects.

● Transmission depends on the middle. It is the best into the water.

● Into the human body, it is reasonable to think 4 to 6/7 cm in depth.


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LARGE FOCUS & CONTROLLED UNFOCUSED:HC SWT is assuring both LARGE FOCUSE & CONTROLLED UNFOCUSED modes.

LARGE FOCUS mode is assuring advantages of focused emission mode, such ashomogeneous distribution into the different cellular layers. LARGE FOCUS is providedwith a quite large area over the body which is assuring the possibility to avoid anypointing system (sonography or rx).

CONTROLLED UNFOCUSED CONTROLLED UNFOCUSED is an innovation into the field of radial emission mode;being more homogeneous and controlled, CONTROLLED UNFOCUSED is granting amore comfortable patient’s feeling during application. This is granting the opportunity touse more energy for getting in touch with the lower tissues.

● High penetration into the different tissues

● No acoustic off-set

● Wide range of applications


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Innovation into the shock-waves modality?

Fast increasing of axyaland lateral beam.Thanks to the control indelivering shock-waves,patient’s comfort is higherthan radial shock-wavesand make controlledunfocused deeper in action.

Small profile beam over thefirst tissues and deep inactio, thanks to the morehomogeneous energytransfe.r

Focused region : hard energydensity concentration over asmall area


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Difference between CONTROLLED UNFOCUSED and Radial?

Traditional Radial shock-waves, based on balistc system, is transferred to the patient’s from metalapplicators which generally could provokes pain which avoid to be able to transfer therapeutic shock-waves into the deepest tissues. Otherwise, CONTROLLED UNFOCUSED mode is more homogeneousand comfortable for granting to use higher energy density and being effective into the deepest cellularlayesr without provoking a pain, so much.


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While the most traditional radial shock-waves are applied over the patient, maximum energy density isdelivered to the first cellular layers (over the skin) where the applicator is put in contact with the patient’sbody. This is why, radial shock-wave is normally mainly indicated, by using low energy density, for gettingin touch with nociceptors and reducing pain. Due to the bad feeling over the soft tissues, radial shock-waves provokes poor penetration and absorption from the different deepest tissues. This is why it isgenerally not useful to use radial shock-waves for treating tendons, big muscles and bone. High energydensity could also provoke a bad feeling and pain over the patient and could provoke hematomas.

THE LIMIT OF FOCUS EMISSION MODE


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Focused shock-waves

We speak about focused shock-waves for all the systems capable to deliver into a very small area(small focus) a quite high energy density, which is normally applied by using sonography or rx from thePhysician, only. Sometimes, sedation is needed. Focused emission mode is coming from urologyc fieldwhere high energy density is commonly used for destrying calcolosis, for responding to the first inquiryof Orthopedics to destry calcinfication. Actually, further to the quite big clinical international experience,we learn that the aim of the treatment, even while calcificationis is present, it is not concerning todestroy calcification which could come again if the physiological conditions are still the same, aims ofshock-waves therapy are as follows:● reducing pain● increasing hyperemia● favouring normal physiological conditions and movements● favouring entrance into the physiotherapy applications.

THE LIMIT OF FOCUS EMISSION MODE


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This is why, into the Physiotherapy/Ortopedics fields, small focused shock-waves are not useful and arenot used. So high energy density in a very small beam, despite their dangerous potentialities, canno beapplied to a very large range of applications. For making small focused shock-waves useful, without provoking collateral effects and being effective,some devices is provided with some special absorbing elements, made by gel/silicon for reducingenergy density over the patient. So, the use of those kind of cushions is reducing penetration of shock-waves in a very simple way, and high and expensive high energy shock-waves devices become agenerator of very bad large focus shock-waves, without any special control.

MECCANISMO D’AZIONE


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■ Shock-waves device is generating a planarbeam

■ Planar wave is delivered form a specialpatented applicator

■ LARGE FOCUS is coming from the applicatorand keeps its size and energy into the deepesttissues

■ CONTROLLED UNFOCUSED is penetratinginto a therapeutic channel avoiding lateraldispersion

LARGE FOCUS & CONTROLLED UNFOCUSED emission modes: specialfeatures for being effective over a large range of applications


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tested penetration and comfort

Penetration is mainly depending on energy density and partially on frequency.Of course, first of all, penetration over the different cellular layers is different and depends on thestructure of each tissue: softer is the tissue (and higher is water/liquid concentration) higher is thepenetration. Patented applicators have been tested at the laboratory of one of the most importantnstitutes in Milan. A special tool has been done for testing energy density, distribution and absoption ofthe different cellular layers (by using special materials provided bosorption index strictly close to the realhuman tissues).


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Thanks to the tests made into the laboratory, PAGANI was capable to optimise shock-waves deliveryand transfer to the patient’s body, by assuring patient’s comfort and a quite interesting and therapeuticpenetration.


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Figura 10 – Time history concerning 5 shocks. CAM02,frequency 4Hz, 3 bar.

Figura 13 – Time history about 5 shocks. CAM02 over muscles, frequency 4Hz, 3 bar.


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Bar Energia mJ/mm2 Penetratiion1,00 0,120 0,50 mm1,10 0,1321,20 0,1441,30 0,1561,40 0,1681,50 0,1801,60 0,1921,70 0,204 25 mm1,80 0,216 20 mm1,90 0,2282,00 0,2402,10 0,252 30 mm2,20 0,264 25 mm2,30 0,2762,40 0,2882,50 0,300 35 mm2,60 0,312 30 mm2,70 0,3242,80 0,3362,90 0,348 45 mm3,00 0,360 40 mm3,10 0,3723,20 0,3843,30 0,396 50 mm3,40 0,408 45 mm3,50 0,4203,60 0,4323,70 0,444 60 mm3,80 0,456 55 mm3,90 0,4684,00 0,480 70 mm


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MECHANISMS OF ACTION


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Direct MECHANICAL and PHYSICAL effects

BIOLOGICAL indirect effects

MECHANISM OF ACTION – MECHANICAL AND PHYSICAL EFFECTS


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MECHANICAL and PHYSICAL effectsIt comes from the piezoelectric properties of shock-waves. Extra Corporeal Shock-WavesTherapy allows to involve the majority part of the cellular layers particularly deeply intothe tissue where emission gives rise to a resonance effect able to provoke molecularionization and increasing of membrane permeability.

MECHANISM OF ACTION – MECHANICAL AND PHYSICAL EFFECTS


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PrePRE

200

25

300

50 100

500

P= 4,0 bar

Zhu S et al Ultrasound in Med & Biol 28:661-671, 2002


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Zhu S et al Ultrasound in Med & Biol 28:661-671, 2002

MECHANISM OF ACTION – PHYSICAL EFFECTS


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Physical effects

Permeabilityexchanges of

membrane cellsand ionic flow

Bubble rotation & associated fluid

movement alongcell membranes

CAVITATION MICRO-STREAMING

Changing ofmembranepermeability andand ionic flow

Changing ofmembranepermeability

Gas bubbleexpansion

Gas bubblecompression


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MECHANISM OF ACTION – BIOLOGICAL EFFECTS


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BIOLOGICAL effects1. Nociceptors action with changing of membrane cells able to avoidpotential action causing making pain;

2. Inhibition of centripet conduction of pain due to pressure impulses overthe nociceptors;

3. Activation and deliver of endorphines and encephalines reducing painfeeling

4. Activation of Merkel’s corpuscles (pressure’s receptors) with anatgonistreaction of stress based on catecolamines

PAIN



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BIOLOGICAL effects1. At the tissutal level some biomolecular modifications come from ESWTsuch as the neoangiogenetic response passing from ESAF (EndothelialStimulating Angiogenic Factor)

2. Citotossic (free radicals)

3. Antiflogistic e neuromodulating (> permeability of assonal membranewith consequent depolarization)

Ogden JA et al Clin Orthop 2001; 387: 22-40

VASCOLARIZATION



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BIOLOGICAL effects

1. It’s reasonable to think that re-vascolarization should be related to tehfollowing actions

2. Neocapillarogenesis coming from the repairing of basal membrane anddue to the flow of endothelial cells into the interstitial spaces.

3. It makes easier and faster metabolic changes into the affected tissues,stimulating reparative processes and “auto-reparative” process of theorganism

VASCOLARIZATION

INDICATIONS


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■ Epicondilytis, epitrocleytis ■ Tendinitis and Tendinosis e.g. upper spinous,achilleous, rotuleous■ Calcifications e.g. shoulder■ Calcanear spur and plantar fascitis■ Pubalgia, Ischiatic intersection syndrome ■ Ileotibialis ■ Jerking “ finger”■ Periostitis ■ Coxarthrosis, gonarthrosis, rizoarthrosis, ■ Sudek syndrome, ■ Pseudoarthrosis e.g. scaphoid

CONTRAINDICATIONS


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Absolute contraindications

■ Pregnancy

■ Tumour over the affected area

■ Alteration of ematic coagulation

■ Assumption of anti-hcoagulant medicines

■ Septic infection of the joints

■ Growing nucleous

Relative contraindications

■ Acute inflammation with pain

■ Osteoporosis

■ Application over the back

■ Close to the polmonar regions

COLLATERAL EFFECTS


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When treatment of Achille’s tendinitis is performed, be careful if a vascular ordermathology pathology is present (flebitis, ulcers, etc.)!

COLLATERAL EFFECTS - IT IS SUGGESTED …


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■ To avoid application into the puberal age in order to avoid any interference with thegrowing-up of the skeletal system

■ Chronic pathologies

■ Indication for surgical intervention


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PATIENT’S PLACEMENTS


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PECULIARITIES OF ESWT


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■ It is made at the Ambulatory without hospitalization■ Any anaesthesia is needed■ Short time length of each treatment■ Few applications needed■ Few contraindications■ Very good results■ Good cost-benefit ratio

■ Some limits into the acute phase■ Not useful over the back

ANTIFLOGISTIC ACTION


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Targets:

■ Increasing of the transcription of anti-inflammatory substances Lipocortina, Citochine- Lipocortina 1- IL-1 Receptor Antagonist

■ Decreasing of the transcription of flogosis substancesCitochine, Adherence particle, Leucotrieni

CASES


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Patients747

CASES


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47% traumatology into the sport

CASES - TENDINITIS


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Tendinitis:Recognized by the modality of Bonar which replaced the previous one made by Clancy:

■ Tendinosis

■ Tendinitis/partial break

■ Paratenonitis (or tenosinovitis)

■ Paratenonitis with tendinosis

CASES - SHOULDER


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255 Shoulder

■ 72% very good (restitutio ad integrum)

■ 15% good (improvement of pain and movement)

■ 9% not so good (small improvement of pain and movement)

■ 4% none (any improvement)

CASES - ACHILLE’S TENDON


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43 Achille’s tendon



■ 6,5% not so good (small improvement of pain and movement)

■ 6,5% none (any improvement)

CASES – PLANTAR FASCITIS


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92 plantar fascitis



■ 6,5% not so good (small improvement of pain and movement)

■ 6,5% none (any improvement)

CASES – EPICONDILYTIS & EPITROCLEYTIS


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104 epicondilytis ed epitrocleytis





CASES - PUBALGIA


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26 pubalgia8 ischiatic intersection syndrome





CASES – TENDINOSIS OF THE KNEECAP


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32 tendinosis of the kneecap





WHY E-SWT?


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Why E-SWT?

Provoking and supporting

■■ Pain■■ Edema■■ Metabolism


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TIMECOSTBENEFIT

PHYSIOPATHOLOGY


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Medical Devices

■ Which is the aim of E-SWT?- Supporting recovery - Stopping, reducing pain- Preparing to further treatments

■ Scientific evidences

■ Indications & Contraindications

■ Knowledge and experience

■ Costs, Benefits, Suitability

PATIENTS


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PATIENTS

PHYSIOPATHOLOGY


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PAIN

Weisberg, J. (1994). Pain. In B. Hecox, T. A. Mehreteab, & J. Weisberg, (Eds.), Physical agents (pp. 37-48). Norwalk, CN: Appleton & Lange.

PHYSIOPATHOLOGY


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Response to the Trauma

■ 3 Steps:- Acute inflammation- proliferation- Maturity

■ The a/m steps will be mixed during the response to the trauma

PHYSIOPATHOLOGY


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Response to Acute Inflammation

■ Reaction of the organism to the damaged or death of cells

■ aim: checking and containing effects of noxa and re-making of homeostatic equilibrium

■ response is made at the following two levels:- Flow changes of local micro-circle- Changes into the cellular functioning

Inflammation is a useful process!!

PHYSIOPATHOLOGY


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Response to Inflammation■ Inflammation process could be:

- Acute inflammation- Starting reaction to a trauma

■ Sub-acute inflammation- from 2 weeks to 1 month post trauma

■ Chronic inflammation - Persisting condition longer than 1 month


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Calcific tendinitis

Normal Tendon

Calcific phase

Salt of Ca

Hypostasis

Pain ±

Post-Calcific PhaseRestitutio

Iperemya

Pain ±

Regressive phase

Fagocitosis

Iperemya

Pain +++

Pre-Calcific PhaseMetaplasia Cartilaginea

Endoarticular

overpressure

Pain-

Uthoff e Sarkar, 1990


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…does calcification make pain… ?


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Lower Acromion Space


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… it’s into the decreasing of the space of shifting where we can find the “primum movens” of impingement and the initial suffering of the cuff…

BORSITIS


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BORSITIS

IMPINGEMENT


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IMPINGEMENT

ROTATOR CUFF


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REACTIVE CALCIFICATION


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DEGENERATIVE CALCIFICATION


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FIBROSIS AND CAPSULAR ADHERENCE


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Fibrosis and Capsular Adherence Generally due to a combination of:

- solving of acuteinflammation process

- chronic evolution of an inflammation process of low degree

- joint immobilization

ACTION


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Also on those pathologies actions shock waves are as follows:

Mechanical effect: demolition of molecular organisation of calcifications

Biological effect: stimulation and macro-phagic activation

RESULTS – CALCIFICATIONS OF SHOULDER


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171 CALCIFICATIONS OF SHOULDER

RESULTS - CALCIFICATIONS OF SHOULDER


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171 Calcifications of shoulder

83% very good (restitutio ad integrum)

9% good (improvement of pain and movement)

5% not so good (small improvement of pain and movement)

3% none (any improvement of pain and movement)

RESULTS – BURSITIS LOWER ACROMION


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Bursitis Lower acromion

RESULTS – CALCIFIC TENDINOSIS


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Calcific Tendinosis Upper spinous

RESULTS – BURSITIS LOWER DELTOID


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Bursitis Lower deltoid

STILL CONCERNING CALCIFICATION…


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…calcification could disappeareven if clinical recovery is not sogood and also a good recoverycould happens even if thecalcification or a part of it is stillpresent…

STILL CONCERNING CALCIFICATION…


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REHABILITATION


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It is advisable to evaluate the activity of physical therapy (when it is possible)in order to support joint’s recovery and tendon functionality.

REHABILITATION


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Rehabilitation

■ Fast immobilization without pain

■ Stabilization of scapular region

■ Activity under kinetic closed chain

■ Activity of whole kinetic chain

REHABILITATION


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“Cross-links” over collagenous fibers

IMMOBILIZATION Changed by Akeson et al, Biorheology 1980

REHABILITATION


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CROSS LINK EFFECTS

Changed byificata da Akeson et al, Biorheology 1980

REHABILITATION


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Effect of the immobilizationover the capsular region

A) acute phase■ techniques for reducing pain■ Application of a low force for making easier the alignment of collagen over the stress line

B) sub-acute phase■ techniques useful to support stimulation of collagen over the stress lines■ application of a“gradual stress”

C) into the transaction/consolidation ■ immobilization techniques provoke few effects over the tissue ■ recovery starts far from the capsular region ■ support recovery

REHABILITATION


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SPORT MEDICINE


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Very good benefits have been got into the Sport Medicine:

■ Improvement of the compliance

■ Reducing of time recovery

■ Faster starting of sport activity “same sport same level”

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dispense hc onde d'urto inglese - paganiintl.it · p hysics eswt - shock-wave device in...

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