SWISS SWISS DOLORCLAST DOLORCLAST APPLICATIONS APPLICATIONS FOR PODIATRYFOR PODIATRY

• EMS/Dolorclast was the first company to EMS/Dolorclast was the first company to develop Lithotripsydevelop Lithotripsy

• Extracorporeal Shockwave TherapyExtracorporeal Shockwave Therapy

• (ESWT) was first used to treat kidney stones (ESWT) was first used to treat kidney stones

• Since 1990 (ESWT) has been used for a Since 1990 (ESWT) has been used for a variety of orthopaedic applicationsvariety of orthopaedic applications..

• More recently, it is used for treating wound ulcers, lymphodema, burns and cellulite

HISTORYHISTORY

Indications for RSWT®

Tennis elbow (Epicondilitis humeri radialis)

Greater trochanteric pain syndrome

Patellar tip syndrome

Plantar fasciopathy

Subacromial pain syndrome

Golfer‘s elbow (epicondylitis humeri ulnaris)

Medial tibial stress syndrome

Achilles tendinopathy

MECHANISMSMECHANISMS

• The procedure accelerates the body's own The procedure accelerates the body's own healing mechanisms by:-healing mechanisms by:-

• Generating impulses of high energy, high Generating impulses of high energy, high pressure sound waves that travel through pressure sound waves that travel through skin to stimulate healing.skin to stimulate healing.

• It is effectively changing a chronic It is effectively changing a chronic condition to an acute condition.condition to an acute condition.

Radial extracorporeal shock wave therapy Radial extracorporeal shock wave therapy RSWTRSWT®®

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Gloria Allery & Val Bryce28.11.2011

RSWT®: basic physics (3) - cavitation

• Which part of shock waves mediates their biological efffects on tissue?

• "A significant tissue effect is cavitation consequent to the negative phase of the wave propagation."

• (Ogden et al., 2001)

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RSWT®: see shock waves on high speed movie:

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RSWT®: basic physics - cavitation

Cavitation bubbles

Secondary shock waves

Applicator

Hydrophone(used to trigger

a high-speed camera)

Wave front

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SCIENTIFIC BACKGROUNDSCIENTIFIC BACKGROUND

• ESWL can trigger a variety of effective ESWL can trigger a variety of effective actionsactions

• Release more substance PRelease more substance P

• Inhibits the COX11 enzymeInhibits the COX11 enzyme

• Activates cellular defensesActivates cellular defenses

• Hyper stimulates nerve fibresHyper stimulates nerve fibres

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RSWT RANDOM CONTROL TRIALS WITH POSITIVE OUTCOMES

Chronic plantar fasciopathy•Gerdesmeyer et al., Am J Sports Med 2008; 36: 2100-2109•Chow and Cheing, Clin Rehab 2007;21: 131-141•Greve et al., Clinics 2009; 64: 97-103

Midportion Achilles tendinopathy:•Rompe et al., Am J Sports Med 2007;35:374-381•Rompe et al., Am J Sports Med 2009;37:463-470

Insertion Achilles tendinopathy:•Rompe et al., Am J Bone Joint Surg 2008;90:52-61

Medial tibial stress syndrome:•Rompe et al., Am J Sports Med 2009 [Epub Sep 23]

PROBLEMS WITH DIABETIC FOOT

• Diabetes= Worldwide= over 200million

Qld = over 200,000

• Over 1 million diabetic amputations year worldwide

• Most common diabetic admissions

Foot ulcers = more than 15%

Amputations = more than 1-3%

STANDARD FOOT ULCER MANAGEMENT

• Control infection

• Improve blood supply

• Optimise wound healing environment

• Protect wound from trauma

TREATMENT

ESWT in conjunction with standard therapies for off loading foot pressure

• Padding

• Insoles

• Orthotics

• Footwear- sandals boots, casts, splints

• Walking aids, crutches, walking sticks, wheelchairs

Case Study

• This patient was treated at a Hairmyres Hospital, Scotland, and had a large diabetic foot ulcer. This had been surgically debrided and had also had larvae therapy. It was not responding to treatment and there was a real chance that the patient would need a lower leg amputation.

• The patient was treated with ESWT over a period of six months during which there was full healing. On average he was treated once every 2.5 weeks.

Large diabetic foot ulcer- March 2010,prior to treatment

24th AUGUST 2010 5TH October 2010

References[1] R. Saggini, A. Figus, A. Troccola, V. Cocco, A. Saggini, and N. Scuderi. Extracorporeal shock wave therapy for management of chronic ulcers in the lower extremities. Ultrasound Med Biol, 34(8):1261– 1271, August 2008.[2] W. Schaden, R. Thiele, C. Kolpl, M. Pusch, A. Nissan, C. E. Attinger, M. E. Maniscalco-Theberge, G. E. Peoples, E. A. Elster, and A. Stojadinovic. Shock wave therapy for acute and chronic soft tissue wounds: a feasibility study. J Surg Res, 143(1):1–12, 2007.[3] A. M. Larking, S. Duport, M. Clinton, M. Hardy, and K. Andrews. Randomized control of extracorporeal shock wave therapy versus placebo for chronic decubitus ulceration. Clin Rehabil, Feb 2010.

• [4] J. Dumfarth, D. Zimpfer, M. Vögele-Kadletz, J. Holfeld, F. Sihorsch, W. Schaden, M. Czerny, S. Aharinejad, E. Wolner, and M. Grimm. Prophylactic low-energy shock wave therapy improves wound healing after vein harvesting for coronary artery bypass graft surgery: A prospective, randomized trial. Ann Thorac Surg, 86(6):1909–1913, December 2008.

• [5] C. Wang, Y. Kuo, R. Wu, R. Liu, C. Hsu, F. Wang, and K. Yang. Extracorporeal shockwave treatment for chronic diabetic foot ulcers. J Surg Res, 152, 96–103 (2009).

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RSWT®: summaryPhysical mechanisms of action understood

Wave propagationCavitation

Molecular and cellular mechanisms of action understoodImmediate pain relief by depletion of substance PBlockade of neurogenic inflammationChange of gene expression in adult stem cells

towards healing

Happy patientsEfficacy and safety demonstrated in various

RCTsEvidence-Based Medicine Level 1 Fast (3 x 5 min treatment) with immediate benefitNegligible side effects when applied properly (skin

reddening)No injections, no cortisone, no surgery!No doping!

we know how it workswe know that it workswe know why it works

your patients become enthusiastic about it!

Enthusiastic patients – successful practice!

A treatment modality becomes successful when...