This document summarizes the author's presentation on shockwave therapy. It discusses different types of shockwaves used in therapy, including focused shockwave therapy (F-ESWT) and radial pulse therapy (RPT). It reviews several studies on the effectiveness of shockwave therapies for various soft tissue conditions. The studies show high-intensity F-ESWT and RPT are generally effective for chronic plantar fasciitis, high-intensity F-ESWT and low-intensity RPT are effective for chronic mid-portion Achilles tendinopathy, and high-intensity F-ESWT is effective for chronic insertional Achilles tendinopathy and calcific rotator cuff tendinopathy. However, the effectiveness depends on

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. Michael Harbo
Clinical expert in sports physiotherapy
fredag den 25. oktober 13

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. fredag den 25. oktober 13

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. 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. S U CCESS HA S
M ANY FATHE R S
fredag den 25. oktober 13

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. 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. 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. 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. SHOCKWAVES
fredag den 25. oktober 13

13. SHOCKWAVES
fredag den 25. oktober 13

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. 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. 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. 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. 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. B UT D O T H E Y WOR K ?
fredag den 25. oktober 13

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. 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. 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. B UT D O T H E Y WOR K ?
fredag den 25. oktober 13

24. B UT D O T H E Y WOR K ?
fredag den 25. oktober 13

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. CONCLUS IO N
fredag den 25. oktober 13

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. 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. 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. Calcific rotator cuff tendinopathy
fredag den 25. oktober 13

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. 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. 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. 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. Calcific rotator cuff tendinopathy
A case story
fredag den 25. oktober 13

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. Calcific rotator cuff tendinopathy
fredag den 25. oktober 13

66. Calcific rotator cuff tendinopathy
No ROM incresement
- 2 treatments more are given ...
fredag den 25. oktober 13

67. Calcific rotator cuff tendinopathy
fredag den 25. oktober 13

68. Calcific rotator cuff tendinopathy
ROM increased to 140 degree
- no treatment given for 4 weeks
fredag den 25. oktober 13

69. Calcific rotator cuff tendinopathy
fredag den 25. oktober 13

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. Calcific rotator cuff tendinopathy
fredag den 25. oktober 13

72. Calcific rotator cuff tendinopathy
fredag den 25. oktober 13

73. TAKE H OME MESS AGE
fredag den 25. oktober 13

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. 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. 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. 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. It hurts - but it works !
fredag den 25. oktober 13

79. It hurts - but it works !
fredag den 25. oktober 13

80. RPT example
fredag den 25. oktober 13

81. T H AN K YOU
fredag den 25. oktober 13