1.
EXTRACORPOREAL SHOCKWAVE
THERAPY (ESWT)
Presenter: Sami Halim
( PT,DPT)

2.
WHAT IS ESWT
 Shockwave Therapy is a noninvasive method that
uses acoustive waves to treat varies
musculoskeletal conditions.
 Extracorporeal = outside body.
 Shockwave = intense, short energy wave travelling
faster than speed of sound.
 Well-controlled mechanical insult to tissue.
 Fast pain reliever and restore mobility.

3.
HISTORY
 In 1983 the first commercial lithotripter, The Dornier
Lithotripter
 Since 1985 other organs such as the gall bladder,
bile duct, pancreas and salivary glands have been
treated with shockwave.
 During the next 10 years shockwave machines
were trialed and have been used to treat
orthopaedic disorders, including pseudo-arthroses,
osteochondrosis and various tendinopathies
(Haupt, 1997).

4.
SHOCKWAVE THEORY
 Extracorporeal shockwaves (ESW) are pressure waves
generated acoustically.
 Shockwaves are different from other acoustic waves because
they are at a lower frequency.
 There are many examples of these sonic pulse waves in real
life. A more day to day version of a shockwave are those
created by clapping.
 Aeroplane breaking the sound barrier which generates an
audible bang and can lead to the breakage of glass even in
distant areas.

5.
CONTI….
 Acoustive waves create compression and shear
loads on the surface of the material.
 This rapid interaction between compression and
shear forces results in what is commonly referred to
as Cavitations.
 Cavitations is a formation of vapor bubbles in a
molecules. This cavitations damages the affected
tissues.

6.
CONTI…

7.
CONTI..
 There are 2 fundamentally different types of shockwave
(McClure & Merritt, 2003).
1. Focused (Hard shockwave often referred to as
lithotripsy)
2. Non-Focused also called Radial or Dispersive (Soft
shockwave)
 Non-focused or radial or dispersive shockwave which is
created by mechanical concussion that creates
expanding wave fronts away from the concussion plate
(the end of the machine) which travel forward into the
body.

8.
BROADER EFFECTS OF ESWT:
 Destruction of Tissues
 Increase Healing/Blood Supply
 Pain Reduction

9.
MEDICAL EFFECTS OF ESWT:
New Blood Vessel Formation:
 Nutrient blood flow is necessary to start and maintain
the repair processes of damaged tissue structure.
 The application of acoustic waves creates capillary
microruptures in tendon and bone.
 Due to microruptures the expression of growth factors
such as eNOS, VEGF, PCNS and BMP is significantly
increased.
 As a result of these processes arterioles are remodeled,
stimulated to grow and new ones are formed.
 The new blood vessels improve blood supply and
oxygenation of the treated area and support faster
healing of both the tendon and the bone.

10.
Reversal of Chronic Inflammation:
 Mast cells are one of the key components of the inflammatory
process. Their activity may be increased by using pervasive
acoustic waves.
 Mast cell activation is followed by the production of
chemokines and cytokines.
 These pro-inflammatory compounds first enhance the
inflammatory process and in the next step help restore normal
healing and regenerative processes.

11.
Stimulation of Collagen Production:
 The production of a sufficient amount of collagen is
a necessary precondition for the repair processes
of the damaged myoskeletal and ligamentous
structures
 Shockwave therapy accelerates procollagen
synthesis. The therapy forces the newly created
collagen fibers into a longitudinal structure which
makes the newly formed tendon fibers more dense
and stiff and creates a firmer structure.

12.
Dissolution of Calcified Fibroblasts:
 Calcium build-up is most often a result of micro-tears or other
trauma to a tendon. Acoustic waves break up the existing
calcifications.
 Shockwave therapy starts the biochemical decalcification of
the calcium build-up of a toothpaste-like consistency and
treats the tendon.
 The granular particles of calcium are then removed by the
lymphatic system.

13.
Dispersion of Pain Mediator
“Substance P”:
 Substance P is a neurotransmitter that mediates
pain information through C-fibers.
 This neuropeptide is generally associated with
intense, persistent and chronic pain. It relays pain
messages to the central nervous system.
 Lowering the concentration of Substance P
reduces the stimulation of afferent nociceptive
fibers and thus reduces the pain.
 Decreasing Substance P, histamines and other
nociceptive metabolites also helps inhibit
development of inflammatory oedema.
 Acoustic waves generated by Shockwave therapy
lower the Substance P concentration and trigger
pain relief.

14.
Release of Trigger Points:
 They are associated with palpable nodules in taut bands of
muscle fibers and have extremely contracted sarcomeres.
 The dysfunctional sarcomeres contract so tightly that they
begin to cut off their own blood supply.
 This causes the waste products to build up. Waste product
build-up irritates the sensory nerve endings which then
causes even more contraction.
 This vicious cycle is referred to as “metabolic crisis”. The
assumed mechanism of action is that the delivered acoustic
energy unblocks the calcium pump and thus reverses the
metabolic crisis in the myofilaments and releases the trigger
points.

15.
Activation of Osteoblasts: (osteogenesis)
 The main effect of shockwave on bone healing is
most certainly the activation of osteoblasts through
integrin activation and differentiation of
mesenchymal stem cells Chen et al. (2004).
 Change in levels of Osteocalcin (OC) and bone
specific alkaline phosphatase (bALP) following
each session of shockwave therapy.
 Extracorporeal shockwave promotes bone marrow
stromal cell growth.

16.
TREATMENT DOSAGE:

17.
CLINICAL INDICATIONS:
 Plantar Fasciitis
 Heel spurs/Heel pain
 Calcific Tendonitis
 Patellar Tendonitis (Jumper’s Knee)
 Achilles Tendonitis
 Rotator Cuff Tendonitis
 Myofascial Trigger Points in muscle
 Iliotibial Band Syndrome (IT Band Syndrome)
 Tennis Elbow and Golfer’s Elbow
 Bursitis
 Heterotopic Ossification (Myositis Ossificans) etc…

18.
IS IT SAFE:
 Mild side effects reported in studies.
 Side effects usually come and go within 3 to 5 days.
1. Redness
2. Swelling
3. Pain (sometime initially)
4. Hematoma

19.
CONTRAINDICATIONS:
 Eyes
 Major Blood Vessels
 Open Wound
 Implanted Devices
 Brain
 Major Nerves
 Epiphysis
 Infection
 Cancer
 Pregnancy
 Joint replacement
 Corticosteriod Injection
 Clotting disorders

20.
HOW SUCCESSFUL IS SHOCKWAVE?
 Shockwave therapy is one of the most widely
researched rehabilitation modalities used in
physiotherapy clinics, with increasing numbers of
scientific studies added each year.
 The majority of research validates the effectiveness
of extracorporeal shockwave, and shows
successful treatment rates of up to 90%.

21.
RESEARCH:
Evidence: Calcific Tendinopathy:
 High-Energy Extracorporeal Shock-Wave Therapy for
Treating Chronic Calcific Tendinitis of the Shoulder.
 Systematic review
 Results: High energy ESWT was effective for treating
calcific tendinitis .Reduced pain, improved function,
resorption of calcifications
 Low energy ESWT is less effective ◦ Regardless of
energy level, ESWT is not effective in treating non-
calcific tendinitis
(Bannuru et al., 2014)

22.
REFERENCES
 http://www.shockwavetherapy.education/theory/cav
itation.htm
 http://www.shockwavetherapy.education/theory.htm
 https://kreja.eu/img/cms/BTL_udarni_globinski_valo
vi_katalog.pdf
 http://www.shockwavetherapy.eu/subpage#medical-
effects
 https://www.yumpu.com/en/document/view/388750
18/understanding-shockwave-therapy-presentation-
ortho-providers/4