New indications for rswt
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New indications for RSWT. Prof. Dr. Christoph Schmitz Full Professor and Head Department of Neuroanatomy, Ludwig-Maximilians University of Munich, Munich, Germany Adjunct Professor Department of Neuroscience, Mount Sinai School of Medicine,New York, NY, USA Medical Scientific Officer

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New indications for RSWT

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New indications for rswt

New indications for RSWT

Prof. Dr. Christoph Schmitz

Full Professor and Head

Department of Neuroanatomy,

Ludwig-Maximilians University of Munich, Munich, Germany

Adjunct Professor

Department of Neuroscience,

Mount Sinai School of Medicine,New York, NY, USA

Medical Scientific Officer

EMS Electro Medical Systems, Nyon, Switzerland


New indications for rswt

Orthopaedic indications for RSWT®(1)

Tennis elbow (Epicondilitis humeri radialis)

Subacromial pain syndrome

Golfer‘s elbow (epicondylitis humeri ulnaris)

Greater trochanteric pain syndrome

Medial tibial stress syndrome

Patellar tip syndrome

Achilles tendinopathy

Plantar fasciopathy


Orthopaedic indications for rswt 2

Orthopaedic indications for RSWT®(2)

Common extensor tendon

Supraspinatus tendon

Achilles tendon

Plantar fascia

Patella tendon


New indications for rswt

RSWT®: RCTs with positive outcome

  • 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]

  • Greater trochanteric pain syndrome:

  • Furia et al., Am J Sports Med 2009;37:1806-1813

  • Rompe et al., Am J Sports Med 2009;37:1981-1990

  • Subacromial pain syndrome:

  • Engebretsen et al., Brit Med J 2009:339:b3360


New indications for rswt

RSWT® for chronic plantar fasciopathy (1)

n=251 (129 vs. 122)


New indications for rswt

RSWT® for chronic plantar fasciopathy (2)

n=251 (129 vs. 122)


New indications for rswt

RSWT® for chronic insertional Achilles tendinopathy

n=50 (25 vs. 25)

EL: 3 x 15 repetitions x 2/d x 7d/w x 12w = 7,560 repetitions


New indications for rswt

RSWT® for chronic midportion Achilles tendinopathy (1)

n=75 (25 vs. 25 vs. 25)

EL: 3 x 15 repetitions x 2/d x 7d/w x 12w = 7,560 repetitions


New indications for rswt

RSWT® for chronic midportion Achilles tendinopathy (2)

n=68 (34 vs. 34)

EL: 3 x 15 repetitions x 2/d x 7d/w x 12w = 7,560 repetitions


Approved indications

Approved Indications

  • Calcifying tendonitis of the shoulder / subacromial pain syndrome

  • Tennis elbow (Epicondylitis humeri radialis)

  • Greater trochanteric pain syndrome

  • Patella tip syndrome

  • Osgood-Schlatter disease*

  • Medial tibial stress syndrome

  • Insertional Achilles tendinopathy

  • Midportion Achilles tendinopathy

  • Plantar fasciopathy

  • Myofascial pain syndrome / trigger point treatment

  • Idiopathic lower back pain / pseudoradicular syndrome

  • Peyronie‘s disease (Induratio penis plastica)*

  • Acute and chronic soft tissue wounds (including diabetic foot ulcera)*

  • Primary and secundary lymphedema*

  • Cellulite*

  • *Approval for the Swiss Dolorclast Smart (SD Classic and Master will get approval soon)


Calcifying tendonitis of the shoulder

Calcifying tendonitis of the shoulder


New indications for rswt

Calcifying tendonitis of the shoulder (1)

(the same recommendations apply for the subacromial pain syndrome)

Palpation of the painful region


New indications for rswt

Calcifying tendonitis of the shoulder (4)

(the same recommendations apply for the subacromial pain syndrome)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 2 - 4 bar

  • Literature: Magosch et al., 2003 Z Orthop 141:629-633 (in PubMed)


New indications for rswt

Calcifying tendonitis of the shoulder (5)

(the same recommendations apply for the subacromial pain syndrome)

  • Treatment with the Power+ handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 1.5 - 3 bar

  • Literature: Magosch et al., 2003 Z Orthop 141:629-633 (in PubMed)


Tennis elbow epicondylitis humeri radialis

Tennis elbow (Epicondylitis humeri radialis)


New indications for rswt

Tennis elbow (Epicondylitis humeri radialis) (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 1.5 - 3 bar

  • Literature: Söller, 2003 In: Maier M, Gillesberger F: Abstracts 2003 zur Muskuloskelettalen Stosswellentherapie. Kongressband des 3. Dreiländertreffens der Österreichischen, Schweizer und Deutschen Fachgesellschaften. Books on Demand, Norderstedt, 2003, pp 121-122.


Greater trochanteric pain syndrome

Greater trochanteric pain syndrome


New indications for rswt

Greater trochanteric pain syndrome (1)

Palpation of the painful region


New indications for rswt

Greater trochanteric pain syndrome (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 3 - 4 bar

  • Literature: Furia et al., 2009 Am J Sports Med 37:1806-1813; Rompe et al., 2009 Am J Sports Med 2009;37:1981-1990 (both in PubMed)


Patella tip syndrome

Patella tip syndrome


New indications for rswt

Patella tip syndrome (1)

Palpation of the painful region


New indications for rswt

Patella tip syndrome (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 2 - 3 bar

  • Literature: Lohrer et al., 2002 Sportverl Sportschad 16:108-114 (in PubMed)


Osgood schlatter disease

Osgood-Schlatter disease


New indications for rswt

Osgood-Schlatter disease (1)

Palpation of the painful region


New indications for rswt

Osgood-Schlatter disease (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000-3,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 2 - 3 bar

  • Literature: Titov and Litvinenko (2007) Abstracts 10th International Congress of the International Society for Musculoskeletal Shockwave Therapy, Toronto, Canada, 2007, pp. 46-47.


Medial tibial stress syndrome

Medial tibial stress syndrome


New indications for rswt

Medial tibial stress syndrome (1)

Palpation of the painful region


New indications for rswt

Medial tibial stress syndrome (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 2.5 - 3 bar

  • Literature: Rompe et al., 2010 Am J Sports Med 38:125-132 (in PubMed)


Insertional achilles tendinopathy

Insertional Achilles tendinopathy


New indications for rswt

Insertional Achilles tendinopathy (1)

Palpation of the painful region


New indications for rswt

Insertional Achilles tendinopathy (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 2.5 - 3 bar

  • Literature: Rompe et al., 2008 J Bone Joint Surg Am 90:52-61 (in PubMed)


Midportion achilles tendinopathy

Midportion Achilles tendinopathy


New indications for rswt

Midportion Achilles tendinopathy (1)

Palpation of the painful region


New indications for rswt

Midportion Achilles tendinopathy (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 2 - 3 bar

  • Literature: Rompe et al., 2007 Am J Sports Med 35:374-383; Rompe et al., 2009 Am J Sports Med 37:463-470 (both in PubMed)


Plantar fasciopathy

Plantar fasciopathy


New indications for rswt

Plantar fasciopathy(1)

Palpation of the painful region


New indications for rswt

Plantar fasciopathy (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 2.5 - 4 bar

  • Literature: Gerdesmeyer et al., 2008 Am J Sports Med 36:2100-2109; Ibrahim et al., 2010 Foot & Ankle Int 31:391-397 (both in PubMed)


New indications for rswt

Plantar fasciopathy (5)

  • Treatment with the Power+ handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 2 - 3 bar

  • Literature: Gerdesmeyer et al., 2008 Am J Sports Med 36:2100-2109; Ibrahim et al., 2010 Foot & Ankle Int 31:391-397 (both in PubMed)


Myofascial pain syndrome trigger point treatment

Myofascial pain syndrome / trigger point treatment


New indications for rswt

Myofascial pain syndrome / trigger point treatment (1)

(treatment of the piriformis muscle shown as example)

Palpation of the painful region


New indications for rswt

Myofascial pain syndrome / trigger point treatment (4)

(treatment of the piriformis muscle shown as example)

  • Treatment with the Power+ handpiece

  • Applicator: 15 mm Trigger

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 300 – 1,000 per trigger point

  • Frequency: 8 - 20 Hz

  • Air pressure: 2.5 - 4 bar

  • Literature: Bauermeister, 2003 In: Maier M, Gillesberger F: Abstracts 2003 zur Muskuloskelettalen Stosswellentherapie. Kongressband des 3. Dreiländertreffens der Österreichischen, Schweizer und Deutschen Fachgesellschaften. Books on Demand, Norderstedt, 2003, pp 24-28.


Idiopathic lower back pain pseudoradicular syndrome

Idiopathic lower back pain / pseudoradicular syndrome


New indications for rswt

Idiopathic lower back pain / pseudoradicular syndrome (1)

Palpation of the painful region


New indications for rswt

Idiopathic lower back pain / pseudoradicular syndrome (4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 8 - 20 Hz

  • Air pressure: 2 - 3 bar

  • Literature: Bauermeister, 2003 In: Maier M, Gillesberger F: Abstracts 2003 zur Muskuloskelettalen Stosswellentherapie. Kongressband des 3. Dreiländertreffens der Österreichischen, Schweizer und Deutschen Fachgesellschaften. Books on Demand, Norderstedt, 2003, pp 29-34.


Peyronie s disease induratio penis plastica

Peyronie‘s disease (Induratio penis plastica)


New indications for rswt

Peyronie‘s disease (Induratio penis plastica)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (in weekly intervals)

  • Number of impulses: 2,000

  • Frequency: 10 - 15 Hz

  • Air pressure: 2 - 3 bar

  • Literature: Haupt et al., 2001Abstracts 19th World Congress on Endourology and SWL, Bangkok, Thailand, 2001.


Acute and chronic soft tissue wounds

Acute and chronic soft tissue wounds


New indications for rswt

Acute and chronic soft tissue wounds (1)

(treatment of diabetic foot ulcer shown as example)

Perform standard wound cleaning and debridement


New indications for rswt

Acute and chronic soft tissue wounds (2)

(treatment of diabetic foot ulcer shown as example)

Place a sterile plastic film on the wound and the surrounding tissue (the plastic film should overlap the wound edges by at least 5 cm)


New indications for rswt

Acute and chronic soft tissue wounds (3)

(treatment of diabetic foot ulcer shown as example)

Apply sterile coupling gel to the film


New indications for rswt

Acute and chronic soft tissue wounds (4)

(treatment of diabetic foot ulcer shown as example)

  • Treatment with the Power+ handpiece

  • Applicator: 36 mm Planar

  • Number of treatments: 6 - 8 (two treatments per week)

  • Number of impulses per treatment: 1,000 per cm2 wound area

  • Frequency: 5 - 15 Hz

  • Air pressure: 3 - 4 bar

  • Literature: Zoech, 2009 JATROS Orthop (1):46-47


New indications for rswt

Acute and chronic soft tissue wounds (5)

  • After the treatment:

  • Remove the plastic film with the coupling gel

  • Clean with sterile saline

  • Apply standard wound dressing according to the individual phase of wound healing


Primary and secondary lymphedema

Primary and secondary lymphedema


New indications for rswt

Primary and secondary lymphedema (1)

Application of coupling gel

(no need for palpation and labeling because the treatment area is visually identified)


New indications for rswt

Primary and secondary lymphedema (2)

  • Treatment with the Power+ handpiece

  • Applicator: 36 mm Planar

  • Number of treatments: 10 (two treatments per week)

  • Number of impulses per treatment: 200 – 300 per cm2 fibrotic skin

  • Frequency: 4 - 10 Hz

  • Air pressure: 3 - 4 bar

  • Literature: Michelini et al., 2008 Eur J Lymphol 19:10


Cellulite

Cellulite


New indications for rswt

Cellulite (1)

Application of coupling gel

(no need for palpation and labeling because the treatment area is visually identified)


New indications for rswt

Cellulite(2)

  • Treatment with the Power+ handpiece

  • Applicator: 36 mm Planar

  • Number of treatments: 8 (two treatments per week)

  • Number of impulses per treatment: 200 – 300 per cm2 cellulite skin (approximately 3,500 per skin region)

  • Frequency: 8 - 20 Hz

  • Air pressure: 3 - 4 bar

  • Literature: EMS (ongoing clinical study)


Indications that are not approved for internal use only

Indications that are not approved(for internal use only)

  • Golfer‘s elbow (Epicondylitis humeri ulnaris)

  • Carpal tunnel syndrome

  • Idiopathic cervical pain

  • EMS received (oral) case reports by experienced therapists with respect to efficacy and safety of radial shock wave treatment with the EMS Swiss Dolorclast for these indications. Based on these case reports, EMS is currently testing efficacy and safety of radial shock wave treatment with the EMS Swiss Dolorclast for these indications in prospective clinical studies. However, the presently available data are not yet sufficient to approve the Swiss Dolorclast for these indications.


Golfer s elbow epicondylitis humeri ulnaris

Golfer‘s elbow (Epicondylitis humeri ulnaris)


New indications for rswt

Golfer‘s elbow (Epicondylitis humeri ulnaris)(1)

Palpation of the painful region


New indications for rswt

Golfer‘s elbow (Epicondylitis humeri ulnaris)(4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 1.5 - 3 bar


Carpal tunnel syndrome

Carpal tunnel syndrome


New indications for rswt

Carpal tunnel syndrome(1)

Palpation of the painful region


New indications for rswt

Carpal tunnel syndrome(4)

  • Treatment with the Radial handpiece

  • Applicator: 15 mm

  • Number of treatments: 3 (at weekly intervals)

  • Number of impulses per treatment: 2,000

  • Frequency: 5 - 10 Hz

  • Air pressure: 1.5 – 2.5 bar


Focused shock waves ems swiss piezoclast

Shock wave focus

Cavitation bubbles

Secondary

shock waves

Focused shock waves (EMS Swiss PiezoClast®)

11 cm


Cavitation zone of the ems swiss piezoclast

Cavitation zone of the EMS Swiss PiezoClast®


Technical aspect focus of the ems swiss piezoclast

Technical aspect: focus of the EMS Swiss PiezoClast®


Cigar shaped focus of focused shock waves

Cigar-shaped focus of focused shock waves


Physical characteristics of the focus

Physical characteristics of the focus

-6 dB focus:

three-dimensional region in

which at least 50% of the

positive peak pressure [P+] is

reached

(definition in relative terms)

5 MPa focus:

three-dimensional region in which a pressure of more than

5 MPa is obtained

(definition in absolute terms)


Requirements for the focus in orthopedics

Requirements for the focus in orthopedics

  • The „cigar zone“ should

    • deliver a sufficient energy flux density to achieve therapeutic success („powerful“), and

    • be no larger than the pathology zone („small“)

  • How to reach a sufficient energy flux density within the focus?

    • make a huge device with a lot of energy output, or

    • make the focus small


Summary of requirements for focused shock waves

Power

Size

Characteristics of the cigar

(„Powerful but small“)

Focus should be

as small as possible

in order to prevent

unwanted side effects

in adjacent, not affected

tissues

A certain energy

flux density

must be reached in order to achieve

treatment success*

Energy flux density

*Calcifying tendinitis of the shoulder: EFD between 0.1 and 0.55 mJ/mm2 (Vavken et al., 2009)

Trigger points: EFD between 0.1 and 0.25 mJ/mm2 (Müller –Ehrenberg, 2009)

Summary of requirements for focused shock waves

Output („the higher the peak pressure the more powerful the shock waves“)

Focusing („the more you focus the smaller the cigar zone“)


Example calcifying tendinitis of the shoulder

Example: calcifying tendinitis of the shoulder

Vavken et al. (2009)


Requirements for the size of the focus 1

Requirements for the size of the focus (1)

2 cm

5 cm

Calcifying tendinitis of the shoulder


Requirements for the size of the focus 2

Requirements for the size of the focus (2)

10 µm

Trigger points

(Hong and Simons, 1998)


Requirements for the size of the focus 3

Requirements for the size of the focus (3)

Nonunion


Requirements for the size of the focus 4

Requirements for the size of the focus (4)

Avascular necrosis of the femoral head


Characteristics of the ems swiss piezoclast

Characteristics of the EMS Swiss PiezoClast®

Sharp focusing (by special arrangement of the piezo crystals)

Sufficient maximum output

(P+ max = 82.2 MPa)

Power

Size

Characteristics of the cigar

(„Powerful but small“)

The smallest focus of all focused ESWT devices available commercially (fx5MPa max = 10.4 mm)

Necessary* energy

flux density

can be reached

(EFDmax = 0.40 mJ/mm2)

Energy flux density

*Calcifying tendinitis of the shoulder: EFD between 0.1 and 0.55 mJ/mm2 (Vavken et al., 2009)

Trigger points: EFD between 0.1 and 0.25 mJ/mm2 (Müller –Ehrenberg, 2009)


Characteristics of the

Characteristics of the...

Example of a big shock wave device

Huge maximum output

(P+ max = 120 MPa)

Focusing

Power

Size

Characteristics of the cigar

(„Powerful but small“)

Delivers energy flux densities that can become dangerous to the patient

(EFDmax = 1.50 mJ/mm2)

Focus ways too large for shoulder, trigger points etc.

(fx5MPa max = 34.0 mm)

Energy flux density


Characteristics of the1

Characteristics of the...

Example of another table-top device

Low maximum output

(P+ max = 47.7 MPa)

Weak focusing

Power

Size

Characteristics of the cigar

(„Powerful but small“)

Does not reach energy flux densities necessary for good clinical outcome

(EFDmax = 0.12 mJ/mm2)

Focus slightly larger than the focus of the Piezoclast

(fx5MPa max = 11.9 mm)

Energy flux density


Characteristics of the2

Characteristics of the...

Example of another combined radial / focused shock wave device

Less maximum output

(P+ max = 62.0 MPa)

(measured: 51.4 MPa)

Focusing

Power

Size

Characteristics of the cigar

(„Powerful but small“)

Necessary energy

flux density

can be reached

(EFDmax = 0.55 mJ/mm2)

(measured: 0.167 mJ/mm2)

Focus larger than the focus of the Piezoclast

(fx5MPa max > 40 mm)

Energy flux density


Thank you for your attention

Thank you for your attention

[email protected]


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