ESWT VS REGENARATION OF THE

CELL

Dr. Octavina Alsim, SpKFR

 physical
principles
 Characteristics of shock waves

• High peak pressure (100 MPa)

• Short duration/lifecycle (10ms)
• Fast rising time (fast pressure rise) (<10 ns)
• Broad frequency spectrum (16 Hz – 20 Mhz)
• Generation of high stress forces upon interfaces
• Generation of traction forces
Interaction between SW and
tissue

1. Pressure compression
2. Tension expansion
3. Back to initial situation
 Type of Shock wave

• The 3 types of devices used to generate shockwaves for

clinical application are shown: electrohydraulic (A),
electromagnetic (B), and piezoelectric (C). (Reproduced
from Odgen et al 16 with the permission from
Lippincott Williams & Wilkins.)
 Electrohydraulic

• mechanism : similar to that of the spark plug in a car

engine.
• High voltage ; is applied across the electrode tips (spark
plug)
• generating a gas bubble filled with vapour and plasma. The
expansion of this bubble produces a sonic pulse and the
subsequent implosion of a reverse pulse will generate the
shock wave.
• Electrohydraulic shock wave devices are usually
characterized by fairly large axial diameters of the focal
volume.
• Focal volume is defined as the area in which 50% to 100%
of the maximal energy is reached
Electromagnetic shock wave
• Electromagnetic shock wave devices pass a strong
electric current through a flat coil, whereby a
magnetic field is induced.
• At the same time, another magnetic field is
induced in a metal membrane overlying the flat
coil. As similar poles repel each other, the
magnetic field generated by the membrane
repels the field generated by the coil.
• An acoustic lens is used to focus the shock wave
and the focal therapeutic point is determined by
the focal length of the lens.
Piezoelectric
• Numerous piezocrystals are mounted on the
inner surface of a sphere and receive a rapid
electrical discharge.
• This causes contraction and expansion of the
crystals. A pressure pulse is induced in the
surrounding water and produces a shock wave.
• The focal volume is determined by the geometric
arrangement of the crystals inside the sphere.
SW vs Radial Pressure Wave
BIOLOGICAL
PRINCIPLES
 PHYSIOLOGICAL EFFECTS
• 4 phases :
1. the direct (mechanical) effect of the shock wave. Due to extracellular
cavitations, ESWT ionizes the molecules and there is an increase of
membrane permeability.
2. the physical-chemical phase. This involves the interaction of diffusible
radicals with biomolecules. ESWT may affect lysosomes and
mitochondria, and interfere with metabolism in the cell.
3. the chemical phase, which may be accompanied by intracellular
reactions and molecular changes. A high temperature is developed
locally during cavitation, which leads to the development of radicals.
4. a biological phase. Physiological responses take place in this phase
when the changes from the first 3 phases persist.

• These 4 phases include the most important therapeutic effects of shock

waves.
 MECHANOTRANSDUCTION
Mechanotransduction describes the cellular processes that translate
mechanical stimuli into biochemical signals, thus enabling cells to
adapt to their physical surroundings.
Jaalouk and Lammerding Nature, 2009

Acute functional response Tissue plasticity

Including structural and functional adaptation

Target are active and passive structures

Muscle
Endothelium Connective tissue
Epithelia
 Biological Effectc of Shock waves

 Permeability change of cell membrane

 Stimulation of mithocondria, ATP release
 Dilution of substance P (neurotransmitter)
 Decrease of small myelinited nerve fibers (biosurggery)
 Anti inflamatory effect
 Angio and vasculogenesis
 Promotion of NO (nitric oxide)
 Promotion of growth factors
 Mobilization, Migration and (differentiation) of stem cells
 Message to be taken home:

Shockwaves do not damage tissue

Shockwaves stimulate biological reaction
via mechanotransduction
BASIC PRINCIPLES
OF SHOCKWAVE
THERAPY
 Indication – First Reflections

• Tissue to be treated
Tendon / Muscle / Bone / Skin / Nerves

• Shockwave to be used
Focused / Radial / Unfocused (planar)
Small machines / Big machines (hospital size)

• Success rate – Evidence

Literature / studies
 Contraindications

• Absolute (Radial and focused SW, focused or

defocused low energy)

Malign Tumor within Focus

• Relative
Pregnancy
 Contraindications

• Absolute ( only focused SW, high energy)

lung tissue within the focal area
Malign Tumor within Focus
ephiphyseal plate in the focus area
severe coagulopathy
brain or spine tissue in the focal area
 ANAESTHESIA
• No local anaesthesia for tendons, muscle and
skin
• Exception : calcifying tendinosis of the
shoulder
• Regional or general anaesthesia for bone
treatment
 Treatment approach
• First treatment approach not to the pathology
• Accustom the patient to noise and local
perception
• Modify the treatment energy and frequence of
impulses (accustomizing treatment up to the
tolerable pain threshold)
• Combination of therapy when possible : f- ESWT
and r- ESWT
• Treatment intervals 1 – 2 weeks
• Medication when needed : painkiller
 Possitive reaction after ESWT
• Reduction of pain :
1. Immediate : after several minutes (lasts 1-2 weeks)
2. Late : 4 (6) – 12 weeks
• Reaction of tissue :
1. Skin regeneration : 1-2 weeks (beginning)
2. Disolution of calcification : 12 weeks (6-12 months)
3. Bone regeneration : 6-8 weeks (small bones),
diaphyseal long bones 3-4 months, final results after 6
months
 Side effects
• Temporary increase pain
• Dysaesthesia
• Pethecial bleeeding
• Reddening of the skin
• Tinitus
 Approved standard indications
1. Plantar fascitis
2. Tennis elbow
3. Rotator cuff tendinitis
4. Pattelar tendinopathy
5. Greather trochanter syndrome
6. Delayed bone healing
7. Non union of the bone
8. Stress fracture
9. Early stage AVN
10. Urologic lithotripsy
Common emperical tested clinical uses
1. Ulnar epicondylopathy
2. Adductor syndrome
3. Pes anserinus syndrome
4. Peroneal tendon syndrome
5. Myofascial syndrome
6. Muscle injury without discontinuity
7. Impared wound healing/burns
TERIMAKASIH