Exploring the Effectiveness and Applications of Shockwave

INTRODUCTION

Electrotherapeutic modalities, such as Shockwave therapy, which may be used by both veterinarians and physiotherapists, have become more popular in the past decade (Rasmussen et al 2008). Research suggests that Shockwave therapy can be an effective adjunct to the surgical management of canine orthopaedic disease both post-operatively (Barnes et al 2019) and in conservatively managed cases such as for hip osteoarthritis (Souza et al 2016, Mueller et al 2017). A Shockwave is a high energy acoustic wave applied externally to the skin via a coupling medium, such as a water based gel, and targeted at affected soft tissue, bones or joints via the shockwave ‘trode’ (Wang 2012).

WHAT IS SHOCKWAVE THERAPY?

Shockwave therapy utilises acoustic sound waves transmitted through a conduction medium and although it can be likened to ultrasound, peak pressure is approximately 1000 times greater (Wang 2012) with maximum pressure at the peak of the shockwave of approximately 500 bar. Pressure waves have been used traditionally for Lithotrispy, which involves breaking down kidney stones, by fragmentation (Wess 2008). In contrast Orthotripsy aims to stimulate repair and regeneration of tissue such as bone, tendon and muscle (Wang 2012) via ‘mechano-transduction’ (D’agostino et al 2015) with the primary effect being the direct generation of mechanical forces on the tissues and the secondary effect via cavitation or the indirect generation of mechanical forces (Ogden, Tóth-Kischkat and Schultheiss 2001) with the aim of stimulating soft tissue healing and inhibiting pain receptors (Rompe, Furia and Maffulli 2009). Therefore Orthotripsy utilises lower energy shockwaves for the desired effect. Medical devices most commonly utilise electro hydraulic methods whereby high-energy acoustic waves are created by an explosion under water (Wang 2012). These can also be produced by electromagnetic means where an electric current passes through a coil to generate an electromagnetic field and then a lens is used to focus the wave (Wang 2012). The third method is via piezoelectric methods whereby piezochrystals mounted in a sphere receive quick electrical discharge creating a pressure pulse into surrounding water generating the shockwave (Wang 2012). The method of shockwave production and the amount of energy transferred to the target tissue can vary depending on the aim of the shockwave therapy and this study sought to identify those used within canine rehabilitation. Within human medicine there is evidence supporting the use of shockwave for soft tissue conditions, which may not routinely be surgically managed or respond adequately to strengthening exercise such as insertional Achilles tendinopathy (Rompe et al 2008) although evidence has also found a comparable effect to eccentric training in this patient group (Rompe et al 2007).

EFFECTS OF SHOCKWAVE THERAPY

Pain relief is one of the primary advantageous effects of Shockwave therapy which has been used to treat pain associated with orthopaedic conditions in human medicine such as tennis elbow (Rompe et al 1996), Tendinopathy (Rompe Furia and Maffulli 2008) and heel pain (Rompe et al 1996) although the mechanism by which pain is relieved via shockwave therapy is uncertain, there are a number of theories in the literature that attempt to explain it and these can be divided into the effect on the nervous system and the effect on the soft tissue. Firstly, some evidence suggests that a pain relieving effect is caused by the mechanisms that exhibit descending inhibitory control at the spinal cord (Rompe et al 1996). This is thought to be via the activation of a serotonergic system, which results in ‘blocking’ of the pain signals at the level of the spinal cord preventing ‘pain signals’ from reaching the conscious brain. In comparison, evidence describes de-innervation of the epidermal nerve fibres following application of shockwave therapy (Ohtori et al 2001) which results in the nerve impulses being unable to travel along the peripheral nerve pathways to the dorsal root ganglia in the spinal cord, thereby never reaching the brain. In such cases, the animal would consciously process the signal and interpret it as a pain experience. Although evidence suggests re-innervation after two weeks meaning that the effects are temporary and repeat treatment would be required to prolong the analgesic affect. In contrast, Wang (2012) suggests that re-vascularisation occurs as a result of the shockwave therapy with resultant tissue healing and therefore relief of pain caused by dysfunction of the tendon. Although there is a lack of research investigating the effects of shockwave therapy on acute tendon pain, expert opinion suggests it should be reserved for chronic tendon issues. Despite the potential benefits highlighted in various studies, there is limited research evaluating the efficacy of shockwave therapy in animals although anecdotally shockwave therapy is used within animal therapy with evidence extrapolated from human research. This study sought to investigate and clarify how shockwave therapy is currently used in veterinary practice to inform clinicians and researchers alike.

AIMS AND OBJECTIVES

This study aimed at investigating the use of shockwave therapy in canine referral practice. It also aims at investigating the use of shockwave therapy in veterinary referral practice. Specific objectives of the study were:

• To investigate whether shockwave therapy is used in the processes mentioned and if so, collect and analyse information relating to its use such.
• To analyse the conditions on which shockwave therapy is used, at what stage of rehabilitation, by whom and at what frequency and dosages.
• To ascertain whether shockwave therapy is used more frequently in relation to clinical diagnosis, clinician or patient demographic.
• To establish the outcome of the shockwave treatment and make recommendations for future use of shockwave therapy in practice and research.

LITERATURE REVIEW
Shockwave therapy Practice in the UK

For over 20 years, shockwave therapy has been used successfully in the management of orthopaedic conditions (Shmitz et al 2013). This process has emerged as a popular and acceptable non-invasive option in the UK for management for both tendon and musculoskeletal system conditions. Recent studies have even shown that SWT has grown more effective compared to other forms of treatment; these include steroid injections, platelet- rich plasma injections, surgery, eccentric exercise and traditional physiotherapy (Schmitz et al 2015). The incidences of Orthopaedic conditions are high; these account for a large percentage of cases seen by small animal veterinarians although there is no information detailing exact numbers, a one survey carried out by Ness et al (1996) found that the top three most commonly surgically treated orthopaedic conditions in Canine Primary Care and Referral practice are Fractures, Arthritis and Cranial Cruciate Disease with almost all cases occurring due to trauma, developmental issues or due to degeneration. Of the cases referred for ongoing management common clinical findings include pain lameness and loss of range of motion of the affected joint and some literature states that management for such cases includes a period of conservative management such as the oral non-steroidal anti-inflammatories (NSAIDS) and restricted exercise alongside physiotherapy to build supporting muscle around the joints involved as is the case in Canine Hip Dysplasia (Edge Hughes 2007). Although there is a lack of literature exploring the efficacy and evaluating the effect of physiotherapy as a primary management strategy and research into orthopaedic disease management tends to be carried out by veterinary surgeons evaluating the effect of surgical interventions. For example in the case of hip Dysplasia, both conservative management and surgical management are explored in the literature. Surgical management is usually aimed at either preventing the progression of

osteoarthritis or preventing the clinical signs of hip Dysplasia. Conservative management is primarily used in animals with intermittent or mild signs. Conservative management involves weight control, nutritional management, pain management, rehabilitation of the body, disease modifying agents and exercise modification (Harper, 2017). According to Bittersohl et al (2012) early treatment is necessary for the treatment of hip dysplasia; consequently, in order to prevent osteoarthritis, treatment of residual hip dysplasia requires corrective surgery. In addition, Harper (2017) highlights that conservative management would primary involve the treatment of osteoarthritis, which would be as a result of hip dysplasia. There is a lack of information regarding the outcome of cases that are treated conservatively in this way and whether or not shockwave therapy is used. This study sought to identify frequency of use of shockwave therapy in the conservative management of orthopaedic disease.

Current use of Shockwaves The parameters considered for s

The parameters considered for shockwave therapy within both human orthopaedic medicine and veterinary rehabilitation include: whether the shockwave is focused or radial, how many impulses and at what pressure, the energy flux density and frequency used, as well as the number of sessions and time intervals (Korakis et al 2018). Radial SWT is the more common type of therapy; with this parameter being used in the treatment of a number of conditions (Worp et al, 2011). Focus SWT, however, has increased treatment options and less risks of pain. Radial waves are generated through the pneumatic system. A projectile is first accelerated to high speeds then decelerated suddenly by a transmitter being held to the targeted area. The surface of the transmitter in this case constitutes the highest energy density and highest pressure; the deeper the shockwaves goes into the body, the less powerful it becomes (Lohrer et al, 2010). The focused shockwaves, on the other hand, are electromagnetically generated through cylindrical coils; a submerged membrane is caused to move and a pressure wave is generated in the surrounding membrane. The amount of energy dispersed in this case is minimal, thereby limiting damage at the skin to the underlying soft tissues. The pressure, energy flux density and frequency used are directly affected by the choice of SWT used. Low energy flux densities may go as low as 0.1 mJ/mm2 whereas high may be at least 0.2 mJ/mm2 (Zhao et al, 2018). These parameters are of most importance especially considerations on the pressure and energy transferred to the tissue when considering therapeutic benefit and patient safety. In that line, a histological study found that a dosage of energy density of 0.28mj/mm2 and 0.6 mJ/mm2 caused an inflammatory reaction and marked histological changes respectively in a rabbit tendon. (Rompe et al 1998). The

potential damaging effects of shockwave have also been identified at lower dosages in patients with Achilles tendinopathy, where reported side effects included bruising and swelling post shockwave treatment applied at an energy flux density of 0.12mj/mm2 (Rompe et al 2009). Shockwave carried out repetitively may destroy nerve fibres which may be considered an advantageous outcome for the animal (Souza et al 2016) or human; given that a delay in re-innervation may provide a longer term analgesic effect (Rompe, Furia, Maffulli 2009). Nonetheless, shockwave is a less aggressive option compared to surgery when used appropriately. It also appears to be a useful tool in rehabilitation in both the human and veterinary fields. This can be backed by current information on the use of canine orthopaedic conditions in both humans and veterinary referrals (Leeman et al 2016; Barnes et al, 2019).

Clinical application of Shockwave Therapy

The first extracorporeal shockwave therapy in clinical practice can be dated back in 1980 where it was used as treatment for non-invasive lithotripsy (Chung and Wiley, 2002). In the recent decades, however, SWT has been used as a method of treatment and solutions to bone growth and musculoskeletal disorders). As a result, various clinical orthopaedic treatments in can be associated with SWT; such to include Achilles tendinopathy, patellar tendinopathy, plantar fasciitis among many others which have been discussed in this review. Modern developments in this process has even led to the treatment being extended to other conditions such chronic treatment resistant- tendinopathies, osteochondritis, femoral head necrosis, and calcified shoulder tendonitis (Chung and Wiley, 2002). Shockwaves involve sound waves produced in high energies with high voltage evaporations and explosions under water. In regards to its application, case in point is the non-invasive lithotripsy. In such cases, shockwaves are used to dissolve nephrolithiasis. In cases of orthopaedic treatment, the neovascularisation at the tendon- bone junction is induced and as a result, growth factors such as the endothelial nitric oxide synthase, proliferating cell antinuclear antigen and the vascular endothelial growth factor are released (Wang, 2003) Consequently, there is improved supply of blood and an enhancement of cell proliferation; ultimately, tissue regeneration responsible for tissue repair is improved. SWT represents a rather innovative treatment method of various musculoskeletal conditions, this applies mostly in cases where conservative therapy methods have failed. There are various additional advantages brought out in that regard, SWT is considered cost effective, non-invasive, safe and possible without the dangers associated with postoperative pain or surgical procedures (Wang, 2003)

The clinical mechanism with regard to SWT has not been fully elucidated (Dedes et al 2018), however, postulations have that shockwaves cause stimulations which activate fibers of small diameters; this results into the activations of a serotoninergic system which is responsible for regulating the transmission of pain stimuli. As a result, the patient’s tolerance for pain is increased. Furthermore, because of increased vascularity, SWT causes localized metabolic reactions which generally promote the natural healing process in both humans and animals (Dedes et al 2018) There are three main ways in which shockwaves may be generated in clinical application; electrohydraulic, piezoelectric and electromagnetic. Each of these represents principles of shockwave generation which represent different techniques involved in the generation of shockwaves. Electrohydraulic shockwaves are high energy shockwaves generated with electrode spark with high voltage discharge. This kind of shockwaves is characterized by large axial diameters of high total energy and focal volume. Electromagnetic shockwaves are generated through passing electric current through a coil which produces strong magnetic fields. The amplitude of the focused waves in this technique, when the acoustic wave propagates towards the focal point, increases by non- linearity. Piezoelectric shockwaves, on the other hand, involve large numbers of piezocrystals (>1000) which are mounted on a sphere to receive rapid electrical discharges which in turn induce pressure pulses in surrounding water. These three generations of shockwaves determine the two main types of shockwaves; radial and focused. Radial shockwaves decreases in energy with increase in square distance from the surface whereas focused shockwaves increase in energy density with the increase in depth of the tissues (Mueller et al, 2015). According to Chun and Wiley (2002), several issues surrounding the use of different types of shockwaves, the intensities, dosage and number of sessions required are still always debatable. There is need for further research, especially in a bid to determine the most beneficial protocols for patient care. The frequency and dosage of administration of shockwaves is dependent on the nature of the condition being treated. For instance, in bone healing, according to Romeo et al (2013), the type of fracture, site, previous treatment, adequate immobilization and stabilization of the size of the fracture gap and the lesion determines the healing rate of the bone unions. In canine SWT, the use of unfocused SW has been shown to gradually normalize healthy bone volumes. In some instances, particular species of oral bacteria react to particular levels of energy used; some pathogens and bacteria associated with different infections are disaggregated with different levels of energy (Romeo et al, 2013 SWT involves different mechanisms and natures, these natures differ depending on the type of technique used and mechanism applicable in different treatments; this

Discussion regarding the use of outcome measures

Shockwave has been used successfully in canines with hip osteoarthritis according to subjective reports from the owners which suggested that there was an improvement in quality of life and level of physical activity following treatment (Souza et al 2016). Although subjective reports from the owner may not be a reliable or valid method of measuring the outcome of the treatment, a suitable alternative may be via a composite outcome measure. There is need to evaluate the effectiveness of treatment interventions objectively, therefore, objective measurement should be included in all physiotherapy areas (Tabor and Williams, 2020). This concept raises the aspect of evidence based practice, in that, visionary medicine and rehabilitation can only demonstrate its theories, modalities, interventions and techniques through evidence based practice; which utilizes reliable, valid and standardized outcome measures in its correlation with objective diagnostic data (Hesbach, 2007). In a demonstration of the same fact, Tabor et al (2020) considered the effectiveness of the treatment in an objective evaluation of the treatment process in ten selected areas; the composite outcome score was used to show whether they were effective in measuring how effective the treatment was. Kinetic data may be a more objective measure also suggested an improvement in limb function following treatment, which lasted for up to 90 days during the follow up period. Similarly, Mueller (et al 2017) found significant improvement in the same measurements lasting for up to 3 months post treatment. Although it should be noted that the assessors were not blinded, which could result in bias and both studies were of a small sample size of 30 and 16 dogs respectively. Another study evaluating the effect of shockwave therapy for joint arthritis as measured via kinetic means, with a comparatively smaller sample size of 7 dogs (Dahlberg et al 2005), did not find a significant difference in outcome during the 3 month follow up. However, in contrast to the control group who did not receive any treatment, neither the stifle range of motion nor peak vertical force deteriorated; this perhaps suggesting that treatment with shockwave therapy lead to attenuation of progression of the disease. The treatment protocol consisted of one treatment per week for 3 weeks at a dosage of 1500 shocks at 0.14 mj/mm2 lower than comparable studies (Mueller et al 2011, Souza et al 2016) whereby radial shockwave treatment was carried out once a week for 3 weeks at dosages ranging between 0.1 to 0.3 mj/mm2 for a total of 2000 shocks. It is also unclear the means by which the shockwaves were produced as this may have affected the treatment administered.

Shockwave Therapy in Musculoskeletal Conditions Use in animals

In animal experiments, most studies have investigated the impact of SWT in musculoskeletal disorders. Wang et al (2001) demonstrated enhanced callus formation and cortical bone formation in acute fractures depicted in dogs; the effect of SWT in their study appeared to be dependent on time. In the conduction of an experimental model in rats, Haupt et al (1992) confirmed that SWT indeed has a positive effect with regard to fracture healing. In contradiction, however, Forriol et al (1994), arrived at a different conclusion; in this study, they concluded that SWT may delay bone healing. Conflicting results in regards to the effect of SWT arise as a result of the different shockwave dosages used and the different types of animals used in the experiments. For instance, Wang et al (2004) used high- energy SWT and produced significantly higher bone mass and better bone strength after fractures of rabbit femurs, compared to the control group. In contrast, the effects depicted by low- energy SWT were recorded to be comparable with the control group, thereby inferring less prevailing effects. Various other studies sought to investigate the effect SWT had on bone healing. The important findings include SWT induces ERK- dependent osteogenic transcription factor (CBFA-1) through the superoxide; mesenchymal cells differentiation towards osteoprogenitors is also a significant finding. Additionally, SWT promotes cell growth in the bone marrow and cell differention towards osteoprogenitors which are directly associated with the induction of TGF- B1 and VEGF (Wang et al, 2002). SWT also mediates Ras activation for osteogenesis and membrane hyperpolarization in the bone marrow. As further demonstrated, SWT’s effects have also been demonstrated in a number of musculoskeletal disorders such as insertional tendinopathy (Rompe et al 1998), plantar fasciitis, lateral elbow epicondylitis, calcifying shoulder tendinitis, Achilles tendinopathy and patellar tendinopathy.

Use in humans

The application of SWT in musculoskeletal disorders in humans has been in existence for around 15 years. Comparable to the effects of the intervention in animals, its application depicts success rates in various musculoskeletal disorders (Wang, 2003). These rates of success have been evident in non- union of long bone fractures, proximal plantar fasciitis, lateral epicondylitis, calcifying tendonitis of the shoulder, avascular necrosis of the femoral head (Wang, 2003). and many others; some of which have been discussed in this study. The complications associated with SWT in musculoskeletal disorders are negligible and low. In such applicability, SWT, just like in animal application, induces a variety of biological responses and musculoskeletal growth and other molecular changes such as the ingrowth neovascularization and regulation of angiogenetic factors of growth which lead to enhancement of tissue regeneration and improvement of supply of blood. In such issues, it is necessary to look at more research on the use of SWT in humans. There is limited evidence on its use in both veterinary and human perspectives (Chamberlain and Colborne 2016).

Shockwave Therapy in plantar fasciitis

The effect of shockwave therapy in plantar fasciitis treatment has been investigated in many studies. According to Dedes et al (2018), significant pain alleviation and improvement in functional ability immediately after the intervention is recorded. These recordings have been continued during the entire follow up periods of 3, 6 and 12 months. In the same line of results, Othman and Ragab applied shockwaves of energy intensities ranging from 17 to 21 kV (0.25 mj/mm2 to 0.6 mj/mm2), 2 Hz and 1500-3000 pulses; as a result of the intervention, there was a marked improvement in pain and half of the patients recorded no limitations to any activity after 6-10 months follow-up. Radwan et al (2012) applied shockwaves of high energy in treatment; 1500 shocks with total energy of 324.25J, similar results were witnessed. This meant significant improvements in functionality and pain maintained between 3-12 weeks post- intervention. This however, continued to a lesser extent as the end of one year approached. The weakness that arises in most studies that focus on SWT treatment in plantar fasciitis is based on the long- term effect of the treatment. Similar to what was experienced in Radwan et al (2012), the effects of SWT on participants in the experimental study were limited to a certain period expressed in post- intervention follow-up. The study lacks specific content on the magnitude of effect and the specific period in which the effects are felt. As a result, this study recommends further clinical research on the matter so as to enhance future practice.

Shockwave for tendinopathy

Similar to literature available on the use of shockwave for osteoarthritis, there are very few quality studies investigating the use of shockwave for soft tissue such as tendinopathy in dogs. One study assessing the effect of shockwave in cases previously treated with shockwave (Leeman et al 2016), a case series (Becker et al 2015) and two case reports (Danova and Muir 2003 and Venzin et al 2004) found favourable outcomes for the use of shockwave in the treatment of Shoulder tendinopathy in canines. Dosages reported ranged from an average of 989 shocks to 2000 shocks at an energy flux density of between 0.03 and 0.2 Mj/MM2. However the outcome of the shockwave treatment across all these studies are based on subjective reports from the owners who had been asked to assess behaviour of the dog, the degree of comfort and lameness following treatment. This is an inherently flawed method of assessing outcome given that there is no standardised method or template given to owners on which to base a judgement, what one owner may class as a severe level of lameness, another may class as mild lameness. Further, there is a lack of blinding of the owners to the treatment carried out which might have resulted in bias when reporting on the outcome of the treatment. Despite the apparent lack of quality evidence exploring shockwave therapy in canine musculoskeletal disorders, anecdotally shockwave therapy is widely used / becoming a more popular Tx option in canine medicine.

Doseages suggested in veterinary literature and manufacturers guidelines

No information regarding how it is used and for what conditions it is used appears to exist within veterinary medicine. Generally, dosages in veterinary literature appear to be in line with instructions provided by the shockwave unit manufacturer for example the Pulse Vet Versatron treatment protocol (https://www.pulsevet.com/versatron-4paws-indications-and-recommended-protocols/) although there are other units available. Whether rehabilitation specialists in practice follow these protocols is not known. Further, the use of SWT in the rehabilitation of soft tissue injury outside of shoulder tendinopathy in canines is unknown and the proposed study would identify the full scope of shockwave use within canine rehabilitation.

Shockwave therapy use in Achilles Tendinopathy

Shockwave therapy has been used to treat chronic Achilles tendinopathy in human medicine (Rompe et al 2007, Rompe, Furia and Maffulli 2009, Rompe, Furia and Maffulli 2008, Costa et al 2005, Rasmussen et al 2008). With radial shockwave being used primarily apart from in one study (Costa et al 2005) where no significant differences were found in outcome measures assessing pain and function at the third month follow up. Significant improvements in pain and function were found at fourth month follow up between groups in one study which compared eccentric training and eccentric training plus shockwave therapy (Rompe Furia and Maffulli 2009) and another found a significant improvement in pain and outcome in the shockwave therapy group when compared to no treatment at all (Rompe Furia and Maffulli 2008). In contrast, one paper found no significant difference between groups when comparing shockwave therapy and eccentric training at four months. However, there was a significant improvement when compared to no treatment at all (Rompe et al 2007). One study found a clinically significant improvement in pain and function at the 8 and 12 weeks follow up (Rasmussen et al 2008). The frequencies used for the treatment of Achilles tendinopathy within the studies reviewed varied from being administered via one session once a week for 3 weeks (Rompe et al 2007, Rompe Furia and Maffulli 2009, Rompe Furia and Maffulli 2008, Costa et al 2005) to a single treatment session once a week for 4 weeks (Rasmussen et al 2008). Others entailed between 1500-2000 shocks of between 0.1 to 0.51 Mj/mm2 of energy density.

Shockwave use in Chronic Patella Tendinopathy

In chronic Patella Tendinopathy research has been carried out comparing focused with radial shockwave therapy (Vanderworp et al 2014), shockwave with Autologous Protein Rich Plasma (Vetrano et al 2013) and eccentric exercises with or without conservative management such as Non-steroidal anti-inflammatory drugs, a strap, physiotherapy and an exercise programme (Wang et al 2007, Thijs et al 2016). Shockwave therapy versus placebo has also been studied (Zwerver et al 2011) but found no benefit of shockwave therapy in the treated group and in comparison to the placebo group although the placebo group also received shockwave at an energy flux density dosage of 0.03mj/mm2. The same dosage to that used for muscle spasticity in adults affected by stroke, which might have caused a treatment effect accounting for the similar outcomes of both groups. Further, they titrated up the dosage administered based on the patients comfort and therefore not all participants would have received the same dosage perhaps accounting for the lack of difference between groups. Nonetheless, this study and one other (Thijs et al 2016) showed no additional effect of shockwave therapy compared to those treated with eccentric exercises at 6, 12 and 24 weeks. All other studies reviewed showed a significant improvement in symptoms and outcome measures (Wang at al 2007, Vetrano et al 2013, Vanderworp et al 2014) over a variety of time frames with the longest follow up of 2-3 years (Wang et al 2007). All studies previously mentioned used focused shockwave with one study comparing the effect of focused and radial. In the study, it was found that no difference in effectiveness for treating this condition at 14-week follow up (Vanderworp et al 2014) arises. Further, although at two-month follow up interval, the effect of shockwave in comparison to protein rich plasma was comparable; at 6 and 12 month the protein rich plasma group had significant improvements in their outcome measures in comparison to shockwave therapy. Dosages for treatment of patella tendinopathy are comparatively higher than studies previously mentioned treating patella tendinopathy and ranged from 1500 to 2400 shocks at energy flux density of 0.12 Mj/mm2 to 0.58 Mj/mm2.

Shockwave Therapy use in Neurological Conditions

In human medicine, shockwave therapy has been used to treat lower limb muscle spasticity in children with Cerebral Palsy using both radial shockwave and focused shockwave. Radial shockwave therapy is also known as defocused or multifocus (Gonkova et al 2013, Corrado et al 2019, Iammarone et al 2008 Amelio and Manganotti 2010). Focused (Mirea et al 2014) and radial shockwaves are used with significant changes in outcome measures related to spasticity in all studies and results lasting between 4-13 weeks. Shockwave therapy has also been used to treat muscle spasticity associated with Stroke in adults for both the upper and lower limb (Manganotti and Amelio 2005, Moon et al 2013, Sohn et al 2011, Bae et al 2010). Significant improvement in outcome measures are reported immediately after treatment and for upto 12 weeks in one study (Manganotti and Amelio 2005), although perhaps a longer follow up time would find comparable results if other literature had followed study participants for longer. Variation in the length of the effect may be due to the type of shockwave used, as all the studies used focused shockwaves. The study with the greatest length of effect used a machine generating the shocks via Electromagnetic Coil (Manganotti and Amelio 2005). In contrast the study showing the least length of effect, significant improvement in spasticity for up to one week after treatment, used shockwaves generated via Piezoelectric Chrystal (Moon et al 2013) which might suggest that this form of shockwave production is less effective than the other two at the dosage used, for spasticity. Two studies found significant results in outcome measures for up to 4 weeks after treatment via Electrohydraulic shockwave generators. The use of focused waves is in contrast to the studies carried out in children with Cerebral Palsy previously mentioned, and Gonkova (et al 2013) found radial shockwave to be better tolerated, less expensive and less painful nonetheless, the study participants tolerated the discomfort caused by the treatment administered. Treatment dosages reported in literature based on treatment of muscle spasticity in children with Cerebral Palsy are wide ranging. Of those mentioned previously dosages of between 0.03 mj/mm2 and

2mj/mm2 of energy density, between 500 and 1500 shocks and both focused (Mirea et al 2014) and Radial shockwave (Gonkova et al 2013, Corrado 2019, Iammarone et al 2008, Amelio and Manganotti 2010, Sohn et al 2011, Manganotti and Amelio 2005) have been reported. Treatment frequency also varies between studies with the lowest frequency being 1 session and highest 5 sessions (one per week for 5 weeks) (Corrado 2019, Gonkova et al 2013). In comparison, adults who underwent treatment for spasticity following stroke dosages reported varied in frequency of application of between one session and once a week for three weeks (Manganotti and Amelio 2005, Moon et al 2013, Sohn et al 2011, Bae et al 2010). With the highest energy being 0.12 mj/mm2 and lowest being 0.03 mj/mm2, comparatively lower energy than children with Cerebral Palsy.

Shockwave use in Greater Trochanteric Pain Syndrome

Greater Trochanteric Pain Syndrome (GTPS) thought to be due to injury to the gluteal tendons (Furia, Rompe and Maffulli 2009) has been experimentally treated with shockwave therapy. SWT was found to be effective for this condition (Furia, Rompe and Maffulli 2009). It was also found to be superior to corticosteroid and home exercise training programme after 1 month and at 4 and 15 months follow up (Rompe et al 2009). Literature also supports education plus exercise over corticosteroid injection beyond 8 weeks for GTPS in human medicine (Mellor 2018) and the added benefit of shockwave here is unknown. There does not appear to be a single best protocol onto which the base dosage in the treatment of GTPS may be established. However, dosages and frequency of treatment reported in the literature vary between three weekly sessions of 2000 pulses with a pressure of three bars (Rompe et al 2009) and one low-energy treatment of two thousand shocks applied with a pressure of 4.0 bar (Furia, Rompe and Maffulli 2009) respectively.

CONCLUSION

Although directly comparing the findings of many different studies is difficult; primarily because of the difference in devices used, mechanisms applied, the output and intensity of shockwaves used and the different dosage of energy flux employed;, results depicted from various studies clearly indicate that SWT can be applied as treatment in various conditions and has achieved significant reductions in pain in both the quality of life and functionality. This evidently occurs after the completion of the therapeutic intervention and the follow ups in the experimental studies involving participants with various conditions; such to include plantar fasciitis, tendinopathies and various musculoskeletal disorders.

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