Extracorporeal shockwave therapy (ESWT) is a non-invasive therapeutic modality approved by the U.S. Food and Drug Administration to treat acute and chronic muscle and tendon pathology. The modality delivers acoustic pressure waves, known as orthotripsy, to pathologic tissues to stimulate tissue metabolism, enhance circulation, and accelerate tissue healing. In general, ESWT is best used in the treatment of chronic inflammatory conditions that are unresponsive to conservative care.
Long: How are you using ESWT in your practice? How do you incorporate ESWT into the overall treatment plan for your patients?
Colvin: I use ESWT in my practice on a regular basis. Patients may be referred to our clinic specifically for ESWT. In fact, many patients will transfer their care to our clinic from other physical therapy clinics. In my everyday practice, I will use this modality to alleviate pain associated with stubborn cases of tendinopathy. I have also used it on individuals with tight musculature. I tend to expose them to the lowest recommended setting for their respective condition and gradually increase the intensity. I have seen a wide variety of results. I can't say that I've seen any negative results. However, some patients will refuse ESWT treatment as a result of a lower pain tolerance.
Johnson: In determining whether ESWT is indicated, I look at the overall history of the injury: is it a chronic tendinopathy or an acute injury? In my practice, I have found value in using ESWT for more chronic conditions that have not responded to standard care. I typically use ESWT in addition to other manual therapy and therapeutic exercise techniques. I always attempt to address the root cause of the tendon or muscle injury, as opposed to simply masking the symptoms associated with the dysfunction. In doing so, I tend to look for training errors or joint restrictions throughout the region as underlying causes of the condition I am treating.
Scifers: The most common uses for ESWT include rotator cuff tendinopathy, lateral epicondylalgia, patellar tendinopathy, Achilles' tendinopathy, and plantar fasciitis. Other, less common uses stated in the literature include iliotibial band syndrome and calcific rotator cuff tendinitis.
Long: For which conditions do you find ESWT to be most useful? Have you experienced conditions that do not respond well to ESWT?
Colvin: I use ESWT on patients with myofascial pain (specifically upper trapezius and low back musculature), plantar fasciitis, tendinopathies, and piriformis syndrome. I have also had success using ESWT on iliotibial band syndrome. Thus far, I have not come across a condition that does not respond favorably to ESWT. Patients with lower pain tolerance tend not to do well with ESWT. Therefore, I try to avoid exposing the patient to this device if I suspect a low pain tolerance.
Johnson: I have found ESWT to be most beneficial for chronic tendinopathies and subacute muscle strains. Recently, I have found myself using ESWT for conditions such as plantar fasciitis, Achilles' tendinosis, and patellar tendinosis. I have experienced good results using ESWT to treat subacute hamstring strains, with the premise that ESWT may prevent scarring of the hamstring associated with injury. I have not found a condition for which ESWT has not been beneficial. As Dr. Colvin mentioned, some patients do not tolerate the treatment as well as others due to a lower pain tolerance, making it difficult to reach the therapeutic parameters necessary to bring about clinically significant results.
Scifers: Literature regarding the benefits of ESWT is generally positive. Numerous studies have investigated the benefits of ESWT for patients suffering from plantar fasciitis and have identified decreased pain and increased function as positive outcomes in a majority of patients. Similarly, research has demonstrated the effectiveness of ESWT in the treatment of rotator cuff tendinopathy, patellar tendinopathy, and, to a lesser extent, Achilles' tendinopathy. Alternatively, research regarding the benefits of ESWT in the treatment of lateral epicondylalgia demonstrated improved patient outcomes in only approximately 50% of studies.
Long: How have you seen ESWT benefit your patients in terms of clinically measurable outcomes, such as decreasing pain and improving range of motion, strength, and function?
Colvin: A common patient report is feeling “looser” following treatment with ESWT. The most commonly reported change due to ESWT is a decrease in the patient's pain following treatment. I have not seen changes in strength directly related to the use of ESWT; however, indirectly, due to the decrease in pain, I have seen secondary improvements in strength.
Johnson: We have the unique situation in that we have several clinics that will refer patients for ESWT following the patient's failure to respond to standard care. I have consistently seen clinical improvements in both pain and functional outcomes in these patients when the only variable changing with regard to their care is the addition of ESWT.
Scifers: The primary findings in the literature focus on decreased pain and increased function. Other findings include decreased rates of reinjury and, in the case of the posterior rotator cuff muscles, decreased tendon calcification.
Long: Have you identified any negative effects from the use of ESWT that you would want other clinicians to be aware of?
Colvin: Contraindications include coagulation disorders, use of anticoagulants, thrombosis, tumor disease, pregnancy, and cortisone therapy. I have seen side effects including soreness, petechiae, and skin lesions in cases of previous cortisone therapy. These side effects tend to be mild and last no more than 2 to 5 days.
Johnson: Mild soreness and bruising in the area are the only negative effects I have experienced. I typically perform the first treatment at a lower intensity to examine patient response to avoid any complications associated with ESWT treatment.
Long: There is a limited amount of peer-reviewed, clinical research regarding ESWT. How would you like to see this technique investigated in the future?
Colvin: I would like to see more research completed regarding the effectiveness of ESWT on different conditions such as Achilles' tendonitis as compared to instrument-assisted soft tissue mobilization and therapeutic exercise. It would be interesting to see if there would be a decrease in total clinic visits between various treatment techniques.
Johnson: I would like to see research conducted that compares ESWT to standard care for chronic tendinopathies. For example, would the combination of ESWT and eccentric exercise be superior to eccentric exercise alone for patients suffering from Achilles' tendinosis? Using tissue samples or diagnostic imaging before and after treatment to examine the physiologic effects of ESWT on tendon healing would also be interesting. In my practice, I have found ESWT to be beneficial in treating subacute hamstring strains. It would be interesting to examine whether the addition of ESWT to traditional rehabilitation programs reduces the reinjury rate. Finally, it would useful to know if ESWT reduces the amount of scar tissue resulting from hamstring injuries.
Scifers: Because most research investigating the benefits of ESWT focuses on subjective reports of pain reduction and patient satisfaction, it would be useful to examine the effect of ESWT on functional return to activity. This would be particularly useful in laborers and athletes, two patient groups who could greatly benefit from ESWT in the treatment of chronic tendon injuries that are resistant to conservative care. Additional research comparing more traditional therapeutic modalities, such as ultrasound, iontophoresis, and laser, to ESWT would be beneficial to practicing clinicians attempting to provide the highest quality care to patients suffering from overuse inflammatory conditions.
Long: How are you billing and collecting payment for ESWT in your practice?
Johnson: Currently, we are incorporating ESWT into our comprehensive services. We provide the treatment, when indicated, but do not specifically bill for the intervention.
Long: For a clinician who has not used ESWT previously, what advice would you offer for getting started with this treatment intervention?
Colvin: Become familiar with the specific device you are using clinically. The manufacturer will provide recommendations for pulses/sessions, energy levels, frequencies and transmitters for specific pathologies. Also, always begin treatment sessions at a low energy level and gradually increase intensity based on the patient's tolerance to the treatment intervention. Finally, apply a sufficient amount of gel to the treatment area and avoid excessive pressure of the transmitter at the site of injury.
Johnson: I would recommend reviewing the research literature to identify which conditions are best treated using ESWT. Also, due to the high expense associated with this therapeutic modality, be sure your patient population matches the indications for the use of ESWT.
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