The shock waves

Shock waves are acoustic waves with an extremely high energy peak like those which occur in the atmosphere following an explosion phenomenon such as a lightning strike or a sonic explosion. A shock wave differs from ultrasound in its extremely wide pressure range. In addition, the ultrasound usually consists of a periodic oscillation while a shock wave is a single pulse.

Extracorporeal shock wave therapy (TOCE) is the application of shock waves in medicine.

When applied to injured tissue, pressure waves stimulate metabolic reactions. It’s clinically proven:

  • Reduction of pain felt by nerve fibers
  • Increased blood circulation in the surrounding soft tissue
  • Beginning of the healing process initiated by the activation of stem cells

Evolution of shock wave therapy

The terms « shock wave therapy » refer to mechanical pressure impulses that spread like a wave through the human body. In 1980, the shock wave method was first used to disintegrate stones in a patient’s kidneys (Journal of Urology (Journal of Urology), 1982).

Therapeutic effect of shock waves

Extracorporeal acoustic wave therapy (unlike lithotripsy) is not used to disintegrate tissue but to cause microscopic extracellular and interstitial biological effects; which includes tissue regeneration. In modern pain therapy, acoustic wave energy is conducted from the point of origin, which is the generator of acoustic waves (via a coupling gel), to the regions of the body experiencing pain. Here, its healing capacity is applied.

After 4 or 5 sessions, more than 80% of patients indicate that they no longer experience pain or that they experience a marked reduction in pain.

Benefits for the patient:

  • Numerous fields of applications
  • Treatment without anesthesia and non-traumatic
  • High cure rate
  • Reduced quality of life and mobility
  • Affordable therapy
  • Motivation by visual assessment process with VAS result
  • 80% success rate
  • Reduced processing time: approximately 10 minutes
  • On average 6-8 treatment sessions required
  • Realistic alternative to surgery

The 2 types of shock waves

Radial shock waves have been used for many years to treat tendinopathies, your Physiotherapy practice in Bascharage also uses focal shock waves which are much more precise and effective for many pathologies. In addition, all radial shock waves are not equal and can be one of the reasons for the success or failure of treatment.

Radial shock waves

Ballistic shock wave generation

Compressed air accelerates a projectile, which strikes a fixed applicator at a high speed (up to 90 km / h). Kinetic energy is converted into a shock wave released into the target tissue through the skin. These shock waves propagate radially for the large areas to be treated.

Pressure characteristics of radial shock waves

  1. The shock wave begins with a compression phase which propagates shear waves in the tissue.
  2. It is followed by a depression or tension phase which generates cavitation bubbles.

The energy flux density (DE or DFE) is represented by the square area below the pressure curve.

Visualization of radial shock waves

Focal shock waves

Piezoceramic shock wave generation

High voltage is applied to 1,000 piezoceramic crystals, thereby generating pressure waves. These penetrate the skin and pass through the tissue, concentrating on a volume in the shape of a cigar.

Pressure characteristics of radial shock waves

  1. The compression phase of the focused extracorporeal shock waves is usually shorter than the radial extracorporeal shock waves and the maximum pressure P + is usually higher than in the radial TOCE.

Both the focused TOCE and the radial TOCE can reach an ED + of 0.4 mJ / mm2, a value that has been proven for almost all indications of TOCE on the musculoskeletal system and the skin.

Visualisation des ondes de choc focales

Les 2 grands impacts dans la thérapie par ondes de choc

Tissue repair and cell growth

Inward growth of neovascularization:

The blood flow of food is necessary to start and maintain the processes of repairing the structure of damaged tissue. The application of acoustic waves creates capillary micro-breaks in the tendon and bone and significantly increases the expression of growth indicators such as eNOS, VEGF, PCNA and BMP.

effets-ondes-de-choc

These two processes stimulate the growth and reshaping of new arterioles. The new blood vessels will improve blood supply and oxygenation resulting in faster healing of the tendon and bone.

Reversal of chronic inflammation:

Chronic inflammation occurs when the inflammation reaction is not completely stopped. It can damage healthy parts of the body and can lead to chronic pain. The activity of mast cells, involved in the inflammatory process, can be increased by insinuating acoustic waves. Mast cell activation can be followed by the synthesis of chemokines and cytokines. Unblocking pro-inflammatory mixtures, if necessary, can help restore normal healing and regenerative processes.

Collagen stimulation:

The production of sufficient amounts of collagen is a necessary precondition for the tissue repair process. Shock wave therapy accelerates procollagen synthesis. The newly created collagen fibers are imposed in a longitudinal structure. These newly formed tendon fibers are denser and harder.

stimulation-du-collagene

Acoustic waves support neovascularization, the production of collagens and restore healing, but they also allow an increase in growth factors, an increase in mesenchymal stem cells and above all a stimulation of metabolism.

Analgesia and rehabilitation of mobility

Dispersion of the Substance P pain mediator:

Substance P is a neurotransmitter that mediates pain information via C fibers. This neuropeptide is generally associated with chronic, persistent and severe pain. It is used to relay pain messages to the central nervous system. The decrease in the concentration of substance P reduces the stimulation of afferent nociceptive fibers and, therefore, reduces pain. The decrease in substance P, histamines and other nociceptive metabolites also help to inhibit the development of inflammatory edema.

Dissolution of calcified fibroblasts:

Calcium deposition is most often the result of micro-tears or other trauma to the tendon. Acoustic waves break existing calcifications. Acoustic wave therapy initiates biochemical decalcification of calcium deposition of toothpaste-like consistency and treats the tendon. Granular calcium particles are removed by the lymphatic system.

calcificationImages à rayons x avant le traitement.
calcification-apres-onde-de-chocX-ray images after 3 shock wave sessions

Trigger point relief:

Trigger points are the main cause of back, neck, shoulder and extremity pain. They are associated with palpable nodules in tight groups of muscle fibers and their sarcomeres are extremely contracted. Dysfunctional sarcomeres contract so hard that they start to cut their own blood supply. This causes a deposit of waste products which in turn irritates the sensory nerve endings, causing even more contractions. This vicious circle is referred to as a “metabolic crisis”. Although the precise medical effects of the acoustic wave are still unclear, it can be said that the acoustic energy supplied unblocks the “calcium pump”. Thus, this reverses the metabolic crisis into myofilaments and relieves these trigger points.

trigger-point

Acoustic waves relieve sarcomeres which are extremely contracted in the trigger points.

Areas of application of shock waves

Extracorporeal shock wave therapy is most commonly used in physiotherapy, orthopedics and sports medicine.

Applications in physiotherapy are most often associated with the treatment of chronic disorders of the muscles and tendons, back, neck pain and trigger points. Compared to conventional, manual and instrumental therapy, EMS DuoClast is extremely effective, it shortens treatment time and provides better results for a long-term follow-up. The most common indications include:

  • Painful shoulders
  • Lateral epicondylalgia / elbow of the tennis player
  • Median epicondylalgia / elbow of the golf player
  • Lower back pain
  • Achilles tendon pain
  • Tendinopathies and chronic enthesopathies in general
  • Trigger point processing
  • Dupuytren’s disease
  • Ledderhose disease
Orthopedic shock wave applications focus on the treatment of calcifications, painful exostoses, different tendonitis and poor fracture consolidation. EMS DuoClast provides an alternative in several cases when a surgical solution seems to be unavoidable. The main indications are:
  • A blocked shoulder
  • A periarthritis humeroscapularis
  • Arthrotic changes: secondary symptoms
  • Heel spur / Plantar fasciitis
  • Shin splints / Anterior tibial syndrome
  • Patellar tendinopathy
  • Achillodynia
  • Myofascial pain syndrome
Shock wave therapy is very often applied in sports medicine for its soft healing of the tissue and its regenerative effect. Thus, the recovery time after injury can be minimized. Common indications are:
  • Muscle distension
  • Prolonged joint distortion treatment
  • Groin pain
  • Hip pain
  • Lower back pain
  • Achillodynia
  • Iliotibial band syndrome

Shock wave therapy is the perfect treatment method for all complex chronic and musculoskeletal conditions.

New indications for shock wave treatment in sports medicine

This therapy can be used for chronic and acute soft tissue disorders in the field of sports medicine. Latest results prove the effectiveness of shock waves in healing muscle tension, shock waves reduce the recovery period and allow the return to full sports endurance.

The indications of sports medicine for shock waves are:

  • Healing of acute muscle tension
  • Support for muscle regeneration
  • Acute muscle spasms
  • Jumper’s knee
  • Epicondylitis
  • Painful shoulder
  • Groin pain
  • Achillodynia

In the event of an acute muscle injury, shock wave therapy is part of my standard therapeutic procedure. I have managed to use them for all my patients, among the best tennis players in the world, including Tomas Berdych (2010 Wimbledon finalist) and other members of the Czech Davis Cup team

Dr. René Kloc, Prostejov Tennis Club, Czech Republic

I had a case of a badminton player with bilateral achillodynia. After the fourth treatment there was still some pain, but a month after the last treatment the pain was completely gone.

Galvão Filipa, Physiotherapist, CLINUS, Portugal

This therapy is an innovative method for the treatment of the musculoskeletal system in sports physiotherapy. It is a non-invasive, safe and effective method. In about 10 days, shock wave therapy can reduce pain in 84% of cases.

Dr. Krzysztof Kijewski PhD, Olympic Medical Centre, Varsovie, Pologne

This therapy is an approach to favor in a part of complex treatment focused on optimizing inflammation and reducing the healing interval. Early activation of injured muscle and stimulation with shock waves play a crucial role in faster muscle recovery.

Dr. Milos Barna, Spécialiste en médecine sportive, Vulcano Medical Centre, Prague, République tchèque

Cryotherapy associated with shock waves

Cryotherapy combined with shock wave is a must!

Shock wave therapy can be uncomfortable or even painful. There is also a risk of bruising. The use of cryotherapy BEFORE shock wave therapy is beneficial:

  • Its analgesic effect makes the treatment completely painless and offers more comfort to the patient. It is thus possible to use appropriate parameters which improve the effectiveness of the therapy.
  • Vasomotor effects decrease the risk of bruising caused by shock wave therapy.
  • The exhaust allows you to improve the healing process and increase the effectiveness of the therapy.

Cryotherapy (thermal shock), combined with shock waves improves patient comfort, makes therapy smoother and increases efficiency. Cryotherapy is the therapeutic application of cold which can be obtained in different ways (ice, cold water, damp linen, methyl chloride, carbon dioxide, etc.).

Your questions

The reported clinical success rate is between 77 and 80% worldwide. Each treatment is cumulative and the results are often felt after three or four sessions. You may even feel an improvement in your condition (usually a reduction in pain) after the very first treatment.

There may be feelings of discomfort during treatment. It depends on the level of pain the patient is already experiencing in this part. However, since the treatments only last about five minutes, most patients are able to tolerate this discomfort fairly well. In addition, the intensity of the treatment can be adjusted at the start of each session to allow analgesic effects.

Most patients will experience immediate pain relief after treatment. However, they may experience irritation in the treated area 2-4 hours after treatment. This irritation is known to be very tolerable and can last from a few hours to several days.

Patients are advised to refrain from physical activity, particularly one that involves the treated part, for 48 hours after each treatment session.

Each treatment session takes approximately 5-10 minutes. Most conditions require 8 to 12 sessions. Treatments are carried out 5 to 7 days apart depending on the patient’s tolerance and the reaction of his tissue.