How is Shockwave Therapy Used in Physical Therapy?

Traditional rehabilitation methods may not always address the diverse needs of every individual, prompting the exploration of alternative approaches, such as undergoing extracorporeal shock wave therapy (ESWT). These alternative options often aim to minimize discomfort, expedite recovery, and optimize physical function, ‌offering a more holistic and effective path to rehabilitation.

In this article, we will discuss the proposed mechanisms of action of ESWT, the musculoskeletal conditions it can address, and the potential risks and contraindications associated with this innovative therapy.

How Extracorporeal Shock Wave Therapy (ESWT) Works

Extracorporeal Shock Wave Therapy (ESWT) is a cutting-edge medical treatment that harnesses the power of shock waves to stimulate the body’s natural healing processes.

While the exact mechanism of action remains a subject of ongoing research and exploration, there are four proposed mechanisms that illustrate the potential impact of ESWT on tissue, summarized as follows:

• Physical phase: According to this proposed mechanism of action, ESWT works by creating positive pressure that leads to energy absorption, reflection, refraction, and transmission to tissues and cells. This process induces tensile forces, cavitation, and increased permeability of cell membranes, activating various signal transduction pathways.
• Physicochemical phase: According to this proposed mechanism of action, ESWT works by stimulating cells to release biomolecules, such as ATP, activating cell signal pathways.
• Chemical phase: According to this proposed mechanism of action, shockwaves alter ion channel functions and calcium mobilization in cells.
• Biological phase: According to this proposed mechanism of action, ESWT modulates angiogenesis, anti-inflammatory effects, wound-healing, and bone-healing through the modulation of specific biological molecules associated with these processes.

What Musculoskeletal Conditions Can ESWT Help With?

ESWT is a non-invasive treatment that uses shock waves to promote healing and reduce pain in musculoskeletal conditions. It shows promising effects in improving symptoms associated with a wide range of musculoskeletal conditions, such as reduction of pain and return of function.

Acute Skeletal Muscle Injury

ESWT can potentially improve muscle injuries, most notably in sports injuries, by stimulating the healing process in injured skeletal muscles. Zissler et al. (2016) demonstrated the significant regeneration of muscle fibers and the acceleration of other healing processes of the injured muscles of rats that underwent ESWT compared to those who didn’t.

Stress Fractures

ESWT shows promise as an effective and minimally invasive alternative to surgery in enhancing bone healing and promoting the remodeling of stress fractures.

This was demonstrated in a retrospective study by Moretti et al. (2009) in soccer players with chronic stress fractures who received three to four sessions of low-middle energy ESWT.

The findings, based on clinical and radiography results at an average follow-up of 8 weeks, indicated excellent outcomes. All players were able to gradually return to sports activities after the ESWT treatment.

Lateral Epicondylopathy of the Elbow

ESWT has been shown to improve symptoms in patients with lateral epicondylopathy of the elbow, also known as tennis elbow. ESWT has been used to alleviate pain and improve function in individuals with lateral epicondylopathy of the elbow, also known as tennis elbow.

For instance, patients who underwent this innovative therapy has been demonstrated to be superior to corticosteroid injections in improving pain levels and functionality of patients in a meta-analysis of randomized controlled trials (Xiong et al., 2019).

In the previously mentioned study, significant improvements in patients’ visual analog scale for pain and grip strength were shown, within the follow-up of more than 12 weeks.

Plantar Fasciitis

ESWT has been used successfully to alleviate the pain and discomfort associated with plantar fasciitis.

For example, in a study by Mokhtarian et al. (2018), results showed that one month after the intervention, the Roles and Maudsley score (RMS) and visual analog scale (VAS) morning score demonstrated better improvement in the intervention group compared to the control group. This means that the pain experienced by the patients with plantar fasciitis significantly improved when they underwent ESWT.

The previously mentioned study also recommended combining ESWT and topical corticosteroid for the improvement of symptoms associated with chronic plantar fasciitis.

Contraindications: Who Shouldn’t Undergo ESWT?

While ESWT is generally considered a safe and well-tolerated treatment, there are certain contraindications that must be taken into account. Patients with the following conditions may not be suitable candidates for ESWT and should be advised against undergoing the procedure:

• Pregnancy: ESWT involves the use of high-energy shock waves to treat various musculoskeletal conditions, and the impact of these shock waves on the developing fetus has not been thoroughly studied. As a precautionary measure, medical providers should advise pregnant women to avoid the procedure and look for alternatives instead, to ensure the safety and well-being of both the mother and the unborn child.
• Infection at the Treatment Site: ESWT relies on shock waves to stimulate the body’s natural healing response, and introducing this treatment to patients with an active infection can potentially exacerbate the condition.
• Malignancy: Although the potential effects on tumor growth of ESWT are not yet well understood, patients with active cancer or a history of malignancy should be advised to avoid undergoing ESWT due to the potential risk of stimulating tumor growth or spreading cancer cells.
• Coagulopathies or Anticoagulant Therapy: Coagulopathies and undergoing anticoagulant therapy are significant concerns before undergoing ESWT due to the potential risk of excessive bleeding or hemorrhage during the procedure. Thorough assessment and management of these conditions are important in minimizing the risk of complications and ensuring the safety and well-being of your patient, should they opt to still proceed with ESWT.
• Body Parts to Avoid: Brain, spine, nerves, lung or pleura, epiphyseal or growth plates must be avoided in treatment focus in instances of high-energy ESWT. These structures are delicate and sensitive, and subjecting them to high-energy shock waves can lead to serious injury, nerve damage, or disruption of normal growth and development.

Side Effects of Undergoing ESWT

As a healthcare provider, ensuring that your patient is fully aware of the benefits and risks of undergoing ESWT is important to properly guide them in deciding whether ESWT is the right choice for their specific condition and needs. This is because, while ESWT is generally well-tolerated, there are some potential side effects that may make patients uncomfortable and may prevent them from immediately resuming their normal activities, such as the following:

• Pain and Discomfort: Patients may experience temporary pain or discomfort during the ESWT treatment, which can be managed with appropriate pain medication or adjustments to the treatment protocol.
• Bruising and Swelling: Some patients may develop minor bruising or swelling in the treated area. This occurs due to the focused shock waves causing microtrauma to the targeted tissue, leading to an inflammatory response. The body responds by increasing blood flow to the area, resulting in bruising and swelling. These side effects are usually temporary and are part of the natural healing process as the body repairs the damaged tissue.
• Skin Redness or Irritation: Mild skin redness or irritation may occur after ESWT, also in connection with the bodily response to the pain and discomfort in this procedure. However, these symptoms are generally short-lived and can be managed with appropriate skin care.
• Vasovagal Reaction: Patients may experience vasovagal reactions such as dizziness and a temporary loss of consciousness after undergoing ESWT, possibly due to the discomfort or pain or possible anxiety and stress associated with the treatment. These reactions go away on their own once the triggering factors are removed or the patient is placed in a comfortable position.
• Numbness or Tingling: In rare cases, patients may experience temporary numbness or tingling sensations in the treated area, which usually subsides without intervention.

Trustworthy Devices and Tools at Regenomedix™

Extracorporeal shockwave therapy (ESWT) has emerged as a valuable tool in the arsenal of physical therapists, chiropractors, orthopedists, and sports medicine specialists, offering a non-invasive and effective approach to treating a wide range of musculoskeletal conditions. This is in addition to a wide range of other applications of ESWT, such as sexual wellness and body contouring.

At Regenomedix™, we’re committed to embracing innovative modalities like ESWT in physical therapy, ensuring that patients receive the most advanced and tailored care available. We aim to consistently provide medical professionals with better access to high-quality devices and tools for alternative medical procedures.

Contact us for more information about the potential benefits of shockwave therapy for your practice, with an emphasis on real-world case studies showcasing ESWT’s efficacy.

References

Auersperg V, Trieb K. Extracorporeal shock wave therapy: an update. EFORT Open Rev. 2020 Oct 26;5(10):584-592. doi: 10.1302/2058-5241.5.190067. PMID: 33204500; PMCID: PMC7608508.

Mokhtarian, A., Vahdatpour, B., Raeissadat, S., Dehghan, F., Nasr, N., & Mazaheri, M. (2018). Enhancement of the Effectiveness of Extracorporeal Shock Wave Therapy with Topical Corticosteroid in Treatment of Chronic Plantar Fasciitis: A Randomized Control Clinical Trial. Advanced Biomedical Research, 7(1), 62. Source

Moretti, B., Notarnicola, A., Garofalo, R., Moretti, L., Patella, S., Marlinghaus, E., & Patella, V. (2009). Shock waves in the treatment of stress fractures. Ultrasound in Medicine & Biology, 35(6), 1042–1049. Source 

Moya, Daniel MD; Ramón, Silvia MD, PhD; Schaden, Wolfgang MD; Wang, Ching-Jen MD; Guiloff, Leonardo MD; Cheng, Jai-Hong MD. The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders. The Journal of Bone and Joint Surgery 100(3):p 251-263, February 7, 2018. | DOI: 10.2106/JBJS.17.00661

Tenforde AS, Borgstrom HE, DeLuca S, McCormack M, Singh M, Hoo JS, Yun PH. Best practices for extracorporeal shockwave therapy in musculoskeletal medicine: Clinical application and training consideration. PM R. 2022 May;14(5):611-619. doi: 10.1002/pmrj.12790. Epub 2022 Apr 14. PMID: 35187851; PMCID: PMC9321712.

Xiong, Y., Xue, H., Zhou, W., Sun, Y., Liu, Y., Wu, Q., … Liu, G. (2019). Shock-wave therapy versus corticosteroid injection on lateral epicondylitis: a meta-analysis of randomized controlled trials. The Physician and Sportsmedicine, 47(3), 284–289. Source

Zissler A, Steinbacher P, Zimmermann R, et al. Extracorporeal Shock Wave Therapy Accelerates Regeneration After Acute Skeletal Muscle Injury. The American Journal of Sports Medicine. 2017;45(3):676-684. doi:10.1177/0363546516668622