Cavitation is King

It's great to see, as the month's progress, the audience for the blog grow. December when I first started this blog, seems like only yesterday, yet here we are, over half way through 2018, and it been great to hear the positive feedback. So welcome. I hope you continue to get a lot from this.

Today I was very pleased to interview another patient, this time with De Quervains tenosynovitis with a 2 year history pending surgery following the birth of child. See Dr Mary Onianwa testimonial to the remarkable help shockwave has afforded and my brief summary of upper limb conditions where shockwave can be effective.


I was asked to repost a Linkedin article about Shockwave that was well received:

9 Things you didn't know about ESWT Shockwave therapy

There have been a few questions from the post, so watch this space for a video follow up. 


There has been a lot of interesting talk recently about cavitation. I don't necessarily agree with the position some educators are giving the public and healthcare professionals, so I thought I would give my point of view here:

Cavitation: Important to successful Shockwave treatment 


Finally, I have agreed to go to Belfast, Northern Ireland to present for the Swiss DolorClast Academy with Algeos

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May's Shockwave Stories

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I'm delighted to advise that the video of all the presentations (incuding mine) made at the third http://www.britishshockwaveassociation.com conference in late March is now available to buy. Apologies for the delay in posting due to technical issues.

You will be able to listen to my thoughts on what, in my professional opinion, works and indeed some areas that fail unnecessaryily so. The upper limbs seemingly respond better to ESWT - the particular condition that comes to mind is Lateral Epicondylitis, as you will see in the slide above confirming Yang et al '17 study.

According to the study and my experiences it is important to ensure that: 

1. That the energy is delivered to the patient at an average of 3.1 bar [Yang]. The patient that was brought in for me to treat at the BSWA had previously undertaken a course of treatment of RSWT. The patient had an average of 1.5 bar delivered X3 treatments. I believe the energy or lack of was the reason the patient responded poorly to treatment and didn't get the outcome both the practitioner and patient desired. This is not an untypical case. 

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You will see that I managed to deliver an average of 3 bar to the patient in the video who was clearly not comfortable with the pain but tolerated it. We managed to work through despite being in front of a big audience. I'm now looking forward to hearing how he gets on with further treatments at this level of energy and that he has a successful outcome now.

Link to presentation and treatment.https://vimeo.com/273241291

 

Link to presentation, please email me and happy to send.

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2. Not all shockwave devices deliver the same energy as this study demonstrates.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4625004/

For example, some handpieces have been proven to lose a substantial amount of energy into the soft tisses, while using ultrasound gel can also affect energy absorption. I really like the Evo Blue as it does not lose energy irrespective of bar pressure. I loved this great progression of a handpiece from EMS and have produced this video which you may find of interest. https://youtu.be/jg2V8Lercug

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3. Lastly, it is important to note that ESWT simply cannot fix every patient. Here's another slide of mine from my presentation. I remember 10 years plus ago, it was fashionable to talk about success outcome rates in percentage terms - PF, MAT etc were always in the high eighties whereas UL was about 70%. Fortunately we've moved on from using percentages as a way of measuring successful outcomes. Now there are recorded research findings that would follow successful treatments - i.e) measuring at three, six and 12 months post treatment. 

Finally, I've decided to attach a recent study using EMS Swiss dolorClast which proved enormously popular on my social media channels. Radial shockwave treatment promotes human mesenchymal stem cell self-renewal and enhances cartilage healing.

https://stemcellres.biomedcentral.com/articles/10.1186/s13287-018-0805-5

That's all for this month guys. Happy continued great outcomes for your patients using ESWT.

April's Review

Paul and Reah

April appeared to be rather quiet but on review, we covered a number of topics, posts, RCTs, and of course, my presentation at the British Shockwave Association weekend.

I'll share that video as soon as it's available (hoping my 'man flu' wasn't too evident), and thanks to those that enquired... the car is all back to normal following the broken window during my talk!

The talk went very well and I think I had more questions and follow up from delegates in this event than any other. It was a great, engaged audience. A lot of the enquiries were about energy requirements to get successful outcomes.  To that end here's a link to a video I posted on our Facebook.com/OsteopathicClinic page answering the questions in more detail. 

 
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April Recap

So let's summarise the April posts and comments in case you missed anything:

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The medical view of Shockwave treatment

I had the pleasure of sitting down with medical practitioner and Shockwave patient, Dr Peter Campbell recently to talk about his experience as a patient and a professional.

Peter had treatment 6 years ago for a persistent Achilles problem, 2 years later for tennis elbow. He talked candidly about the treatment and the outcomes.

A must watch for anyone in practice.


Shockwave training

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I had the pleasure of providing in-house training at a local clinic, My Physio Croydon last month.
It was a great session and I'd just like to wish Chirag and his really enthusiastic team all the very best.

 

If you're introducing Shockwave to your practice, or looking to further develop your team, we have a program suited to you. Just drop me an email and we'll take it from there. 


Swiss Dolorclast Course

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I understand a great course was held in London under the care of Chris Downton with Mr Manog Sood and Mr Jonny Wride last month. It's great to see so many people becoming certified.

Check out the next course in Birmingham this month (schedule).

This is another must for anyone serious about bringing Shockwave to their patients.

Academic March

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What a busy March, with posts starting with upper extremities and stroke patients, O/A 1st CMC, a super study on human mesenchymal cells and finally my presentation at the British Shockwave Association


Best Study so far...

I think this is the study of the year so far. Rviewed by record breaking numbers and appreciable  comments from colleagues.

In the present study, we found that radial shockwaves significantly promoted the proliferation and self-renewal of MSCs in vitro and safely accelerated the cartilage repair process in vivo, indicating favorable clinical outcomes.

Also a great plug for the outstanding work currently being research and clearly that for the devise i.e EMS Swiss Dolorclast, keeping Radial Shockwave a the forefront where it clearly belongs.

The link to the study is below 

https://stemcellres.biomedcentral.com/articles/10.1186/s13287-018-0805-5


British Shockwave Association Presentation

I was delighted to be asked to present more on the practical aspects of Shockwave and what works in practice.

To be terribly honest I was so unwell, I had a nasty Chest Infection, missed all the lectures before me, getting out of my hotel bed just 30 minutes before my talk.

The talk was well received and people appreciated the fact that I made it. Professor Nicola Maffulli gave a very nice intro and also appreciated the part of talk informing what, in my opinion, does not work.

There will also be a video available of the conference, form the organisers, if any of you wish to purchase  

Those wishing to get a copy of my presentation can email me. I'm happy to share as long as it's not reproduced, which I'm sure you can appreciate.

Whilst being open and honest with colleagues I recently found a few individuals copying my website, using my photos and content, claiming this as there own material. It's very frustrating and clearly plagiarism which I though was a thing of the past.

The presentation was a varied topic but I really looked at the conditions that failed and why, Chronic Lateral Epicondylitis was a favourite, comparing the evidence in Yang's 2017 study for a condition that should respond well, to the outcomes people see when it's not 'done right'.

The organisers brought in a patient who had a course of treatment with another devise that failed miserably. Whilst the video recording is not positioned well, I think the approach is self explanatory. At least 3bar 15mm head is required locally (Yand et al 3.1 ) 10 hz and 2000 impulses. An additional 1000 impulses using a 36mm head to the extensor group distally. In this case from the musculartendinous junction towards the radial head.


As mentioned, a busy month with Shockwave. Let's look to the future and hope to continue with supplying great studies and continued conversations with you all.

Finally, it made my day at the presentation to hear a fellow colleague travelled from the USA to see me at the BSWA, thanking me most sincerely for the information we share here and on the social channels. He downloads, goes through content and it helps in clinical work with ESWT. Comments like that make it worth while. Appreciated that John, thank you.

Eventful February

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Another month down. As the weather slowly improves, we're seeing a few patients who've been in hibernation over the winter start to come out as they think about their health in the year ahead.

Here's a quick recap of what's been happening this month.

PS: Remember, you can follow me on LinkedIn to see these as they happen...


RCT Review

Interestingly not so much from the RCT's to end this month, well certainly not at this stage.


Persistent Plantar Fasciopathy

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Had a really interest case where clear signs of a tear of the Plantar Fascia duration 18 months resulting from sporting activities. The patient had visited a local consultant who uses RSWT but the problem being that the devise is a desk top version and I really have concerns with the amount of energy that can be delivered in order for angiogenesis to occur. There may also be loss of energy being delivered and consequntial poor cavitation!

This patient presented to me as he had a course of treatment but very poor outcome and if Im being terribly honest, have seen a few from Laptop shockwave devices.

Im very pleased to say that I have helped this man get to 80%, his 5th shockwave treatment was delivered after this video and I will be following up in 4 weeks time. Interesting point was that he was incredibly tender on the medial tubercle of the calcaneus as you would expect, but also that in the fat pad. Both not unusual but not to that degree , I treated accordingly following Yangs study on the elbow where considerations looked a failed treatments, really giving the patient as much as they could tollerate was followed. Those that have read my posts from the past will no my thoughts on energy and this is also very clear in my book.

Yangs study: Yang et al., Am J Phys Med Rehabil 2017;96:93-100.

Just a tip with recalcitrant PF, always check the achilles you may need to apply 1000 shots 8HZ . 2-3 bar should help if necessary.


BSWA UK Conference

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Finally, it's 4 weeks to go to the 3rd Shockwave UK conference which takes place in London on 24th March. Yours truly will be speaking amongst some very learned experts in the field of Shockwave Therapy.

You can register here

Progressive February

Well February most certainly been busy with a few good posts and confirmation of the 3rd Shockwave UK Conference organised by Professor Nicola Maffulli with a good cast of speakers, guest speaker Professor Ludger Gerdesmeyer who really launched ESWT with his study on Plantar Fasciopathy https://www.ncbi.nlm.nih.gov/pubmed/18832341?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

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The day is really looking interesting with Imaging with Dr Otto Chan, as mentioned we have Ludger Gerdesmeyer on the science and really couldn't have anyone better on this with two FDA approvals on his books.

There's also auditing and setting up a shockwave service, Jonathan Wrides EMS UK  principle educator is talking about realities in clinical practice, I'm looking forward in discussing the conditions that we know work and there's also a chance for everyone to join in and experience ESWT from a practical perspective with Jonathan and myself. 

We also have Dr Adam Read discussing data collection and Finally there's a speaker on Urology.

Those that are interested Professor Muffulli is presenting the inauguration of the  British ShockWave Association

Prior to the founding of BSWA, there was no shockwave association in the UK. The primary aim of this newly formed association is to bridge the gap between device companies, clinicians and patients, to facilitate an exchange of knowledge and ideas between all of us. We will adhere to national and international guidelines, whilst maintaining a pragmatic, non-exclusive approach in all specialties in which SWT has been proven to be effective.

Our ethos is that it is essential that all healthcare personnel administering SWT are trained to the highest standards, and are aware of all the relevant research and up to date to provide effective SWT.

BSWA will facilitate future collaborative research in SWT to ensure a bright, long future.

Please save this date, it will be full of academics and practical solutions.

Two post that caught my eye earlier this month,

Nice to see this in one of our main journals confirming best clinical results in terms of energy is low to mid and the endorsement of FSWT on Calcific Tendinopathies, not sure of the name given to RSWT though.

https://www.linkedin.com/pulse/role-extracorporeal-shockwave-treatment-disorders-paul-morrissey/?trackingId=YL8Xpw80AUfcfV9zOoxxSA%3D%3D

Finally, another good post confirming FSWT for another Hip pathology. Like the post last year with early AVN Focused seems to be helpful

https://www.linkedin.com/pulse/high-energy-extracorporeal-shock-wave-therapy-femoral-paul-morrissey/

Finally please take time to look at this testimonial from young Simon who had 6 years plus of knee pain and now finally out of pain and now is looking to get back into his of Football thanks to Radial Shockwave.

Busy January

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Where has the month of January gone! Lots going on.

Here's a quick recap of the updates I posted this month.

PS: Remember, you can follow me on LinkedIn to see these as they happen...

 

New and Accurate Predictive Model for the Efficacy of Extracorporeal Shock Wave Therapy in Managing Patients With Chronic Plantar Fasciitis

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To identify factors for the outcome of a minimum clinically successful therapy and to establish a predictive model of extracorporeal shock wave therapy (ESWT) in managing patients with chronic plantar fasciitis.

 http://dx.doi.org/10.1016/j.apmr.2017.05.016

This study establishes a new and accurate predictive model for the efficacy of ESWT in managing patients with chronic plantar fasciitis. The use of these parameters, in the form of a predictive model for ESWT efficacy, has the potential to improve decision-making in the application of ESWT.

 

Effect of Extracorporeal Shockwave Therapy Versus Intra-articular Injections of Hyaluronic Acid for the Treatment of Knee Osteoarthritis

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Study has limitations for sure, placebo, sample size and indeed energy selection. However, ESWT and intra-articular HA therapy are effective in alleviating pain and improving physical functions in patients with knee OA. Statistically, no significant differences in curative effects were observed between the two treatments. Therefore, ESWT can be considered another option that is as effective as intra-articular HA injections for treating knee OA.

 https://doi.org/10.5535/arm.2017.41.5.828 

https://www.ncbi.nlm.nih.gov/pubmed/23953895 ( Zhao's study Dec 13 )

 

Analgesic Effect of ESWT Combined with Fascial Manipulation Theory for Adhesive Capsulitis of the Shoulder: A Retrospective Study

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Understand this study but honestly prefer ESWT as a stand alone treatment. Fascial work has on its own some really good RCTs in this study the ESWT followed fascial theory local and distally. Notable pain and slight functional improvement was achieved through this ESWT-FM.

I tend to use ESWT in late stage and get good results thereto, excellent with Diabetic patients

https://doi.org/10.1155/2018/3450940

 

Comparative Effectiveness of Radial Extracorporeal Shockwave Therapy and Ultrasound-Guided Local Corticosteroid Injection Treatment for Plantar Fascii

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This was floating around last week on Twitter, worth a share for sure and not surprise from the JAPMA.

http://www.japmaonline.org/doi/abs/10.7547/14-114

Conclusions: Both rESWT and corticosteroid injection therapy are effective modalities for treatment of chronic plantar fasciitis. However, rESWT seems to be superior to corticosteroid injection therapy due to its longer duration of action.

 

Comparison of single-dose radial extracorporeal shock wave and local corticosteroid injection for treatment of carpal tunnel syndrome

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Good news for mild-moderate severe CTS, for RSWT users, similar to results from London Olympics. See EMS for this info.

https://doi.org/10.1186/s12891-018-1948-3

Recent studies have reported that radial extracorporeal shock wave therapy (rESWT) reduces pain and improves function in patients with mild to moderately severe carpal tunnel syndrome (CTS) compared to a placebo. However, most of those studies used multi-session rESWT combined with wrist support and evaluation of efficacy was limited to a maximum of 14 weeks.

There was significantly greater improvement in symptom severity scores, functional scores and Boston questionnaire scores at weeks 12 to 24 in the rESWT group compared to the LCsI group. When compared to the baseline, there was significant reduction of VAS and functional score in the rESWT group at weeks 12 and 24. The LCsI group had no statistically significant differences in VAS reduction and functional score of the same period.

Conclusions

Treatment of CTS using single-dose rESWT has a carry-over effect lasting up to 24 weeks suggesting that single-dose rESWT is appropriate for treatment of mild to moderate CTS and provides longer-lasting benefits than LCsI.


What to watch out for...

There's some really intersting news on a new development for Shockwave in the UK happening in March. Stay tuned and I'll update you as soon as I can.

I'm also seeing more and more social reports and comments on Shockwave which can only be a good thing around the world. It's great that more people are starting to spread the word.

Lastly, a great testimonial from Triston James, European Jiu Jitsu Gold Medalist, about his success after treatment.
It's great to see the perspective of patients already in tune with their bodies, like sports professionals.

 

 

Happy New Year, 2018's first Blog

I hope that you all had some quality time out with the family and now recharged. Im not sure that if your like me after time out its difficult and harder to get going following the New Years break, but it takes decisions, start strong and plan for a better year.

With respect to Shockwave the end of the year presented with some nice papers on the upper and lowerlimbs, my new website www.shockwave-therapy.co.uk was launched and indeed this blog. By the way appreciate those kind works on the efforts and looking forward to sharing continued studies and posts with you all.

Also one very exciting postive move is that been asked to get involved Knee studies using Focused and Radial. Not cleared yet but think O/A and P/T chronic tendinopathies, without question will let you know how I get on.

One area that gave me much pleasure in receiving was the latest info from EMS regarding PEDro which is a free database of over 29,000 randomized trials, systematic reviews and clinical practice guidelines provided by the George Institute for Global Health in Sydney.

Hers the link http://shockwave-therapy.co.uk/peer-reviews/  

 30/45 of the randomized controlled trials (RCTs)2 on rESWT listed in the PEDro database3, 4 were performed with the Swiss DolorClast®
> In 80% of these studies, the Swiss DolorClast® resulted in better clinical outcome than the control group
> In the remaining 20% of these studies either not enough energy was applied5 or patients with indications not approved for the Swiss DolorClast® were included

So if your a clinican and looking to get into shockwave therapy then this should speak volumes.

Heres to a great year, Happy Shockwaving just like the Pro Body Builder below who really enjoys Shockwave ( as if,)  just likes the results !

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9 Things you didn’t know about ESWT Shockwave Therapy

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IT’S NON INVASIVE
Shockwave Therapy can be used to treat longstanding pain and discomfort. We use an EMS Swiss DolorClast shockwave machine. A hand-held device is moved over a conductive gel on the skin to send waves of energy to painful areas in the body. These mechanical pressure pulses – known as shockwaves - work by reinjuring tendons and tissues, which in turn stimulates blood flow helping problem areas to heal (neoangiogenesis).

 

IT’S RISK FREE
Shockwave Therapy requires no surgery which means there’s no chance of infection and there’s very littlerisk of tendon rupture, which may occasionally occur with steroid injections. There’s no need to take medication. It’s a wonderful technique to consider if all your other treatment options have failed.
The Shockwave Solution

 

 

IT’S NOT JUST FOR TENDON INJURIES
Yes Shockwave Therapy can be used to treat pain in areas such as the achilles tendon, but evidence shows it can help other conditions from Peyronie’s Disease (bent penis syndrome) to refractory plantar fasciitis (Policeman's Heel) and even help reduce the appearance of cellulite! It’s also great for chronic shoulder pain (calcific tendonitis of the shoulder), and hip bursitis inflammation around the outside of the hip joints, which can cause people discomfort on one side when they lie down or try to do certain exercises.

IT’S NOT TIME CONSUMING
A course of 3 sessions is generally needed but the sessions only last 15 minutes and after treatment you can go about your daily business. Exercises may be given at the end but it is inadvisable to participate in sport until your practitioner has given you the all clear.

THERE’S MORE THAN ONE OPTION:

FOCUSED SHOCKWAVE: This is generally used to treat targeted deep-rooted painful conditions and is particularly useful for joint related problems. The device uses piezoceramic crystals to generate a pressure wave through the tissue into the target area at a depth of 8cm. This creates cavitation bubbles which collapse, creating a secondary shockwave. This approach is less painful than the radial option.

 
 

RADIAL SHOCKWAVE: This is ideal for 90% of the problems we see in clinic. For example, soft tissue/ tendons which are more superficial. In fact some studies have shown this treatment can help with osteoarthritis and bone healing such as delayed non-union fractures. This process works in the same way as the Focused approach except the Radial shockwave does not penetrate as deep and therefore its use is considered for more superficial conditions. 

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IT’S USED BY ATHLETES
Some of the best sports teams in the world including The AC Milan football club and its scientific research centre, the Milan Lab, have researched and used Shockwave Therapy as a way of keeping their athletes in peak condition.

 

IT’S APPROVED FOR USE IN THE UK
NICE (the National Institute for Health and Care Excellence) has reviewed Extracorporeal Shockwave Therapy (ESTW) and approved its use in the treatment of six conditions. The machine we use is on a number of databases around the world such as PEDro. 80% of randomised controlled studies featured on PEDro, have been undertaken using the Swiss DolorClast machine. 

IT’S NOT AS EXPENSIVE AS YOU MIGHT THINK
A full consultation will be given. If you are deemed suitable for a course of Shockwave Therapy, then the cost of three sessions including the consultation is £600. If you are not considered suitable for the treatment, then the consultation fee is £65. Would you put a price on becoming pain free? 

 

INSTANT ACCESS FROM AN EXPERT ON YOUR DOORSTEP

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This treatment should only be performed by an expert practitioner with an understanding of the underlying adverse biomechanics of the body to ensure the results are the best they can be. Step in Paul Morrissey. Author of ‘The Shockwave Solution – The Non-Surgical Answer to Becoming Pain Free’. Paul has treated patients using Shockwave Therapy for the past 14 years. He’s also an ambassador and qualified trainer for EMS. And the best part is there’s no waiting list. Book an appointment today.