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JHOME RUIDI Extracorporeal Shockwave Therapy

Time：2023-03-07 Click：370

Extracorporeal Shockwave Therapy (ESWT)

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History of Extracorporeal Shockwave Therapy

Extracorporeal Shockwave Therapy (ESWT) otherwise referred to as shockwave therapy, was first introduced into clinical practice in 1982 for the management of urologic conditions [1]. The success of this technology for the treatment of urinary stones quickly made it a first-line, noninvasive, and effective method [2]. Subsequently, ESWT was studied in orthopedics where it was identified that it could loosen the cement in total hip arthroplasty revisions[3]. Further, animal studies conducted in the 1980s revealed that ESWT could augment the bone-cement interface, enhance osteogenic response and improve fracture healing [4][5]. While shockwave therapy has been shown to be beneficial in fracture healing, most orthopedic research has focused on upper and lower extremity tendinopathies, fasciopathies, and soft tissue conditions.

Physiology of ESWT

Shockwaves are sound waves that have specific physical characteristics, including nonlinearity, high peak pressure followed by low tensile amplitude, short rise time, and short duration (10 ms). They have a single pulse, a wide frequency range (0-20 MHz), and a high pressure amplitude (0-120 MPa)

These characteristics produce a positive and negative phase of shockwave. The positive phase produces direct mechanical forces, whereas the negative phase generates cavitation and gas bubbles that subsequently implode at high speeds, generating a second wave of shockwaves.[6]

In comparison to ultrasound waves, the shockwave peak pressure is approximately 1000 times greater than the peak pressure of an ultrasound wave.[7]

Mechanism of Action

The effects of ESWT treatment are unknown[8]. However, the proposed mechanisms of action for ESWT include the following: promote neovascularization at the tendon-bone junction [9], stimulate proliferation of tenocytes [10] and osteoprogenitor differentiation [11], increase leukocyte infiltration [12], and amplify growth factor and protein synthesis to stimulate collagen synthesis and tissue remodeling [10] [11] [13] [14].

Principles of Shockwave Therapy

Shockwaves are transient pressure disturbances that propagate rapidly in three-dimensional space. They are associated with a sudden rise from ambient pressure to their maximum pressure. Significant tissue effects include cavitation, which are consequent to the negative phase of the wave propagation.

Direct shockwave and indirect cavitation effects cause hematoma formation and focal cell death, which then stimulate new bone or tissue formation.

Indications for Shockwave Therapy

Shockwave therapy is primarily used in the treatment of common musculoskeletal conditions. These include:

There is no standardized ESWT protocol for the treatment of musculoskeletal conditions.

Contraindications to ESWT in Physiotherapy

  1. Pregnancy
  2. Over major blood vessels and nerves
  3. Pacemakers or other implanted devices
  4. Open wounds
  5. Joint replacements
  6. Epiphysis
  7. Blood clotting disorders including thrombosis
  8. Infection
  9. Cancerous tissues
  10. A compromised mental status of the patient and/or the inability to cooperate.

Differences between ESWT and Therapeutic Ultrasound

  • Therapeutic ultrasound utilises high frequency sound waves, while ESWT utilises lower frequency waves.
  • Ultrasound may produce either thermal or non-thermal effects in tissues, while ESWT does not result in heating effects.

Similarities between Therapeutic Ultrasound and ESWT

  • Both modalities employ acoustic waves to produce therapeutic benefits.
  • They both make use of a coupling medium to transmit sound waves to the tissues being treated.
  • They are both non-invasive forms of treatment.

Evidence-based

According to a study performed by Rompe and coworkers[17], stretching exercises in combination with radial shock wave therapy is more efficient for the treatment of chronic symptoms of proximal plantar fasciopathy than repetitive radial pressure wave therapy alone. Patients were subjected to three sessions of 2000 radial pressure pulses (EFD = 0.16 mJ/mm 2) in weekly intervals, generated with a ballistic device (air compressor pressure 4 bar; rate 8 Hz) manufactured by Electro Medical Systems.

  • Tendinopathy of the Shoulder.png

A study to investigate the clinical outcomes of ESWT on calcaneal spurs of 108 patients and its correlation with radiologic changes were reported by Yalcin et al. [18]. All the patients underwent radial pressure wave therapy once a week for 5 weeks (2000 pressure waves starting at an EFD of 0.05 mJ/mm 2 and increasing up to 0.4 mJ/mm 2). After the therapy, approximately 67 % of the patients reported no pain; however, there was no correlation between clinical outcome and radiologic changes. The authors concluded that even without radiologic change.

Related articles
Tendinopathy Treatment Adjuncts - PhysiopediaIntroduction On this page we are going to look at the different types of treatment in adjunct to exercises / rehabilitation . We will explain each method with a summary of each treatment and link to some more evidence for you to read. Extracorporeal Shockwave Therapy (ESWT)[edit | edit source] ESWT has been researched as a conservative treatment option for various tendinopathies.[1][2][3][4] There is conflicting evidence for and against its use. ESWT is when high energy acoustic pressure waves are delivered to the affected area. This is done through a probe that touches the skin similar to an ultrasound head. The evidence for use is only recommended in certain chronic/degenerative tendons with the idea that this treatment can reverse the degenerative process and take the tendon back into the acute stage to stimulate the healing process again.  There are a couple of drawback with this treatment, that the treatment itself can be painful but also the machine is very costly.  Have a futher look into the research here:  A systematic review for shockwave therapies in soft tissue conditions: focusing on the evidence  Extracorporeal shockwave therapy for patella tendinopathy: A review of the litrature  ESWT in the management of patella tendinopathy  The effectiveness of extracorporeal shockwave therapy in lower limb tendinopathy: A systematic review  Glyceryl Trinitrate (GTN)[edit | edit source] Tropical glyceryl trinitrate (GTN) has been used in the past to treat tendinopathy. The theory behind the use of GTN is that it stimulates healing within the tendon by increasing the amount of nitric oxide. It is said to induce the reaction of fibroblast proliferation, collagen synthesis and contraction of collagen lattices.[5] There is some conflict in the research with the use of GTN and as with all research, further research needs to be done to withdraw conclusion. But you can read some of the articles here:  Tropical glyceryl trinitrate treatment of chronic patella tendinopathy; A randomised, double blinded placebo-controlled clinical trial  50 Recalcitrant Achilles Tendinopathy Treated With Exercise And Glyceryl Trinitrate: A Case Report Randomised, double-blind, placebo-controlled clinical trial of a new topical glyceryl trinitrate patch for chronic lateral epicondylosis Ultrasound Electrotherapy[edit | edit source] Ultrasound in a very common treatment modality. It is a non invasive procedure which involves sending soundwaves at different depths and rates into the tissue to atempt to have a physiological affect and aid in the healing process. There are many articles on the use of electrotherapy and ultrasound any of which not if favour. The BC Physical Therapy Tendinopathy Taskforce recently did an extensive litrature serach on the effectivness of treatments on tendinopathy, ultrasound was one of these modalities. They came to the conclusion that there was no evidence to support the use of ultrasound in the acute phase but this could be physiologically reasoned, but for the more chronic phase neither could be supported. Some of the research is here: Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon Splints, Orthotics and Taping  [edit | edit source] Splints and Introduction to Orthotics can be used alongside other treatments for tendinopathy. There is research looking at foot orthosis, tennis elbow clasps and taping in tendinopathy. Research does not suggest that orthotics or taping alone will treat the poblem, they may assist in the management as an adjunct. For example a heel lift may off load an achilles tendinopathy for pain management, but the appropriate rehabilitation is still required which you can read about here. Some articles of interest are listed below: Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial Cost effectiveness of brace, physiotherapy, or both for treatment of tennis elbow Effects of taping on pain, grip strength and wrist extension force in patients with tennis elbow The efficacy of taping for the rotator cuss tendinopathy: A systematic review and meta-analysis Injections [edit | edit source] Corticosteroid injections are a common treatment modality for tendinopathy, but do they work? Looking at the research different methodology is used therefore this makes studies hard to compare, leaving gaps in the research. More current research suggests that initially injections may be beneficial but in the intermediate and long term other treatments may be more beneficial. There has been a high incidence in reoccurance of symptoms after injection. So does it have it's place? Potentially when working with high level athletes if they have a competition or a game, but this still is not a full gone conclusion and is just based on clinical reasoning with all the risks of an invasive procedure and no long term benefits known, although is reccommended in British Medical Journal for many tendinopathies.[6] Take a look at the research below to inform your clinical reasoning.  Corticosteroid Injections for Common Musculoskeletal Conditions The challenge of managing tendinopathy in competing athletes Corticosteroid and other injections in the management of tendinopathies: a review Acupuncture[edit | edit source] Acupuncture is an area of controversy as randomised controlled blinded studies can be nearly impossible to elicit as patient who undergo a placebo acupuncture with placebo needles or other method which include applying pressure to the acupuncture spot can elict a similar response as an acupuncture needle through acupresure, an important point to consider when resding the methodology. Acupuncture has been show effective in treating the pain in patients with tendinopathy both acute and chronic. So possibly a worth while adjunct to our rehabilitation. Here is some of the research which may help you in your clinical reasoning.  Acupuncture for chronic Achilles tendnopathy: a randomized controlled study Is there a role for acupuncture in the treatment of tendinopathy? Randomised clinical trial comparing the effects of acupuncture and a newly designed placebo needle in rotator cuff tendinitis Effects of acupuncture and placebo TENS in addition to exercise in treatment of rotator cuff tendinitis Manual Therapy and Massage [edit | edit source] A skill which is used throughout physiotherapy - whether it is mobilising a joint, mobilising soft tissue, deep transverse friction massage or general soft tissue massage. Clinically reasoned throughout our treatments, but does it apply to tendinopathy? Evidence has suggested that manual therapy may help to decrease pain from sources of which are potentially biased and other research suggests massage has no greater effect of symptoms than other treatment modalities. Many reviews have been conducted to look at the effectiveness of hands on treatments: The Efficacy Of The Use Of Manual Therapy In The Management Of Tendinopathy: A Systematic Review Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial Dry Needling[edit | edit source] Dry needling is another potential treatment for Tendinopathy. A combined therapy of dry needling with percutaneous hydrostatic decompression yielded promising outcomes in terms of pain and function. However, in a recent cohort study, a high-volume image-guided injection (HVIGI) without dry needling compared with a lower volume of HVIGI with dry needling resulted in greater improvement in managing Tendinopathy[7] https://www.ncbi.nlm.nih.gov/pubmed/27286927 https://www.deepdyve.com/lp/springer-journals/ultrasound-guided-dry-needling-with-percutaneous-paratenon-Ix80T1BKCF Non-Steroidal Anti-Inflammatory Drug NSAIDs[edit | edit source] Current reasearch suggests that inital short term does of NSAIDs may help with pain relief and assist with the compliance of physiotherapy but have no longer term affects on tendinopathy. NSAIDs are a topic for discussion when it comes to tendinopathies, as in the title of nonsteroidal ANTI-INFLAMMATORY drug, when the whole discussion of inflammation within tendinopathy is debatable. If it helps in the short term with pain, is this debate and discussion necessary or just something to be aware of? Have a further read in some of the journals below and see what you think. Current Opinions on Tendinopathy The efficacy of oral non-steroidal anti-inflammatory drugs for rotator cuff tendinopathy: a systematic review and meta-analysis Tendons – time to revisit inflammation Platelet-enriched Plasma (PRP) injection therapy[edit | edit source] High concentrations of platelets and growth factors in platelet-enriched plasma (PRP) injections is believed to promote tendon repair and inhibit pain.[8] PRP is made by extracting blood from the patient, centrifuging the sample and separating it into components to return platelets to the donor's effected tendon. Evidence is patchy however some success has been reported in the treatment of patella tendiopathy, lateral epicondylitis and plantar fasciopathy. PRP therapy is also being used to treat acute muscle injuries with ongoing research underway [9][10] Blood Flow Restriction Training (BFRT) therapy[edit | edit source] Although currently there is limited evidence to support BFRT in the upper limb, there are a number of case studies being published that have seen positive results in treating upper limb tendinopathy.[11] BFRT is also known as tissue flossing. BFRT, or tissue flossing, involves applying an external pressure above or below a muscle or joint of the extremities, typically by using a circumferential, elastic band. The pressure provided by the coiled band safely maintains arterial inflow of blood but reduces or occludes venous outflow distal to the site. Read more about BFRT here.Knee Electrotherapy - Physiopedia Introduction This page will look at popular methods of electrotherapy and the evidence to support it in the use of knee conditons specifically.  Pulsed Shortwave Therapy [edit | edit source] Pulsed shortwave therapy is an electrotherapy modality that is used in practice, and there are 2 types off effects suggested. Electric field – upon literature reviewing there is very little evidence to support this theory, and almost all of the literature supports the magnetic field effect. Magnetic field – the main effect of the pulsed magnetic field has been documented to work at a cellular level at the cell membrane. It has been suggested to assist in the transportation of ions across the membrane. The effects are said to be in the acute and inflammatory process and documented effects are on: Muscles Nerves Areas of oedema Haematosis Effusion [1] Therefore this would suggest that the use of pulse short wave therapy in knee conditions that resulted in effusions and oedema is effective: i.e. ligamentous injuries, arthritis and meniscal lesions, as these can all produce inflammation and swelling. A study in 2010 by Al – Mandeel and Watson found that there were significant physiological changes (blood volume) through the use of low and high doses of pulsed shortwave therapy. Limitations of this study was that this was done in healthy subjects therefore there were no pathology within the joint and people with excess adipose tissue were excluded as this was identified to effect the effectiveness of the therapy. (Level of evidence: 2b) [2] Whereas Callaghan et al in 2005 looked at the effects of PSWT on levels of inflammation in patients with OA knee. The primary outcome used was sophisticated radioleucoscintigraphy to identify levels of inflammations pre and post treatments. They found that there was little inflammation in those with OA knee to start with but that there was no significant change in their levels after PSWT. (Level of evidence: 1b) [3] The National Institute for Clinical Excellence (NICE) has not recommended the used of PSWT for OA but the use of TENS as an adjunct only. (Level of evidence: 1a) [4] There is limited evidence looking at the effect of PSWT on knee conditions specifically, therefore a search was conducted on the effectiveness of PSWT on oedema and effusions, a study was identified that looked that the use of cryotherapy versus PSWT on swelling post calcaneal fractures. There were no differences found in either group and swelling had significantly improve by day 5 anyway. Cryotherapy was recommended from this study as this was a cheaper alternative which could be transported anywhere. (Level of evidence: 4) [5] The majority of the literature surrounding the used of PSWT in the knee looks at Knee OA, and due to the lack of evidence found it and guidance from NICE the use of PSWT cannot be recommended from the literature. This Physiopedia page looks at the suggested effects of PSWT  Transcutaneous Electrical Nerve Stimulation (TENS)[edit | edit source] TENS is a method of electrical stimulation which primarily aims to provide a degree of symptomatic pain relief by exciting sensory nerves and thereby stimulating either the pain gate mechanism and/or the endogenous opioid system.  Pain relief using a TENS machine with 'the pain gate' theory involves excitation of the 'A beta (Aβ) sensory fibres, and by doing so, reduces the transmission of the noxious stimulus from the ‘c’ fibres, through the spinal cord and hence on to the higher centres. The Aβ fibres appear to appreciate being stimulated at a relatively high rate (in the order of 90 - 130 Hz or pps). It is difficult to find support for the concept that there is a single frequency that works best for every patient, but this range appears to cover the majority of individuals.' [6] [7] 'An alternative approach is to stimulate the A delta (Aδ) fibres which respond preferentially to a much lower rate of stimulation (in the order of 2 - 5 Hz), which will activate the opioid mechanisms, and provide pain relief by causing the release of an endogenous opiate (encephalin) in the spinal cord which will reduce the activation of the noxious sensory pathways.'[8][9] Although with all of the new research evolving about pain neuroscience the 'pain gate theory' is now being challenged. [10]It was initially developed in 1965 by Ronald Melzack and Patrick Wall, to which Wall had later said: “The least, and perhaps the best, that can be said for the 1965 paper is that it provoked discussion and experiment”[11] A lot of the research for the use of TENS to manage pain has been focused on chronic pain, therefore a Cochrane review was done in 2000 which concluded that TENS could not be recommended for general chronic pain management at this stage due to the lack of consistent stimulation parameters or comments on long-term effectiveness.[12] Although a protocol has been published in 2015 for a more upto date review of the literature in the use of TENS as a pain management tool.[13] Although there is still the debate as to whether the use of TENS in chronic pain is effective, NICE and Arthritis UK have recommended this as an adjunct to other treatments.(Level of evidence: 1a)[14][15] A more recent Cochrane review has looked at the use of TENS in the acute stages of pain and has evaluated that all studies reviews have found it beneficial there were lots of flaws to their studies such as high risk of bias, poor sample sizes, incomplete results reported and unsuccessful blinding,[16] therefore this needs to be taken into consideration when looking at the evidence but possibly something that can be used as an adjunct again with patients who have acute knee pain.  Research is limited in the field of TENS and specific knee complaints therefore it is recommended that current research around the use of TENS for pain and clinical reasoning is used.  Ultrasound (US)[edit | edit source] Therapeutic US is divided into two effects: thermal and non-thermal, but each effect can occur at any one treatment. It has been suggested that US can help speed up and improve the quality of tissue healing. [17] To read more on how US can help at the different stages of healing read this Physiopedia page. Around the knee the tissue that may be influenced by US are the patellar tendon and the ligaments. Looking at pathologies of the tendon (tendinopathy) and the effectiveness of therapeutic US there is little evidence which has specifically evaluated this, therefore a search was conducted looking further afield. There have in vivo and in vitro studies and studies on animal tissue which showed positive physiological changes in tendinopathy using US but there has yet to be any positive results using live human tissue [18]. This is confimed by a systematic review and meta analysis which was published in 2015 looking at the treatment of tendinopathy in the shoulder. They found that there were no good quality studies to base recommendation on this as a treatment modality therefore recommendation was made that US should not be used as a treatment. (Level of evidence: 1a) [19] It can only be concluded that evidence is lacking in proving the efficacy of US as a treatment modality for tendinopathy such as patella tendinopathy.  Soft tissue injuries such as ligamentous injuries have historically been treated with therapeutic US, a study which looked at the MCL in rats and has shown that low-intensity pulsed ultrasound exposure is effective for enhancing the early healing of medial collateral ligament injuries. (Level of evidence: 3b).[20] Again when the research is then applied to the human population it has it's pitfalls as highlighted by Robertson and Baker in 2001 where they found that there was little evidence that therapeutic US is more effective than placebo ultrasound, for not only treating ligamentous pathologies but with patient who are in pain or a range of musculoskeletal injuries or for promoting soft tissue healing.(Level of evidence: 1a) [21] This was then clarified later in 2005 by Zammit and Herrington who specifically looked at the management of lateral ankle ligament sprains. They found no added benefit of using US at a set dose for lateral ligament ankle sprains.(Level of evidence: 1b)[22] Overall from the literature reviewed including RTC's, Systematic reviews and meta analysis it cannot be concluded that therapeutic US is of benefit to soft tissue repair, patella tendinopathy or ligamentous sprains in humans.  Extracorporeal Shock Wave Therapy (ESWT)[edit | edit source] "Shockwave therapy is essentially a large-amplitude compression wave, as that produced by an explosion or by supersonic motion of a body in a medium. Just like an ultrasound wave, the shock wave consists of a high pressure phase followed by a low pressure (or relaxation) phase. When a shock wave reaches a 'boundary', some of the energy will be reflected and some transmitted." [23] The research began with looking at calcific tendons and bone healing, where as today this has moved onto chronic tendon and ligament problems. [24] In 2009 NICE acknowledged that ESWT as a treatment modality for achillies tendinopathy (Level of evidence: 1a)[25]. Diehl et al, found that ESWT as a treatment for achillies tendinopathy demonstrated promising results but felt that long term studies were needed to fully evaluate their effectiveness. [26] Rees et al 2009, suggested from their review of the literature that ESWT had been shown to be more beneficial in international and calcific tendinopathies. (Level of evidence: 1a)[27] At this point all the literature was looking promising for the treatment of tendinopathy and calcific tendons, although the majority of the research had been done in the achilles tendon, it is possible to draw conclusion and apply elsewhere such as the patellar tendon. Then in 2014 van der Worp did a RCT to look at the different types of shockwave therapy in treating patellar tendinopathy. They found that there was no difference between the group who received focused or radial shockwave therapy, but that all of the participants had improved. (Level of evidence: 1b) [28] Conflicting this; van der Worp was involved in research some previous years in 2011 where they found there was no effect of ESWT as a solitary treatment during the competitive season, and has no benefit over placebo treatment (Level of evidence: 1b) [29]. Thijset al 2016 was in agreement from their study that there was no added benefit of using ESWT in participants with patellar tentindopathy, although they did highlight that they only had a small sample size, therefore is not a true representation of the population.(Level of evidence: 1b) [30] Similarly was Park et al 2016, who looked at the use of ESWT in calcific and non calcific lateral epicondylopathy. (Level of evidence: 2b) [31] In summary ESWT has conflicting evidence, there is some evidence to suggest that use in soft tissue complaints such as international or calcific tendinopathy may be beneficial, whereas other evidence conflicts that. ESWT is a painful / uncomfortable experience, that is expensive with confliting research therefore clinical reasoning and critiquing the literature is essential. Summary[edit | edit source] In summary the literature for supporting electrotherapy within knee pathologies is variable. The only guidelines that suggests the use of electrotherapy for a knee complaint is the use of TENS in knee OA. Pulsed shortwave therapy has limited evidence to support it's use in the management of tissue healing and the evidence that is available is of poor quality and conflicting, similarly to ultrasound and ESWT. The use of TENS is possibly the strongest evidence of all in pain management but the theory itself is under criticism, through the volume of literature surrounding pain neuroscience.  There is a selection of evidence quoted and carried out by electrotherapy.org with references that are unobtainable; therefore they have not been taken into consideration in creation of this page. It would be beneficial to critique this literature, as this group of researchers highly promote the use and effectiveness of electrotherapy. Ultimately the use of electrotherapy in the treatment of knee pathologies needs to be evaluated and clinically reasoned by the clinician prior to use, being  aware of all of the appropriate contraindications and precautions. Therapeutic Modalities - PhysiopediaIntroduction Therapeutic modalities refer to the administration of thermal, mechanical, electromagnetic and light energies for therapeutic purposes. [1] They are commonly used by physiotherapists to help their patients/clients achieve therapy goals [2]: pain relief or modulation reduce inflammation improve circulation tissue healing scar tissue remodelling skin condition treatment increase ROM enhance muscle activation decrease unwanted muscular activity preservation of strength after injury or surgery reduction or elimination of oedema [3] Therapeutic modalities have been a part of physiotherapy-used modalities for decades.[4] They are commonly used with other physiotherapy tools e.g. exercise, manual techniques, patient education, and although there is some evidence that different patients may benefit from different modalities, it is suggested that they should not be used as stand-alone treatment. [5] The term "therapeutic modalities" is often used interchangeably with the term "electrophysical agents" to describe all interventions that create physiological therapeutic effects. [1] Examples of therapeutic modalities include: Electrical stimulation / Iontophoresis Biofeedback Thermotherapy (superficial or deep) Cryotherapy Ultrasound / Phonophoresis Extracorporeal Shockwave Therapy (ESWT) Laser therapy Magnetic therapy Massage Mechanical traction Clinical guidelines argue for the use of therapeutic modalities according to various grades of evidence. [6] However, the choice of which modality to use may depend on a specific condition, clinician's preferences and patient's needs and goals. [7] This page will look at the rationale for use of a modality and its safety considerations. For further information about therapeutic modalities, see the following pages: Transcutaneous electrical nerve stimulation Interferential current Biofeedback Thermotherapy Infrared therapy Tecar Therapy Cryotherapy Ultrasound Extracorporeal Shockwave Therapy Low Level Laser Therapy High Power Laser Therapy Transcranial Magnetic Stimulation Massage Lumbar Mechanical Traction Electrical Stimulation[edit | edit source] Electrical stimulating currents such as transcutaneous electrical nerve stimulation (TENS) and interferential current (IFC) utilize electrical energy, the flow of electrons or other charged particles from one area to another, causing depolarization of muscle or nervous tissue. Electrical stimulation has most commonly been used for the modulation of pain through stimulation of cutaneous sensory nerves and the following analgesic mechanisms:[8] Activation of large diameter A-beta fibers inhibits the pain transmission, carried by A-delta and C afferent fibers, from the spinal cord to the brain - also known as the gate control theory of pain Stimulation of A-delta and C fibers causes the release of endogenous opioids (endorphin and enkephalin) resulting in prolonged activation of descending analgesic pathways Iontophoresis refers to the introduction of ions into the body tissues by means of a direct electrical current. [9] The rationale behind this technique is that the therapeutic effects of a drug may be maximised while minimising possible adverse reactions. [9] Contraindications Precautions Risks  Deep venous thrombosis or thrombophlebitis Hemorrhagic conditions Pregnancy Eyes, anterior neck, carotid sinus, head, reproductive organs Impaired cognition or communication Regenerating nerves Cardiac failure (local) Damaged or at-risk skin (local) Infection or tuberculosis (local) Malignancy (local) Recently radiated tissue (local) Electronic device (local) Impaired sensation (local) Active epiphysis Skin disease Impaired circulation Chest, heart Pain Skin irritation Surge [8] Additional considerations Test sensory integrity prior to application by asking patients to differentiate between light touch and painful stimuli Tissue with high resistance to electrical current include skin, bone, and necrotic tissue - electrodes should not be placed directly over bony prominences Factors increasing skin impedance include the presence of hair and oil, and cooler skin temperatures Applying IFC or TENS in combination with a thermal modality is not recommended as it increases the likelihood of an adverse effect Large electrodes are more comfortable and allow current to travel deeper but the target is less specific - only large electrodes should be used with medium frequencies (IFC) to disperse the current Placing electrodes further apart will allow the current to travel deeper - at least 1 inch apart for pain control With any electrical device, increasing the intensity will first cause an electrical sensation followed by a motor response and finally noxious stimuli Remember that the modulation of pain is not treating the cause of pain [8] Biofeedback[edit | edit source] Biofeedback uses visual, physical, auditory feedback in real-time as a way to better control body functions and thus, maximise patient performance. [10] There are different types of biofeedback, with their applications varying in the clinical setting. [11] As a technique, it is generally considered safe and there are no absolute contraindications. [12] However, the patient must be able to comprehend and follow commands in order to actively participate in the process. This is possibly the reason why biofeedback should be used with caution in acute psychiatric episodes. [13] Patients will complete paralysis are also not suitable candidates for this modality. Thermal Energy [edit | edit source] Thermotherapy and cryotherapy, the application of therapeutic heat and cold, are referred to as conductive modalities - they utilise the conduction of thermal energy to produce a local and occasionally a generalised heating or cooling of superficial tissues with a maximum depth of penetration of 1 cm or less.[8] Thermotherapy[edit | edit source] Thermotherapy can involve the use of superficial or deep tissue thermal energy to induce a specific biological response. Superficial heating may be induced by a warm whirlpool, warm hydrocollator packs, paraffin baths, sauna, infrared radiation and fluidotherapy. Deep tissue heating involves the use of modalities such as ultrasound, radiowave, microwave and Tecar diathermies. Primary physiological effects of heat include:[8] Vasodilation and increased blood flow Increased metabolic rate Relaxation of muscle spasm Pain relief via the gate-control mechanism and reduced ischemia Increased elasticity of connective tissue It also works by stimulating fibroblast proliferation[14], accelerating endothelial cell proliferation[15], and improved phagocytic activity of inflammatory cells[16]. Heat is believed to have a relaxing effect on muscle tone by reducing muscle spindle and gamma efferent firing rates; there is also the theory that relaxation of muscle is assumed to occur with the disappearance of pain.[8] Contraindications Precautions Risks  Deep venous thrombosis or thrombophlebitis Hemorrhagic conditions Reproductive organs Impaired cognition or communication Acute injury or inflammation (local) Impaired circulation or sensation (local) Damaged or at-risk skin (local) Infection or tuberculosis (local) Malignancy (local) Recently radiated tissue (local) Skin disease (local) Active epiphysis Cardiac insufficiency or failure Pregnancy Eyes, anterior neck, carotid sinus Metal (jewelry, metal implants or staples, bullets) Topical irritants Burn Fainting or dizziness (vaso-vagal response) Bleeding (open wounds) Additional Considerations Test sensory integrity by asking patients to differentiate between hot and cold stimuli Wrap heating pads in 6 - 8 layers of toweling to protect the skin from burns Check patient after initial 5 minutes for excessive redness, blistering, signs of burning, generalised sweating (increased core temperature) Risk of burn increases with decrease in the amount of subcutaneous fat because fat serves as an insulator Patients should not lie on top of hot packs or pads as pressure that compresses skin capillaries compromises the normal vasodilator response Cryotherapy[edit | edit source] Cryotherapy includes ice massage, cold hydrocollator packs, cold whirlpool, cold spray, contrast baths, ice immersion, cold compression, and cryokinetics, Primary physiological effects of cold include:[8] Vasoconstriction and decreased blood flow (within first 15 - 20 minutes) Decreased metabolic rate Pain relief with decreased muscle spasm via gate-control mechanism and decreased nerve conduction velocity Restriction of local blood flow reduces the potential for edema to develop. Slower metabolism releases fewer inflammatory mediators, reduces edema formation and decreases oxygen demand of tissues to minimize their chances of further injury from ischemia.[17][18] Cold decreases local neural activity, appears to raise the threshold stimulus of muscle spindles and depresses the excitability of free nerve endings, resulting in an increased pain threshold and reduced muscle spasm.[19][20] Contraindications Precautions Risks  Deep venous thrombosis or thrombophlebitis Hemorrhagic conditions Chronic wound Impaired cognition or communication Cold hypersensitivity or urticaria Vasospastic pathology Cryoglobulinemia or hemoglobulinemia Anterior neck, carotid sinus, regenerating nerves Impaired circulation (local) Tuberculosis (local) Damaged or at-risk skin Cardiac failure Hypertension Impaired sensation Infection Eyes Superficial main branch of a nerve Frostbite Fainting (vaso-vagal response) Negative impact on nerves (superficial) Additional Considerations Test sensory integrity by asking patients to differentiate between hot and cold stimuli Cold has the greatest benefit in acute injuries - avoid cold if healing is delayed because it could further impair recovery Rate of skin cooling is reduced with a towel between the agent and skin - 1 or 2 layers of protection is sufficient Water has a higher conductivity than air – apply moisture to the towel Patient will report uncomfortable sensation of cold, stinging or burning, aching sensation, and complete numbness If core temperature is not maintained, reflex shivering results in increased tone Re-warming period should be at least twice as long as the treatment time (too frequent application increases likelihood of frostbite) Hierarchy of cooling, from most to least efficient, is as follows: ice immersion, crushed ice, frozen peas, gel pack – choose an agent with less cooling potential if the patient has risk factors for an adverse reaction Local pain awareness, proprioception, muscle strength, and agility are reduced immediately post-cryotherapy – caution in prescribing activity Also see page for cryotherapy guidelines. Ultrasound[edit | edit source] Ultrasound utilises sound energy, pressure waves created by the mechanical vibration of particles through a medium. The flow of ultrasound may be delivered as an uninterrupted stream (continuous mode) or delivered with periodic interruptions (pulsed mode). Ultrasound is classified as a deep heating modality capable of producing a temperature increase in tissues of considerable depth because it travels very well through homogenous tissue (e.g. fat tissue).[21][22] Traditionally it has been used for its thermal effects but it is capable of enhancing healing at the cellular level. Continuous ultrasound is most commonly used when thermal effects are desired but non-thermal effects will also occur.[23] It has been shown to alter all phases of tissue repair: stimulates phagocytic activity of inflammatory cells such as macrophages,[24] and promotes release of chemical mediators from inflammatory cells which attract and activate fibroblasts to the site of injury, stimulates and optimizes collagen production, organization and ultimately functional strength of scar tissue.[25] An examination of research studies to assess changes in blow flow with ultrasound produced inconclusive results; however, recent studies show that nitric oxide released by ultrasound therapy may be a potent stimulator of new blood vessel growth at the site of injury.[26] Ultrasound also aids in pain relief and the literature has proposed reduced conduction of pain transmission as a possible mechnism for the analgesic effects.[27] More recently, low-intensity pulsed ultrasound has been shown to accelerate the rate of healing of fresh fractures due to the enhancement of angiogenic, chondrogenic, and osteogenic activity.[28] Phonophoresis uses acoustic energy in the form of ultrasound to transfer molecules across the skin into the tissues. [8] Pulsed Ultrasound[edit | edit source] Contraindications Precautions Risks  Hemorrhagic conditions Eyes, anterior neck, carotid sinus, reproductive organs Electronic device Deep venous thrombosis or thrombophlebitis (local) Malignancy (local) Pregnancy (local) Tuberculosis (local) Recently radiated tissue (local) Active epiphysis Acute injury or inflammation Damaged or at-risk skin Infection Skin disease Impaired circulation or sensation Impaired cognition or communication Plastic or cement implants Regenerating nerves Pain Surge Continuous Ultrasound[edit | edit source] Contraindications Precautions Risks  Acute injury or inflammation Hemorrhagic conditions Impaired circulation or sensation Impaired cognition or communication Eyes, anterior neck, carotid sinus, reproductive organs Deep venous thrombosis or thrombophlebitis (local) Infection or tuberculosis (local) Malignancy (local) Recently radiated tissue (local) Pregnancy (local) Skin disease (local) e.g. psoriasis, eczema, etc. Electronic device (local) Plastic or cement implants (local) Active epiphysis Chronic wound Damaged or at-risk skin Regenerating nerves Burn Pain Surge Additional Considerations Test sensory integrity by asking patients to differentiate between hot and cold stimuli or between light touch and painful stimuli Avoid pre-treatment of the area with superficial heating or cooling agents - cumulative effect of a hot pack and ultrasound can lead to skin damage Recommended treatment is 2 – 3x the effective radiating area (ERA) Circular head movement produces more even delivery of ultrasound energy since hot spots are dissipated better To minimize the impedance difference at the steel/air interface, a suitable coupling medium must be utilized Best absorption of ultrasound energy in tendon, ligament, fascia, joint capsule and scar tissue [29]  Extracorporeal Shockwave Therapy (ESWT)[edit | edit source] ESWT involve the application of low frequency sound waves with specific parameters that produce significantly greater peak pressures than ultrasound waves. [30] Contraindications Precautions Risks Pregnancy Over major blood vessels and nerves Pacemakers or other implanted devices Joint replacements Open wounds Epiphysis Blood clotting disorders Infection Cancerous tissues Cooperation issues Osgood-Schlatter disease Sever's disease Redness Swelling Bruising Soreness Numbness Laser[edit | edit source] Light Amplification for the Stimulated Emission of Radiation (LASER) utilizes electromagnetic radiant energy, the movement of photons through space. The low-power or cold laser produces little or no thermal effects but seems to have some significant effect on soft-tissue and fracture healing as well as on pain management. Light at the wavelength typically employed in laser therapy is readily absorbed by enzymes, hemoglobin, fibroblasts, and neurologic tissue. Laser has been shown to stimulate cell degranulation causing the release of potent inflammatory mediators such as growth factors,[31] activate phagocytic processes at the site of injury,[32] and activate fibroblast cell function to increase collagen deposition and improve tensile strength.[33].Some reports also show a small decrease in edema produced by inflammation following laser therapy.[34].Absorption by hemoglobin releases nitirc oxide resulting in endothelial cell proliferation and increased microcirculation.[35] Low dosages also result in significantly decreased sensory nerve conduction velocity effect in reducing pain.[36] Contraindications Precautions Risks  Hemorrhagic conditions Eyes, reproductive organs Deep venous thrombosis or thrombophlebitis (local) Malignancy (local) Pregnancy (local) Tuberculosis (local) Impaired cognition or communication Infection Photosensitivity or systemic lupus Recently radiate tissue Anterior neck, carotid sinus Eye damage Bleeding (open wounds) Additional Considerations Reduce the risk of adverse effect on the eyes by applying laser in a closed environment, providing protective goggles when necessary, and performing an 'in-contact' technique Magnetic Therapy[edit | edit source] Magnetic therapy is a type of therapy where the body is exposed to a particular form of energy i.e. low frequency magnetic field. When body tissues are exposed to magnetic fields, a weak electrical current is produced which may: Enhance cellular permeability and ability to reduce swelling Regulate painful stimuli and reduce pain Improve blood circulation through a visolidating effect Promote muscle relaxation and bone healing [37] Strengthen the immune system Massage[edit | edit source] Massage involves the use of the hands of the therapist on the patient's body to help decrease pain, improve circulation and promote muscle relaxation. There are many massage techniques, e.g. Effleurage (Stroking) Petrissage (Kneading) Tapotement or Percussion Myofascial release Trigger point therapy Reflexology Deep transverse frictions Compression massage Cross-fibre massage Lymph drainage massage Contraindications Precautions Risks Serious circulatory problems Active processes e.g. inflammatory, infectious Fever Cancer Skin infections Severe osteoporosis Hypo/Hypertension Dermatitis Impaired sensation Fibromyalgia Autoimmune disorders Pericarditis/endocarditis Osteopenia Bruising Blood clots Fractures Nerve damage Transmission of infectious skin conditions Traction[edit | edit source] Traction is a manual technique aiming to reduce pressure on the affected painful segments of the spine and stretch soft tissues. By pulling the vertebra away from the disc, pressure is released from the disc and associated structures. Several types of traction are described in the literature. [38] Contraindications Precautions Risks Spinal malignancy Spinal cord compression Spinal infections Osteoporosis Acute fracture Aortic or iliac aneurysm Pregnancy Elderly Midline disc herniations Abdominal problems (lumbar region) Headache Nausea Fainting Soft tissue injury Resourses[edit | edit source] The focus of this page is the rationale for use of a modality and its safety considerations. Contraindications, precautions, risks, and safety considerations are outlined in detail by Houghton et al.[39]Modalities Used in Animal Physiotherapy - PhysiopediaIntroduction Modalities are the physical entities used a part of a treatment plan. Many of these modalities introduce an energy source to the body to stimulate or support the healing process. For instance, thermotherapy and cryotherapy, electoral muscle stimulation, laser therapy, ultrasound therapy, pulsed electromagnetic field therapy, extracorporeal shockwave therapy and hydrotherapy.[1] Crypotherapy (Superficial cold therapy)[edit | edit source] Cryotherapy is most often used in the acute phase of an injury or immediately post operatively. It can also be used in exercise-related injury. Application of a cold pack to an area will reduce blood flow to that area. Cryotherapy has been shown to interfere with pain transmission. It also reduces oxygen demand from the surrounding tissues and will help reduce swelling. If cryotherapy is applied under pressure, this results in greater reduction in swelling and reduced pain scores.[2] Superficial Hot Therapy (Thermotherapy)[edit | edit source] Superficial heat is often used in chronic conditions such as OA and can also be useful for reducing muscle spasm. It promotes blood flow to an area, reduces pain and increases joint and soft-tissue flexibility. Superficial heat will penetrate about 1-2 cm in depth. Sources of heat include a damp towel placed in the microwave, wheat bags, heat mats, gel packs heated in hot water and special hot packs that generate heat on the mixing of two chemicals. Again a towel or similar be placed between the hot pack and the animal's body.[3] Electrical Muscle Stimulation (EMS)[edit | edit source] Electrical muscle stimulation is sometimes referred to as Estim or NMES (neuromuscular electrical stimulation). These are all the same thing. EMS is sometimes also referred to as TENS (transcutaneous nerve stimulation). Whilst both use the same machine, TENS uses completely different settings to achieve pain relief by stimulating the sensory fibres. EMS is used to reverse or reduce muscle atrophy by stimulating motor fibres. Mobile units are most commonly used in veterinary physiotherapy. EMS machine consists of a small box with a battery and buttons for adjusting the settings and two sets of leads. Each set of leads has a pad at each end. The pads are placed at the top and bottom of the muscle and a current is passed. This causes the muscle to contract. Clipping of the furs and application of an aqueous gel are required to ensure a good contract. The kit comprises two set of leads, so that two muscle groups can be stimulated at the same time. For instance, one pair of pads could be attached to the quadriceps muscle group and the other to the hamstring group of muscle. The muscle can be made to contract at the same time, in which case the joint will not move, or set contract alternately, in which case the stifle extends and flexes as each group contracts.[4] Laser Therapy[edit | edit source] Lasers have been used or many years in human physiotherapy and are now beginning to make quite an impact in the veterinary market. Penetration is determined by wavelength. Wavelength is predetermined in each machine. Therapeutic wavelength range is 600-940nm. Lasers deliver engird (joules) that depends on the power (watts) of the laser and the time the laser is on. Class 3b lasers only have up to 500mW of power. The laser probe can be directed at the target joint or tissue and held in place while the dosage is delivered (normally measured in joules per centimetres squared). A Class 4 laser produces so much energy that the lead has to be held away from the patient and constantly moved in order to prevent burning. Health and safety for Class 4 lasers requires that all people in the room where lasers are used must wear protective goggles, the patient should be hooded, the doors to the room must be locked or a clear NO ENTRY LASER THERAPY IN PROGRESS sign must be displayed. The effects of therapeutic lasers cause an increase in cell metabolic rate by affecting part of Kreb's Cycle in the mitochondria. The result is an increase in ATP production and cell metabolic rate. This increase in cell metabolic rate results in faster production of the material the cell manufactures. For example, fibroblast produce more collagen and chondrocytes produce more cartilage matrix. Lasers also decrease the number of microorganisms, by increasing lymphocyte production, which can have a dramatic effect on granulating wounds and contaminated/infected areas. Lasers also cause the local release of nitrous oxide, which causes vasodilation. Therefore, lasers increase the blood supply to an area. Lasers also reduce the production of prostaglandins and Cox-2 (cycle-oxygenase coenzyme-2) in the synovial membrane and synovial fluid and in so doing reduce joint pain. Lasers also reduce pain by reducing nerve firing at neuromuscular junctions. Lasers also cause the release of endorphins that enhance pain relief.[5] Pulsed electromagnetic field therapy (PEMET)[edit | edit source] This is often referred to as short wave. At higher power level (over 5W), there can be some thermal effects. There is little or no scientific evidence to support the use of static magnets as therapeutic agents despite their popularity. The exact mechanism of action is not yet known. It has been suggested that PEMET interferes with nerve transmission in small unmyelinated nerve. For instance, C fibres (pain) by changing resting cell membrane potentials. Also in damaged tissue, there is a leakage of potassium from within cells into the interstitial tissue. This again alters the resting cell membrane potential. It is thought that PEMET can increase ion exchange in areas of damage. Ion exchange is responsible for oxygen utilisation within the cell. The system consists of a mat that contains a wire coil and a control box. Electric current is passed through the wire coil which produces a three-dimensional magnetic field around the coil. The current is switched on and off (pulsed) very rapidly. This background pulse may then have an interference pulse applied. Settings vary from manufacturer and model. The action of PEMFT is aimed at blocking pain transmission or increasing oxygen utilisation in areas of damage. The area to be treated is positioned so as to be in the magnetic field. This may just involve lying on the mat or wearing the coat. Treatment times are up to 20 minutes. The effects of PEMET will last for approximately 6 hours after treatment. Treatment can be repeated twice daily. PEMFT units are inexpensive and maybe considered for owners to buy for treating their animals at home.[6] Extracorporeal shockwave therapy (ESWT)[edit | edit source] Extracorporeal shockwave therapy (ESWT) does not involve electrical shocks. It is sometimes referred to as high-energy pressure therapy. It uses a very short burst of very high-energy waves or pulses to create large sudden changes in pressure. ESWT penetrates deeper than any other modality. ESWT works in two ways. The first is by causing micro-fractures in the target tissue be it bone or soft tissue. These micro-fractures causes a new wave of inflammation. ESWT is particularly useful in treating tendons and ligaments where often the inflammatory process has stopped despite the healing process being incomplete. ESWT also stimulates the production of angiogenic growth factors that promote increased blood supply to the area. The second way ESWT works is as the shockwave passes through the tissues, there is a void behind the wave. Cavitation bubbles form in this void. When the cavitation bubbles hit a hard surface, they collapse. As the bubbles collapse, they break down mineral deposits, such as calcified nodules in tendons. A gel is applied to the dog's coat to ensure good contact with the head (trade). Different trade sizes are available for different target areas. Typical settings for shoulders tendinopathy in a Labrador would be 800-2000 shocks per treatment depending on type of ESWT machine. The treatment time is only a few minutes. Occasionally, dogs may feel a littler discomfort for 48 hours after treatment.[7] Land Treadmill[edit | edit source] These are similar to a human treadmill, but have sides to prevent the dog from jumping off. Land treadmills are good for strengthening, endurance and cardiovascular fitness. Most are able to incline/decline that also allows increased weight distribution to back/front legs accordingly. Care must be taken hen using the incline/decline not to exacerbate or over load pathological conditions such as hip OA or carpal hyperextension.[8] Hydrotherapy[edit | edit source] Hydrotherapy has become well established as a treatment options for animals. Hydrotherapy works in several different ways to facilitates a return to normal function. In relation to water temperature for hypdrotherapy, be it a pool or underwater treadmill, is between 29 and 32 degrees C. This has the effect of warming and increasing blood supply to the submerged tissues as well as relaxing the patient. It provides an excellent environment for doing therapeutic exercises that maybe difficult on land. The warm water also produces sensory stimulation that is important in spinal cases. For buoyancy, the more of the body that is submerged, the less weight will be taken through the joints. This allows painful joints to move more easily due to reduced loading. Hydrostatic effect is the pressure the water puts on th parts of the body that are submerged. The hydrostatic effect will help reduce swelling and venous congestion in the sub-chondral bone that has been cited as a major cause of pain in arthritic joints. Moreover, water viscosity provides resistance to movement. This is an extremely good way to help rebuild muscle. Resistance can be further increased by the use of water jets. The resistance can also be useful to correct gait abnormalities such as the swaggering gait with hip dysplasia. The water offers support to the body that it would not experience on land. This is useful for the neurological patient who maybe uncoordinated and liable to falling. The water will support the body and slow down the fall. This allows the patient to take more time to correct the incoordination and avoid failing.[9]Achilles Tendinopathy Toolkit: Section C - Summary of Evidence and Recommendations for Interventions - PhysiopediaIntroduction Clinicians want to provide evidence-informed management of tendinopathy but many struggle with accessing, appraising and synthesizing the vast array of literature available on this topic. This section forms part of the Achilles Tendinopathy toolkit project created by the BC (British Columbia) Physical Therapy Knowledge-Broker facilitated project team. The evidence below has been modified for Physiopedia and produced in collaboration with the authorship team to support the information found in the toolkit. Explanation of clinical implications[edit | edit source] When researching treatment options it is important to consider the clinical implications. The following interventions have been reviewed and graded according to the supporting evidence. See the table below for an explanation. Strongly consider: High level/high quality evidence that this should be included in treatment. Consider: Consistent lower level/lower quality or inconsistent evidence that this should be included in treatment. May consider: No clinical evidence but expert opinion and/or plausible physiological rationale that this should be included in treatment. Consider NOT: High level/high quality evidence that this should not be included in treatment. Load Management[edit | edit source] Load management can be described as the temporary reduction of external physiological stressors with the goal of improving overall fitness and performance while maintaining musculoskeletal and metabolic health. Monitoring load as part of Achilles tendinopathy rehabilitation is essential in order to enhance recovery and minimise the risk of re-injury. A good understanding of the principles of exercise rehabilitation can help identify a programme that suits each individual. Accurate measurement and monitoring of external and internal loads is vital to a successful outcome and return to function. State of pathology Acute Chronic Clinical Research Evidence No Yes 2 CPG[1][2] 1 RCT[3] Published Expert Opinion Yes 2 CPG Yes Take Home Message Expert opinion[4] and clinical practice guidelines recommend that advice and education should be given to maintain pain levels of 5/10 or below on a VAS/NPRS for all activities. Two clinical practice guidelines, one RCT and expert opinion[4] recommends that advice and education should be given to maintain pain levels of 5/10 or below on a VAS/NPRS for all activities. Clinical implication May consider maintenance of daily activity during an acute phase, alongside advice to reduce loading from symptomatic (painful) activities to 5/10 on the VAS/NPRS May consider maintenance of daily activity during an acute phase, alongside advice to reduce loading from symptomatic (painful) activities to 5/10 on the VAS/NPRS Exercise[edit | edit source] Exercise prescription is part of all rehabilitation programmes and it is important to choose exercises that are relevant, effective and safe. Although there are many exercise principles advocated, the evidence is not always available to support these claims. The table below gives an overview of the current available evidence. Stage of pathology Acute Chronic Clinical research evidence No Yes 9 SR[5][6][7][8][9][10][11][12][13] 1 RCT[14] Published expert opinion Yes[15] Yes[15] Take home message A small amount of expert opinion exists to support the use of stretches in the acute stage. No evidence to support or refute the use of isometric exercise in the acute phase. There is a large amount of clinical research evidence to support the use of exercise in the chronic stage but the precise parameters to ensure effectiveness are not clear. Eccentric exercise in particular is supported although some protocols use both concentric and eccentric exercise. One RCT showed heavy slow resistance training is equally as effective as eccentric training and appears to have higher compliance than eccentric training. Clinical implication May consider a trial of using stretching exercises in the acute stage. No prescription parameters are provided. ACSM recommends 10-30 sec hold, 2-4 repetitions. Strongly consider using strengthening exercise in the chronic stage * OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews. Manual Therapy[edit | edit source] Manual therapy is often suggested to address mobility impairments found on assessment. There is not much clinical research evidence to support. The table below gives an overview of the available evidence and suggestions on the clinical implications. Joint mobilisations Stage of pathology Acute Chronic Clinical research evidence No Yes 1CPG Published expert opinion Yes Yes Take home message There is no clinical research evidence available to guide recommendations in the acute stage. There is a bio-mechanical rationale and published expert opinion that supports the use of mobilization if mobility impairments are found on assessment. There is a small amount of clinical research evidence and m ore substantial expert level of consensus to support the use of joint mobilizations to address physical impairments to improve mobility and function and this may enhance rehabilitation. Clinical implication May consider a trial of joint mobilizations in the acute stage to improve mobility and function if impairments are identified after undertaking a comprehensive biomechanical evaluation of the hip, knee, foot and ankle. May consider a trial of joint mobilizations in the chronic stage to improve mobility and function if impairments are identified after undertaking a comprehensive biomechanical evaluation of the hip, knee, foot and ankle. Combining with a strengthening exercise program may or may not produce superior results. Soft-tissue techniques Stage of pathology Acute Chronic Clinical research evidence No Yes 1 CPG[16] 1 RCT[17] 1 Other*[18] Published expert opinion Yes 1 CPG Yes Take home message There is no clinical research evidence available to guide recommendations in the acute stage. There is physiological rationale and published expert opinion that supports the use of soft tissue techniques to increase range of motion. There is a small amount of clinical research evidence and expert level consensus that supports the us of soft tissue techniques to increase range of motion. Clinical implication May consider a trial of soft tissue techniques, such as frictions or pressure massage, to improve range of motion. May consider a trial of softtissue techniques, such as frictions or pressure massage in the chronic stage to increase range of motion. Combining with a strengthening exercise program may or may not produce superior results. CPG- Clinical practice guideline, MA- Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews *Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc). Low level laser therapy (LLLT)[edit | edit source] Low level laser therapy is a non-invasive light source treatment that generates a single wavelength of light. it is believe to affect the function of connective tissue cells by accelerating repair and reducing inflammation. As such it is often chosen as an intervention in the treatment of Achilles tendinopathy. The table below reviews the current available evidence and recommendations for its use! Stage of pathology Acute Chronic Clinical research evidence Yes 2 Other Yes 1 MA[19] 8 RCT[20][21][22][23][24][25][19][26] 3 Other[27][28][29] Published expert opinion Yes Yes Take home message There is no clinical evidence, but there is a physiological rationale, and multiple animal studies to support the use of LLT in the acute stage. There is conflicting clinical evidence and conflicting expert opinion to suport the use of LLT in the chronic stage. Two recent studies involving the use of higher energy (J) per treatment demonstrate improvements in pain. Clinical implication May consider a trial of LLLT in the acute stage at the doses recommended by the World Association for Laser Therapy (www.walt.nu) i.e., 2‐4 J/point (not per cm2)*, minimum 2‐3 points. *See 'Section D ' for further details on calculation of dosage. Consider a trial of LLLT in the chronic stage at the following parameters: 0.9 J/point (not per cm2)*; 6 points on tendon. If Class III, may consider a tial of LLT in the chronic stage at 450J _ 520J per treatment over the whole tendon. *See Section D ' for further details on calculation of dosage. Therapeutic Ultrasound (US)[edit | edit source] Therapeutic ultrasound is an intervention used in rehabilitation to promote tissue healing. Although it is classified under the term electrotherapy it is in fact a form of mechanical energy. There are both thermal and non-thermal changes observed in the tissues caused by the oscillation of particles as the waves through the tissue. Whether the changes are thermal or non-thermal will depend upon the setting used. There is currently no evidence to support or refute the use of US in the acute or chronic stages of Achilles tendinopathy but the physiological rationale may support its use during the acute stage. Stage of pathology Acute Chronic Clinical research evidence No No Published expert opinion|- No No Take home message There is no clinical evidence, but there is physiological rationale, to support the use of US in the acute stage. There is no clinical evidence and no physiological rationale to support the use of US in the chronic stage. Clinical implication May consider a trial of US in the acute stage at a low to moderate dose (0.5 ‐ 1.0 W/cm2, pulsed 1:4‐1:1, 3 MHz, 5 mins for each treatment area equivalent in size to transducer head). No evidence to support or refute the use of therapeutic ultrasound in the chronic phase. CPG- Clinical practice guideline, MA- Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews *Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc). Extracorporeal Shock Wave Therapy (ESWT)[edit | edit source] ESWT also known as shock wave therapy and has often been used in the treatment of urinary stones and fracture healing. The shock waves are actually sound waves, and as they pass through tissues the positive and negative phases cause direct mechanical forces and generate cavitation and gas bubbles. There is no evidence or physiological rationale to support its use in the acute stages of Achilles tendinopathy. Although there is often conflicting evidence in the research relating to its use in the chronic stages it has been suggested that it may have some benefits, especially where more commonly used conservative treatment interventions have not resulted in a positive outcome. Stage of pathology Acute Chronic Clinical research evidence No Yes 2 CPG[2][30] 1 MA[31] 1 SR[32] 1 Other*[33] Published expert opinion No Yes Take home message There is no clinical evidence and no physiological rationale to support the use of ESWT in the acute stage. There is conflicting evidence to support the use of high or low energy ESWT devices in the chronic stage. The evidence suggests that outcomes are dependent upon the dosage ( measured in mJ/mm² or Bars) rather than the type of shock wave generation (focused or radial ESWT vs. radial pulsed-pressure ESWT). Local anesthetic required in high energy protocols may decrease the effectiveness of ESWT. Therefore, using low energy ESWT protocols without the need for anesthetic are recommended as more practical, more tolerable, and less expensive with equivalent results to high energy protocols. Low energy protocols could apply to focused or radial ESWT; or radial pulsed-pressure ESWT devices. Because of heterogeneity in study designs, the optimum protocol has yet to be determined Clinical implication Consider NOT using Extracorporeal Shock Wave for the acute stage. Consider a trial of ESWT in the chronic stage for refractory cases that have failed to resolve with other conservative treatment. Recommended parameters: Focused or Radial ESWT, including pulsed-pressure ESWT devices. Low energy: EFD (energy flux density) 0.10 – 0.28 mJ/mm² (equivalent to approximately 2-4 Bars using a pulsed- pressure device) 1500-3000 shocks 4-15 Hz 3-5 sessions, weekly intervals. ESWT may enhance outcomes compared to exercise alone, therefore patients should be instructed to continue with a well-designed exercise program. Appropriate time intervals for follow-up should be delayed in the short term (within 3 months of starting ESWT treatment) to allow for cellular repair models to be influenced through the mechanotransduction action of ESWT. The benefit of ESWT may further improve in the medium (6 months) and long term (12 months). CPG- Clinical practice guideline, MA- Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews *Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc). Iontophoresis Using Dexamethasone[edit | edit source] Iontophoresis is a process where an electrical current is passed through the skin. The affected body part is submerged in water which allows ionised (charged) particles to cross the normal skin barrier. Iontophoresis is considered as a non invasive method to deliver drugs transdermally. Stage of pathology Acute Chronic Clinical research evidence Yes 2 CPG[2][34] 1 RCT[35] No Published expert opinion Yes No Take home message There is a small amount of evidence to support the application of iontophoresis using dexamethasone in the acute stage. There is no evidence or expert opinion that anti inflammatory intervention with iontophoresis using dexamethasone has a useful role in the chronic stage. Clinical implication Consider, in the acute stage, a trial of iontophoresis, 0.4% dexamethasone (aqueous), 80 mA‐min; 6 sessions over 3 weeks. A program of concentric‐eccentric exercises should be continued in combination with iontophoresis, if exercise loading is tolerated. No evidence to support or refute the use of iontophoresis in the chronic phase. CPG- Clinical practice guideline, MA- Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews *Other study designs (eg. Cohort, case control, case series, quasi-experimental studies, etc). Rigid Taping[edit | edit source] Rigid taping is commonly used as an adjunct or temporary technique, to restrict movement, reduce swelling, and support anatomical structures in the acute and chronic stages of Achilles tendinopathy. It is also used post injury to protect against re-injury. Stage of pathology Acute Chronic Clinical research evidence Yes 1 CPG[2] Yes 1 CPG 1 SR[36] 2 Other*[37][38] Published expert opinion Yes Yes Take home message There is expert opinion to support the use of rigid taping in the acute stage. There is expert opinion and a small amount of clinical evidence to supportthe use of rigid taping in the chronic stage. Clinical implication May consider a trial of rigid taping in the acute stage. May consider a trial of rigid taping in the chronic stage. CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews *Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc). Orthotics[edit | edit source] Orthotics are often used during the acute stage of Achilles tendinopathy to reduce the load through the tendon. There is inconsistent evidence on the benefits of using orthotics during the chronic stage Stage of pathology Acute Chronic Clinical research evidence Yes 1 CPG 1 Other* Yes 1 CPG 2 SR[36][39] 2 RCT[40][41] 6 Other*[42][43][44][37][38][45] Published expert opinion Yes Yes Take home message There is a small amount of clinical evidence to support the use of orthotics in the acute stage in specific cases, to reduce load through the Achilles tendon. There is inconsistent evidence and expert opinion regarding the effectiveness of orthotics in the chronic stage Clinical implication May consider a trial of orthotics in the acute stage – may consider taping first to assess potential response to orthotics. May Consider a trial of orthotics in the chronic stage to reduce strain in the Achilles tendon, if indicated by the clinical assessment. CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews *Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc). Night splints and braces[edit | edit source] Night splints are rigid supports that are used to protect, support or immobilse the injured joint. The use of night splints in Achilles tendinopathy to maintain the length and of muscle and tendon but clinical guidelines recommend that these are not used during the acute stage. Stage of pathology Acute Chronic Clinical research evidence No 1 CPG Yes 1 CPG[2] 2 SR[46][39] 3 RCT[47][48][49] 1 Other* Published expert opinion Yes Yes Take home message Clinical practice guidelines recommend against the use of night splints for Achilles tendinopathy. There is a small amount of evidence and expert opinion that adding a night splint to eccentric exercise provides no benefit. Clinical implication Consider NOT using night splints in the acute stage Consider NOT using night splints in the acute stage CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews *Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc). Bracing[edit | edit source] Using a brace (airheel) is often used during the acute stages and also as an adjunct to eccentric exercise. However, despite there being expert opinion there is no high level clinical research to support its use during the acute stage and only a small amount of evidence available of the benefits in the chronic stage of Achilles tendinopathy. State of Pathology Acute Chronic Clinical research evidence No 1 CPG Yes 1 CPG[2] 1 SR[36] 3 RCT[1][50][51] Published Expert Opinion Yes Yes Take Home Message There is expert opinion to consider using a brace (Airheel) in the acute stage. There is a small amount of evidence suggesting that adding a brace (Airheel) to eccentric exercise provides no benefit. There is expert opinion that a brace (Airheel) may be considered in the chronic stage. Clinical implication May consider trialing a brace in the acute stage. May consider trialing a brace in the chronic stage. Heel raise inserts[edit | edit source] Heel raise inserts are sometimes used to reduce the load on the Achilles tendon but there is very little evidence to support their use. Refer to the table below for more guidance. Stage of pathology Acute Chronic Clinical research evidence No Yes 1 CPG[52] 2 RCT[53][42] 2 Other*[54][55] Published expert opinion No Yes Take home message There is physiological rationale that the application of heel inserts can reduce load on the Achilles tendon There is conflicting evidence and expert opinion for and against the use of heel inserts in the chronic stage Clinical implication May consider a trial of inserts in the acute stage to reduce loads through the Achilles tendon. Consider a trial of heel inserts in the chronic stage. Dry Needling Techniques[edit | edit source] Dry needling is an invasive procedure where a fine needle or acupuncture needle is inserted into the skin and muscle. There is no published evidence to support its use in the acute stages and no high quality evidence to support or refute its use in the chronic stages. Stage of pathology Acute Chronic Clinical research evidence No Yes 1 RCT[56] Published expert opinion No No Take home message There is no evidence or published expert consensus to support the use of acupuncture or other needling techniques in the acute stage There is a small amount of evidence that dry needling (Gunn intramuscular stimulation) provides no additional benefit to exercise. Clinical implication Consider NOT using dry needling in the acute stage. No high-quality evidence to support or refute the use dry needling in the chronic stage. CPG - Clinical practice guideline; MA - Meta-Analysis; RCT - Randomized controlled trials; SR - Systematic reviews *Other study designs (e.g. Cohort, case control, case series, quasi-experimental studies, etc). **“Dry needling is a broad term that refers to a treatment technique that uses solid filament needles to puncture the skin for therapeutic purposes. It includes a range of approaches, such as acupuncture, trigger point dry needling, intramuscular stimulation, or similar treatment...” – The Safe Practice of Dry Needling in Alberta. Health Quality Council of Alberta, 2014 Resources[edit | edit source] Click to go back to the Main Achilles Tendinopathy Toolkit page Click to go back to Section A - Clinical Evaluation Click to go back to Section B - Outcome Measures Click to continue to Section D - Exercise Programs Click to continue to Section E - Low Level Laser Therapy Dosage Calculation Click to continue to Section F - Medical and Surgical Interventions UBC Achilles Tendinopathy Toolkit

References

  1. ↑ Chaussy C, Schmiedt E, Jocham D, Brendel W, Forssmann B, Walther V. First clinical experience with extracorporeally induced destruction of kidney stones by shock waves. Jour Urol 1982;127: 417-420
  2. ↑ Argyropoulos AN, Tolley DA. Optimizing shock wave lithotripsy in the 21st century. Eur Urol 2007; 52: 344-352
  3. ↑ Park SH, Park JB, Weinstein JN, Loening S. Application of extracorporeal shock wave lithotripter (ECSWL) in orthopedics. I. Foundations and overview. J Appl Biomater 1991; 2:115-126
  4. ↑ Weinstein JN, Oster DM, Park JB, Park SH, Loening S. The effect of the extracorporeal shock wave lithotriptor on the bone-cement interface in dogs. Clin Orthop Relat Res 1988; 235:261-267.
  5. ↑ Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M. Influence of shock waves on fracture healing. Urology 1992; 39: 529-532
  6. ↑ van der Worp H, van den Akker-Scheek I, van Schie H, Zwerver J. ESWT for tendinopathy: Technology and clinical implications. Knee Surg Sports Traumatol Arthrosc 2013; 21:1451-1458
  7. ↑ Jump up to:7.0 7.1 Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res 2012; 7:11
  8. ↑ Reilly JM, Bluman E, Tenforde AS. Narrative Review on the Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions PMR 2018; 10(12): 1385-1403.
  9. ↑ Wang CJ, Huang HY, Pai CH. Shockwave-enhanced neovascularization at the tendon-bone junction: An experiment in dogs. J Foot Ankle Surg 2002; 41:16-22
  10. ↑ Jump up to:10.0 10.1 Chen YJ, Wang CJ, Yang KD, et al. Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression J Orthop Res 2004; 22: 854-861
  11. ↑ Jump up to:11.0 11.1 Wang FS, Yang KD, Chen RF, Wang CJ, Sheen-Chen SM. Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-beta. J Bone Joint Surg Br 2002; 84: 457-46.
  12. ↑ Rompe JD, Kirkpatrick CJ, Kullmer K, Schwitalle M, Krischek O. Dose-related effects of shock waves on rabbit tendo Achillis. A sonographic and histological study. J Bone Joint Surg Br 1998; 80: 546-552.
  13. ↑ Bosch G, Lin YL, van Schie HT, van De Lest CH, Barneveld A, van Weeren PR. Effect of extracorporeal shock wave therapy on the biochemical composition and metabolic activity of tenocytes in normal tendinous structures in ponies.Equine Vet J 2007; 39: 26-231
  14. ↑ Waugh CM, Morrissey D, Jones E, Riley GP, Langberg H, Screen HR. In vivo biological response to extracorporeal shockwave therapy in human tendinopathy. Eur Cell Mater 2015; 29: 268-280.
  15. ↑ Vahdatpour B, Taheri P, Zwre Zade A, Moradian S. Efficacy of Extracorporeal Shockwave Therapy in Frozen Shoulder.International Journal of Preventive Medicine 2014; 5(7): 875-881
  16. ↑ Wang CJ, Ko JY, Weng LH, Wang JW, Chen JM, Sun YC, Yang YJ. Extracorporeal Shockwave Shows Regression of Osteoarthritis of the Knee in Rats. J Surg Res. 2011; 171(2): 601-608.
  17. ↑ Rompe JD, Furia J, Cacchio A, Schmitz C, Maffulli N. Radial shock wave treatment alone is less efficient than radial shock wave treatment combined with tissue-specific plantar fascia-stretching in patients with chronic plantar heel pain.International Journal of Surgery. 2015;24:135-42.
  18. ↑ Ogden JA, Tóth-Kischkat A, Schultheiss R. Principles of shock wave therapy. Clinical Orthopaedics and Related Research (1976-2007). 2001; 387:8-17.
  19. ↑ Langmore Podiatry. Shockwave Therapy Demonstration. Available from: https://www.youtube.com/watch?v=P5dibaAu7pQ [last accessed 6/17/2018]


Original Editor - Ayushi Tomer

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