Focused Extracorporeal Shockwave Therapy in Physical Medicine and Rehabilitation

Abstract

Purpose of Review Focused extracorporeal shockwave therapy (fESWT) is a physical treatment modality developed over the last 25 years for musculoskeletal indications. It has many indications in the field of physical medicine and rehabilitation (PM&R) and is effective, time-efficient, and cost-efficient. This review focuses on basics and on clinical indications as well as on significant trends in fESWT. Recent Findings In PM&R, stimulation of healing processes in tendons, surrounding tissue, and bones via mechanotransduction seems to be a relevant biological effect. The International Society for Medical Shockwave Treatment (ISMST) describes different types of indications (such as approved standard indications—in accordance with most scientific evidence—like calcifying tendinopathy of the shoulder, plantar fasciitis lateral epicondylopathy of the elbow, greater trochanter pain syndrome, patellar tendinopathy, Achilles tendinopathy and bone non-union, common empirically tested clinical uses, exceptional or expert indications, and experimental indications). Summary fESWT is a relevant treatment option in PM&R and regenerative medicine. In recent years, historical paradigms (for example, application in cancer patients) have changed and new indications (such as nerve regeneration, myofascial trapezius syndrome, low back pain, dermatosclerosis, and lymphedema) are supported. Future translational research should focus on establishing actual exceptional indications and experimental indications for clinical routine.

Best practices for extracorporeal shockwave therapy in musculoskeletal medicine: Clinical application and training consideration

“…Three main forms of F‐SWT are used in commercial devices available for clinical use: electrohydraulic, electromagnetic, and piezoelectric 6 . In contrast, R‐SWT generates pressure waves that exert maximal pressure at the applicator and attenuate as waves travel to deeper structures 1 . These outward directed pressure waves are generated via different mechanisms compared to F‐SWT 1,6 .…”

“…Although clinical evidence has suggested that ESWT is effective in treating musculoskeletal conditions, the precise mechanisms remain unknown. Cellular mechanotransduction, or mechanotherapy, explains how mechanical stimuli lead to cellular migration, proliferation, differentiation, or apoptosis 1 . Higher levels of energy may result in disruptive, shear stresses rather than serving as a mechanical stimulus 7 .…”

“…In the hands of a qualified physician, ESWT is generally a safe and well‐tolerated procedure. Common complications or adverse effects are described in Table 8 1,6,14 . Although ESWT is considered a relatively low‐risk procedure, there have been a few cases with major complications reported in the literature.…”

“…Extracorporeal shockwave therapy (ESWT) is used in a variety of clinical applications including the management of musculoskeletal conditions. Initial use of ESWT in clinical practice was in urological application of lithotripsy in the early 1980s and subsequently expanded to musculoskeletal conditions 1 . Physiologic effects of shockwaves have been widely investigated with observations that different energy forms can have effects on the musculoskeletal system, reducing pain and facilitating tissue healing.…”

Commentary: Onco-Esthetics Dilemma: Is There a Role for Electrocosmetic-Medical Devices?

“…Although some research has been done on the effects of ESWT on cancer cells, the current consensus does not support its use for this indication (9). Furthermore, in cancer patients with musculoskeletal pain, metastatic disease should be excluded prior to the initiation of ESWT (15)(16)(17). A similar recommendation could presumably be made for patients suffering from skin ulcers or delayed wound healing, however, to our knowledge, research on this topic is lacking.…”