Radialspec Radial Shockwave Therapy

1. Radialspec� Radial Shockwave Therapy A review of one years clinical experience. JPC The Jerusalem Physiotherapy Center. Nicole Levy MCSP , Daniel Kersenti BPT

2. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. The Jerusalem Physiotherapy Center is a private physiotherapy clinic treating a wide range of musculoskeletal conditions as well as some general rehabilitation with maintenance neurological, geriatric and orthopedic problems. We have an average patient load of 416 treatments each month seen by two experienced manual physiotherapists, with a combined clinical experience of 62 years.

3. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. 87% (362 patients) are musculoskeletal of which 34% (123 patients) are back and neck and the rest are miscellaneous orthopedic and muscular problems.

4. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. There is an increasing interest in Radial shockwave therapy for musculoskeletal conditions with some interesting studies recently published in the journals. Kudo et al 2006.Pettrone and McCall 2005. We were asked to evaluate the Radialspec� ,an unfocused radial shock wave therapy device manufactured by Medispec for the treatment of orthopedic conditions.

5. Radialspec� There is an increasing interest in Radial shockwave therapy for musckuloskeletal conditions with some interesting studies recently published in the journals. We were asked to evaluate the Radialspec� ,an unfocused radial shock wave therapy device manufactured by Medispec for the treatment of orthopedic conditions.There is an increasing interest in Radial shockwave therapy for musckuloskeletal conditions with some interesting studies recently published in the journals. We were asked to evaluate the Radialspec� ,an unfocused radial shock wave therapy device manufactured by Medispec for the treatment of orthopedic conditions.

6. Physical Characteristics RSWT(General) Radial shock waves are unfocused low pressure waves created by an electromagnetic projectile mechanism The pressure waves are transmitted radially. Energy decreases proportional to the square of the distance from the surface. Therefore, RSWT is effective mostly for the treatment of superficial pathologies. Some details about the physical characteristics of Radial Short Wave TherapySome details about the physical characteristics of Radial Short Wave Therapy

7. Physical Characteristics � Comparison To ESWT ESWT = EXTRACORPOREAL SHOCK WAVE THERAPY RSWT = RADIAL SHOCK WAVE THERAPYESWT = EXTRACORPOREAL SHOCK WAVE THERAPY RSWT = RADIAL SHOCK WAVE THERAPY

8. Biological Effect of Radial Shockwave Therapy (based on studies) 3 months post RX.RSWT: At the cellular level; -No evidence of inflammation. -Ligament � slight stromal sclero hyalinosis, increased collagen production, increased activated fibroblasts. -Plentiful wrinkled endoplasmic reticulum. Ammediola et al 2001, Wang et al 2004

9. Biological Effect of RSWT (based on studies)

10. Biological Effect of RSWT (based on studies) Enhances new bone formation in a rabbit animal model. High osteoblast activity, with extended osteoid formation. Possibility- RSWT has comparable effects on healthy bones as ESWT in rabbit animal models. Wang et al 2004.Haupt et al 1990.McClure et al 2000

11. Biological Effect of RSWT (based on studies) Disintegration of calcific deposits. Analgesic effect- mechanism unclear. Ammendiola et al 2001

12. Clinical Indications Plantar Fasciitis (with/without heel spur) Shoulder tendonitis (with/without calcifications) Achilles Tendonitis Epicondylitis Muscular Back Pain Non-unions � superficial bones. Sciatica Jumper�s Knee Tibial Edge Syndrome (painful shins) Veterinary Indications

13. Adverse Events Adverse events are equivalent to those of conventional ESWT � Transient pain Petechia / subcutaneous hematoma (up to 4%) Kudo et al 2006.Deisch et al 1999 Local symptoms are much more common in RSWT d/t lower penetration energy area. Local irritation does not appear to be of lasting clinical significance. Deisch et al 1999.Gremion et al 2000.Kudo et al 2006

14. Radialspec�s Technical Data Three Operating Modes: 10Hz, 20 Hz, Burst Two Energy Levels: 80mJ, 115mJ Three different probe tips: 6mm � Acupuncture, and trigger point treatment. 10mm � Soft tissue problems. Dimensions: 200X260X280 mm Weight: 12Kg Portable mJ = millijoules !!!!!!!!!mJ = millijoules !!!!!!!!!

15. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Specifications of machine used in our clinic High � 115mJ at tip point/ 10Hz -600shocks/min Low � 80mJ at tip point 4Hz-240shocks/min

16. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Over the course of one year we selected and treated a wide group of patients and documented their progress. Selection was via clinical history. All patients were examined by the treating physiotherapist. There was no blinding or cross examination of the patients. This was not a clinical trial, just a record of our clinical experience with this device.

17. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Patients treated N=76 Average age =55.5 yrs Shoulder dysfunction N=28 Plantar fasciitis N=12 Achylliodynia N=11 Trigger finger N=3 Epicondylitis N=2 Miscellaneous other N=20 We saw 28 patients with shoulder dysfunction 2 with epichondylitis 12 with planter faciitis 11 with achylliodynia 3 with trigger finger 20 other miscellaneous orthopedic problems such as patella tendonitis and ischial bursitis ,medial knee pain, chronic hamstring strain sacroiliitis etc...We saw 28 patients with shoulder dysfunction 2 with epichondylitis 12 with planter faciitis 11 with achylliodynia 3 with trigger finger 20 other miscellaneous orthopedic problems such as patella tendonitis and ischial bursitis ,medial knee pain, chronic hamstring strain sacroiliitis etc...

18. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. All patients were assessed for both palpable pain levels and functional pain levels and recorded using a VAS (Visual analogue scale). We did modify the VAS during the year as we felt it gave greater accuracy and was less leading to the patient. -The patients were divided into two groups ; Chronic � those with symptoms persistent for greater than 3 months. Acute � New soft tissue injury that we would otherwise treat with cross frictional mobilizations (Cyriax ) such as partial hamstring tear or collateral ligament sprain of the knee..-The patients were divided into two groups ; Chronic � those with symptoms persistent for greater than 3 months. Acute � New soft tissue injury that we would otherwise treat with cross frictional mobilizations (Cyriax ) such as partial hamstring tear or collateral ligament sprain of the knee..

19. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Modification of VAS (visual analogue scale)

20. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. These were the clinical indicationsThese were the clinical indications

21. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. The combined population showed an average VAS of 6.78 prior to treatment and an average of 2.02 post treatment which constituted an improvement of 4.76The combined population showed an average VAS of 6.78 prior to treatment and an average of 2.02 post treatment which constituted an improvement of 4.76

22. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. The combined population showed a Vas of pretreatment function of etc.. The combined population showed a Vas of pretreatment function of etc..

23. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center.

24. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center.

25. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center.

26. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Of the patients with shoulder pathologies 5 were followed up after three months . Average VAS = 5.4

27. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center.

28. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Of these patients 5 were followed up after 1 and three months. They show an average VAS of 1 . This constitutes a substantial change in their pain syndromesOf these patients 5 were followed up after 1 and three months. They show an average VAS of 1 . This constitutes a substantial change in their pain syndromes

29. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Of the patients with plantar fasciitis 5 were followed up after three months . Average VAS = 1.0

30. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center.

31. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center.

32. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Of the patients with Achylliodynia 4 were followed up after three months . Average VAS = 0.5

33. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Comparison of VAS scores Pre /Post and 3 months post treatment. Pathology VAS pre Rx VAS post Rx VAS 3 months post Rx Shoulder 6.96 1.90 5.4 Achylliodynia 6.46 2.11 0.5 Plantar fasciitis 6.53 0.66 1.0 Average number of treatments \pathology = 3.04 When we compared the overall Vas scores we found that initially the shoulder pathologies had a good improvement but over the course of 3 months the results were not as good as for achylliodynia and plantar fasciitis. Was this because of the greater complexity of upper quadrant dysfunction? Was it because most of the patients seen were given ongoing remedial exercises to maintain their gain and it is easier not to use your shoulder rather than a leg\foot? Was it because the majority of approach was anterior and maybe we should be directing the shockwave towards the posterior aspect of the capsule ? Was it because there were a few different shoulder pathologies and in the beginning they were all lumped together..a biceps tendonotis is not the same as a supinatous tear or adhesive capsulitis. ? We are now subclassifying each category for greater accuracy..When we compared the overall Vas scores we found that initially the shoulder pathologies had a good improvement but over the course of 3 months the results were not as good as for achylliodynia and plantar fasciitis. Was this because of the greater complexity of upper quadrant dysfunction? Was it because most of the patients seen were given ongoing remedial exercises to maintain their gain and it is easier not to use your shoulder rather than a leg\foot? Was it because the majority of approach was anterior and maybe we should be directing the shockwave towards the posterior aspect of the capsule ? Was it because there were a few different shoulder pathologies and in the beginning they were all lumped together..a biceps tendonotis is not the same as a supinatous tear or adhesive capsulitis. ? We are now subclassifying each category for greater accuracy..

34. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. We asked ourselves what effect would RSWT have on more acute soft tissue lesions of the type usually treated with Cyriax type deep tissue friction? We had good results for 3 cases of acute medial collateral ligament strain and one hamstring strain using low frequency RSWT. All groups were treated 3 times at 1 week intervals

35. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center.

36. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Discussion There seems to be a place for shockwave treatments for incalcitrant soft tissue lesions, resulting in ongoing decreased pain and increased function . This is a group of patients who were always difficult to help and if a non-invasive technique is effective and can quickly return them to normal function, there is a place for these treatments clinically. Discussion There seems to be a place for shockwave treatments for incalcitrant soft tissue lesions, resulting in ongoing decreased pain and increased function .This is a group of patients who were always difficult to help and if a non-invasive technique is effective and can quickly return them to normal function, there is a place for these treatments clinically. There would also appear to be a place to examine the effect of this type of treatment on acute soft tissue injury of the type that most commonly becomes a chronic long standing problem such as collateral ligament sprain of the knee or acute hamstring tendonitis.We recommend future study of more acute conditions. Discussion There seems to be a place for shockwave treatments for incalcitrant soft tissue lesions, resulting in ongoing decreased pain and increased function .This is a group of patients who were always difficult to help and if a non-invasive technique is effective and can quickly return them to normal function, there is a place for these treatments clinically. There would also appear to be a place to examine the effect of this type of treatment on acute soft tissue injury of the type that most commonly becomes a chronic long standing problem such as collateral ligament sprain of the knee or acute hamstring tendonitis.We recommend future study of more acute conditions.

37. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. Discussion cont. There would also appear to be a place to examine the effect of this type of treatment on acute soft tissue injury of the type that most commonly becomes a chronic long standing problem such as collateral ligament sprain of the knee or acute hamstring tear leading to tendonitis. We recommend future study of more acute conditions.

38. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. The Physio. Perspective. From our stand point as physiotherapists, there are two points of treatment; To reduce the condition To reduce the cause of the condition. The Physio. Perspective. From our stand point as physiotherapists, there are two points of treatment; - To reduce the condition -To reduce the cause of the condition. If biomechanical dysfunctions are not addressed the underlying cause of the tendonitis or chronic soft tissue strain will re-occur and the condition is likely to return. It is not enough to just reduce the immediate cause of pain but we have to endeavor to prevent reoccurrence of the condition by educating the patient to change the functional biomechanics and if necessary assist with orthopedic devices such as custom made orthotics. The Physio. Perspective. From our stand point as physiotherapists, there are two points of treatment; - To reduce the condition -To reduce the cause of the condition. If biomechanical dysfunctions are not addressed the underlying cause of the tendonitis or chronic soft tissue strain will re-occur and the condition is likely to return. It is not enough to just reduce the immediate cause of pain but we have to endeavor to prevent reoccurrence of the condition by educating the patient to change the functional biomechanics and if necessary assist with orthopedic devices such as custom made orthotics.

39. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPC The Jerusalem Physiotherapy Center. If biomechanical dysfunctions are not addressed the underlying cause of the tendonitis or chronic soft tissue strain will re-occur and the condition is likely to return. It is not enough to just reduce the immediate cause of pain but we have to endeavor to prevent reoccurrence of the condition by educating the patient to change the functional biomechanics and if necessary assist with orthopedic devices such as custom made orthotics.

40. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPCThe Jerusalem Physiotherapy Center. Summary and conclusion There seems to be a place for shockwave treatments for incalcitrant soft tissue lesions, resulting in ongoing decreased pain and increased function. More research is required to evaluate the tissue changes caused by these modalities and how long do they remain effective. Further review and long term follow-up of these patients is necessary. Comparison with other treatment methods with double blind studies would be helpful. Summery Where incalcitrant musculoskeletal problems persist there seems to be a place for Radiospec� treatment. This would be helpful combined with careful biomechanical assessment and an understanding of why the problem arose. From our stand point as physiotherapists, there are then two points of treatment; - To reduce the condition -To reduce the cause of the condition If biomechanical dysfunctions are not addressed the underlying cause of the tendonitis or chronic soft tissue strain will re-occur and the condition is likely to return. It is not enough to just reduce the immediate cause of pain but we have to endeavor to prevent reoccurrence of the condition by educating the patient to change the functional biomechanics and if necessary assist with orthopedic devices to assist in this aim i.e. custom made orthotics.Summery Where incalcitrant musculoskeletal problems persist there seems to be a place for Radiospec� treatment. This would be helpful combined with careful biomechanical assessment and an understanding of why the problem arose. From our stand point as physiotherapists, there are then two points of treatment; - To reduce the condition -To reduce the cause of the condition If biomechanical dysfunctions are not addressed the underlying cause of the tendonitis or chronic soft tissue strain will re-occur and the condition is likely to return. It is not enough to just reduce the immediate cause of pain but we have to endeavor to prevent reoccurrence of the condition by educating the patient to change the functional biomechanics and if necessary assist with orthopedic devices to assist in this aim i.e. custom made orthotics.

41. Radialspec� Radial Shockwave TherapyA review of one years clinical experience.JPCThe Jerusalem Physiotherapy Center. The present drive to be more cost effective in our treatment approach can then include fewer treatment sessions with an added educational/prevention bias as well as just treating the acute pain syndrome.