What You Should Know About Shockwave Therapy

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Continuing Education Course #125 — November 2004

I am very pleased to introduce the latest article, “What You Should Know About Shockwave Therapy,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Extracorporeal shockwave therapy (ESWT) has been a subject of controversy as various experts have debated its efficacy in treating chronic plantar fasciitis. With this in mind, Lowell Scott Weil Jr., DPM, explores the various types of shockwave therapy and provides a thorough analysis of the literature on ESWT.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Editor-In-Chief
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 61 and successfully answering the questions on pg. 66. Use the enclosed card provided to submit your answers or fax the form to the NACCME at (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by the NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Weil has disclosed that he has received grant and/or research support from Healthtronics, EMS DolorClast, UMS Wolf and Orthometrix.
This article contains discussion of published and/or investigational uses of agents that are not indicated by the FDA. Neither NACCME nor HMP Communications recommends the use of any agent or device outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings.
GRADING: Answers to the CE exam will be graded by the NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: November 2004.
EXPIRATION DATE: November 30, 2005.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the different types of technology used to create medical shockwave;
• cite the potential benefits of ESWT for patients with chronic plantar fasciitis; and
• discuss the recent literature on electrohydraulic, piezoelectric and radial shockwave therapy.
Sponsored by the North American Center for Continuing Medical Education.

What One Randomized Study Revealed About Electrohydraulic Shockwave
What One Randomized Study Revealed About Piezoelectric Shockwave
What One Randomized Study Revealed About Radial Shockwave
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Author(s): 
By Lowell Scott Weil, Jr., DPM, MBA

   Last year, I wrote “Extracorporeal shockwave therapy (ESWT) has a long way to go to prove it has overwhelming medical benefits that are claimed by the manufacturers, but it is still in the early stages of its evolution. With time, it will be necessary to prove these claims through prospective studies.” (See “Extracorporeal Shockwave Therapy: Hope Or Hype?,” page 46, November 2003 issue.)

   While this article is not intended to prove beyond a statistical doubt that ESWT works, emerging research via prospective placebo-controlled, double-blind studies shows that ESWT is effective and should be considered a proven technology.

   Employing ESWT for the treatment of musculoskeletal (MSK) disorders evolved in Europe in the early 1990s. ESWT is a derivative of lithotripsy, the mechanical breaking up of renal stones with sound waves. ESWT has been considered valuable in treating many different MSK disorders including plantar fasciitis, epicondylitis, tendinitis and non-unions of bone. In all situations, it is considered the non-invasive alternative to surgery.

   Clinicians should only consider ESWT for treating a pathology after more common, accepted and proven non-invasive treatments have failed.

   In the United States, ESWT received its first FDA-approved indication for the treatment of plantar fasciitis. Up to 15 percent of podiatric visits result from painful plantar fasciitis. Given the prevalence of plantar fasciitis in the U.S., with over 1 million people suffering from it annually, it has become the epicenter of debate about ESWT.

   Numerous studies have proven that 80 to 90 percent of people suffering with plantar fasciitis will be treated successfully with conservative treatment over a six-month period of time. There is little debate over the most effective conservative management options for plantar fasciitis although the only randomized, proven method is the use of night splints in the chronic cases.
   However, continued controversy abounds regarding the proper method of treating the 10 to 20 percent of plantar fasciitis sufferers who do not respond to conservative care in a timely fashion.

   Over the years, many different procedures have been described for treating chronic heel pain. These procedures include: large incisional sectioning of the plantar fascia with removal of bone spur; only sectioning the plantar fascia; decompressing a branch of the lateral calcaneal nerve with partial sectioning of the plantar fascia; minimally invasive techniques with or without an endoscope; in-step fasciotomies; and more recently, injections of different chemical agents, either Botox or alcohol. For the past four years, ESWT has been on the list of available treatments in the U.S.

Understanding The Different Shockwave Technolologies

   Electrohydraulic, electromagnetic, piezoelectric and radial are four different technologies that are currently utilized to create medical shockwave.

   The electrohydraulic system is also known as spark gap technology and was employed with the first generation of shockwave machines. A spark plug is used to generate heat and a sonic pulse, resulting in cavitation. Eisenmenger first described the electromagnetic principle in 1962. This involves the passing of an electrical current through a coil, which produces a strong magnetic field. The subsequent compression of the fluid creates a shockwave.

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