EBM IN ULTRASOUNDS AND

SCHOCK WAVES
PIETRO MARANO
DEPT. OF NEUROLOGY AND
NEUROREHABILITATION, DANNA CLINIC,
PALERMO
NEUROREHABILITATION TEACHING,
UNIVERSITY G.DANNUNZIO, CHIETIPESCARA
REGIONAL SECRETARY SIMFER FOR SICILY

Ultrasounds
Therapeutic ultrasound is one of the most widely and
frequently used electrophysical agents
The effectiveness of ultrasound for treating people
with pain, musculoskeletal injuries and soft tissue
lesions remains questionable

Nussbaum et al. 97 reported that ultrasound is one of

the most frequently used electrophysical agents in
physical therapy practice
Physiatrists have given many reasons for using
ultrasound such as for the physiological effects or
because of beliefs in clinical results or expected
effects

Other trials focused on using ultrasound for either a

combination of pain and soft tissue healing or to
change a consequential functional loss.

Very few articles present a systematic review of

randomized controlled trials (RCTs) in which
ultrasound was used to treat people with
pathological conditions
All the RCTs were old, they are published between
1975 and 1999

 Each trial was designed to investigate the

contributions of active and placebo ultrasound to the

patients outcomes measured.
Depending on the conditions, ultrasounds (active
and placebo) was used alone or in conjunction with
other interventions in a manner designed to identify
its contribution and distinguish it from those of
other interventions

Robertson et al. (2001) have analized 35 english

language RCTs were published
Each RCT identified was scrutinized for patients
outcomes and methodological adequacy

 Ten of the 35 RCTs were judged to have acceptable

methods using criteria based of those developed by

Sackett et al.
Of these RCTs the results of 2 trials suggest that
therapeutic ultrasound is more effective in treating
some clinical problems (carpal tunnel syndrome, and
calcific tendinitis of the shoulder) than placebo
ultrasound, and the results of 8 trials suggest that it
is not.

There was little evidence that active therapeutic

ultrasound is more effective than placebo
ultrasound for treating people with pain or a range
of musculoskeletal injuries or for promoting soft
tissue healing.
The few studies deemed to have adequate methods
examined a wide range of patient problems.

The dosage used in these studies varied considerably,

often for no discernable reason
Given the importance of ultrasound in physical
therapy we believe that a new systematic review of
ultrasound for pain and soft tissue is necessary

These variables include the intensity of ultrasound

applied, the size of the area treated and the duration
of treatment for specific problems.

We found few RCTs that investigated the

contribution of therapeutic ultrasound to patient
outcomes that met the minimal standards of
methodological adequacy.
Of the 10 RCTs that did meet our standards, 2
studies demonstrated improvements in outcome
measures in subjects treated with ultrasound

Ultrasound has been used therapeutically for over 6

decades in the ways reported in all the studies
examined
Any clinically significant effects should, by now, have
been identified in a number of rigorous studies that
showed which patient outcomes are improved by
using therapeutic ultrasound.

We found that the dosages of ultrasound used in

the studies we reviewed varied considerably and
for the reasons that were not always clear.
Furthermore, without adequate data, theer is little
scientific basis for dosage selection in clinical
practice.
This leave a question of the extent to which the
diversity of dosages used helps explain the limited
evidence of effectiveness of therapeutic ultrasound.

Conclusions
When methodologically flawed trials were
excluded, there were few RCTs that investigated
ultrasound and those RCTs provided little clinical
evidence for the efficacy of therapeutic ultrasound
Finally, there is still little evidence of the clinical
effectiveness of therapeutic ultrasound as currently
used in physical therapy, to treat people with pain
and musculoskeletal injuries and to promote soft
tissue healing. There are, however, apparently
considerably different beliefs as to what is an
acceptable dosage.

Take Home Message

The findings of the present communication indicate
the importance of systematically investigating the
clinical effectiveness of therapeutic ultrasound and
establishing whether there is a dose-response
relationship
The first stage is to identify clinical problems for
which ultrasound is anecdotally effective.

The next stage should be to establish experimental

and treatment protocols and standardized methods
for ensuring the output of all ultrasound equipment
used.
With sufficient such studies, meta-reviews should be
possibile and able to indicate more convincingly than
systematic reviews the extent to which ultrasound
affects clinical outcomes and under which
conditions.

Extracorporeal Schockwave Therapy ( ESWT)

The sources of schockwave generation include
electromagnetic and piezoelectric principle.
Electrohydraulic schockwaves are high energy
acoustic waves generated under water explosion with
high voltage electrode.
The vast majority of the published papers including
randomized control trials and cohort studies showed
positive effects and evidence base medicine in favor
of ESWT

However a few studies reported that ESWT is

ineffective or less effective with the results
camparable to the placebo effect, and this has stirred
up the debate and controversy.

Mechanism of schockwave therapy

The mechanism of schockwave therapy is not fully

understood.
The most important physical parameters include the
pressure distribution, energy flux density and the
total acoustic energy.

Proximal Plantar Fasciitis

The majority of the published papers reported a
positive and beneficial effect of ESWT in proximal
plantar fasciitis.
Rompe et al. Suggested that three weekly treatments
with 1,000 impulses of low-energy schockwave at
0.06 mJ/mm2 appear to be an effective therapy for
plantar fasciitis with significant alleviation o fpain
and improvement in function

Wang et al treated 79 patients (85 heels) with plantar

fasciitis including 59 women and 20 men with an
average age of 47 yrs (range 15-75 yrs) with
schockwave therapy
At one yr follow up the overall results were 75.3%
complaint free, 18,8% significantly better, 5.9%
slightly better and no unchanged or worse.

In contrast feww studies reported the opposite

results of ESWT in the treatment of plantar fasciitis
Several studies compared the effects of ESWT with
surgery, local corticosteroid injection or physical
therapy
Surgical treatment and ESWT showed comparable
functional outcomes.

Lateral epicondylitis of the elbow

Several studies investigated the effects of ESWT in
patients with lateral epicondylitis of the elbow and
the success rate ranged from 69% to 91%
Few studies reported no effect of ESWT or less
effect comparable to the placebo. In a review of 9
placebo-controlled trials, Buchbinder et al
concluded that there is a platinum level of ESWT
provides little or no benefit in term of pain and
functionin laterale elbow pain.

Calcifying tendinitis of the shoulder

The success rate of ESWT in patients with calcific
tendinitis of the shoulder was reported ranging from
78% to 91%
Radiographs showed complete elimination of
calcium deposits in 57.6% parttial elimination or
fragmentation in 15.1 %, and unchanged in 27.3% for
the shockwave group.

Patellar tendinopathy (Jumpers knee) and

Achilles tendinopathy
Several studies have reported favorable results of
ESWT in athletes with Jumpers knee with the
success rate ranged from 73.5% to 87.5%.
ESWT was also utilized in patients with patellar
tendinopathy secondary to harvesting of the patellar
tendon for ACL reconstruction.

Ultrasonographic examination showed a significant

increase in the vascularity of the patellar tendon and
a trend of reduction in the patellar tendon thickness
after ESWTas compared to conservative treatments.
Many studies investigated the effect of ESWT in
Achilles tendinopathy, and most reported favorable
results with similar success rate as patellar
tendinopathy

Rompe et al. Compared 25 patients treated with

eccentric stretching exercises with 25 patients
treated with repetitive ESWT, and the results showed
that eccentric loading is inferior to ESWT in the
treatment of patient with chronic recalcitrant
Achilles tendinopathy.

Bone disorders
Non union and delayed union of long bone fracture

Several studies investigated the effect of schock

waves therapy for non union and delayed union of
long bone fractures, and reported the success rate
of achieving bony union ranged from 50% to 85%
Schaden et al reported a success of 85% in the
treatment of 115 delayed and non union
Valchanou et al. Reported bony unions in 70 of 82
patients with delayed or chronic non union of
fractures of various locations.

The results of ESWT in non union of long bone

appear to be camparable to surgical intervention
However, the advantages of ESWT include no
surgery with no surgical pain and surgical risks

AVNFH
Avascular necrosis on the femoral head

For hip affected by AVNFH, conservative treatments

are generally not successful, and surgeryis indicated
with the type of surgery varying according to the
stage of the disease
Core decompression with or without bone grafting is
considered the gold standard of femoral head
preserving procedures

Other disorders
Several studies reported a positive effect of shckwave
therapy in Peyronies disease and complex regional
pain syndrome (RSD or reflex sympathetic
dystrophy), osteoarthritis of the knee, spine fusion,
malignant cells, gene therapy

Conclusions
In conclusion ESWT is a new non invasive
therapeutic modality with effectiveness, convenience
and safety
ESWT has the potential of replacing surgery in many
orthopedic disorders without the surgical risks
The exact mechanism of shockwave therapy ramains
unknown

Take home message

There is a great potential for traslational research
and development in the armamentarium of
extracorporeal schockwave technology.

Thank you for your kindly attention