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EXTRACORPOREAL SHOCK WAVE THERAPY
(RESWT + FESWT)
GREATER TROCHANTERIC PAIN SYNDROME (GTPS)
(LATERALE HOFTESMERTER)
JENS ERIK JØRGENSEN. MSCPT
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Aalborg. 2018
•FØRSTE BEHANDLING MED ESWT FOREKOM I 1980 – NYRESTEN
•SOM FØLGE HERAF BEGYNDTE MAN AT UNDERSØGE OM DENNE BEHANDLING HAVDE NOGLE
BIVIRKNINGER
•FORSKNING FOKUSEREDE PÅ ZONEN HVOR ENERGIEN VAR MEST FOKUSERET, OG DERNÆST I DET
OMKRINGLIGGENDE VÆV.
•MAN FANDT AT UD AF AT ESWT HAR GAVNLIG EFFEKT MED LAVERE DOSER, OG EN
ØDELÆGGENDE EFFEKT MED FOR HØJE DOSER
•I 90ÉRNE TOG FORSKNINGEN INDENFOR DET MUSKULOSKELETALE OMRÅDE FOR ALVOR FART. MEN
DET ER FORTSAT EN RELATIV NY BEHANDLINGSFORM – DERMED OGSÅ DOKUMENTATIONEN
Jens Erik Jørgensen. MScPT Aalborg. 2018
•PÅ BAGGRUND AF DENNE FORSKNING INTRODUCERES FORSKELLIGE
APPARAT TYPER PÅ MARKEDET I 90ÉRNE
•fESWT I 90ÉRNE: TIL AT BEGYNDE MED 4-6 CM DYBDE, NU 5-20 CM DYBDE
(”ÆGTE SHOCKWAVE”)
•rESWT EFTER 2000: 0 -6 CM DYBDE. (”TRYKBØLGE”). DE VAR BILLIGERE,
MINDRE OG VAR NEMMERE AT HÅNDTERE I FORHOLD TIL DE STORE
fESWT APPARATER
Jens Erik Jørgensen. MScPT Aalborg. 2018
•DEN AFGØRENDE FORSKEL MELLEM DE 2 BEHANDLINGSFORMER ER AT fESWT PRODUCERE TRYK
DER ER 100 GANGE STØRRE EN rESWT, MED EN PULS DER ER 1000 GANGE KORTERE
•I MANGE TILFÆLDE ER EFFEKTEN AF fESWT OG rESWT ENS I DE SUPERFICIELLE LAG INDENFOR DET
MUSKULOSKELETALE BEHANDLINGS FELT
•I 90ÉRNE BEHANDLEDE MAN KUN PATOLOGI DER HAVDE EN DIAMETER PÅ MELLEM 5-10 MM OG I
EN DYBDE PÅ 5-10 CM, DA MAN KUN ANVENDTE fESWT
•EFTERHÅNDEN SOM TEKNIKKEN SKIFTEDE TIL rESWT (EFTER ÅR 2000) , ÆNDREDE
BEHANDLINGSMULIGHEDERNE OGSÅ. MAN BEGYNDTE AT BEHANDLE STØRRE OMRÅDER, OG MERE
KOMPLEKSE TILSTANDE. NU ER DER STUDIER DER OMFATTER BEHANDLING AF TRIGGERPOINTS /
MYOFACIELLE PROBLEMSTILLINGER
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Aalborg. 2018
KUN 3 BEHANDLINGER ?
•DET ER VIGTIGT AT BEHANDLE MED DE KORREKTE PARAMETRE (DOSIS, ANTAL GANGE, TID I MELLEM
BEHANDLINGER OSV)
•DEN ACCEPTERET STANDARD PÅ BAGGRUND AF DE STUDIER DER ER PÅ OMRÅDET I ØJEBLIKKET
ANBEFALER:
•3 BEHANDLINGER MED 1 UGES MELLEMRUM
•2000 SLAG PER GANG
•INTENSITETEN ER DET MAXIMALE PATIENTEN KAN TÅLE
•HVOR KOMMER DET SÅ FRA?
DET ER DEN STANDARD MAN HAR VEDTAGET FOR AT KUNNE SAMMENLIGNE STUDIER – ALTSÅ ER
DET FORSKNINGSBASERET, OG IKKE NØDVENDIGVIS DOSIS-RESPONS RELATERET ELLER KLINISK
”KORREKT”/ RELATERET.
Jens Erik Jørgensen. MScPT Aalborg. 2018
DEN KLINISKE HVERDAG ER IKKE STANDARD VÆRDIER:
•DER FINDES STUDIER DER VISER AT VARIGHEDEN AF SYMPTOMBILLEDET HAR EN INDFLYDELSE PÅ
ANTAL. DVS. MEGET LANG SYMPTOMBILLEDE KAN INDIKERE AT DER ER BEHOV FOR FLERE
BEHANDLINGER , ELLER HØJERE DOSIS (F.EKS. FLERE SLAG).
•BEHANDLING MED rESWT KRÆVER MULIGVIS FLERE BEHANDLINGER, DA DER BEHANDLES MED EN
LAVERE DOSIS - OVERVEJE EVT. AT SKIFTE TIL fESWT.
•FORELØBIG DOG INGEN KONSENSUS, MEN TAGE UDGANGSPUNKTET I STANDARDEN
•DESUDEN ER DET SJÆLDENT AT ESWT ER ENESTE BEHANDLINGSFORM I EN BEHANDLINGS SEANCE.
ESWT KOMBINERES MED f.eks TRÆNING, MANUAL BEHANDLING , VEJLEDNING OSV.
Jens Erik Jørgensen. MScPT Aalborg. 2018
Et eksempel fa den kliniske hverdag
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Herning 2018
MCD: 2.0
Jens Erik Jørgensen. MScPT Aalborg. 2018
MCD: 7
DOSERING – TIL SMERTER
FÅR ALLE SAMME DOSIS ??
Jens Erik Jørgensen. MScPT Aalborg. 2018
SAMME DOSIS ????
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Aalborg. 2018
British Journal of General Practice, March 2005 199 -204
•The incidence of trochanteric pain in primary
care is 1.8 patients per 1000 per year.
•After 1 year 76% of the responders still
suffered from trochanteric pain
•After 5 years approximately 63% suffered.
ESWT AND GTPS ?
Jens Erik Jørgensen. MScPT Aalborg. 2018
PainManag.(2018)8(1),45–55
Jens Erik Jørgensen. MScPT Aalborg. 2018
•GTPS AFFECTS 10–25% OF THE POPULATION IN DEVELOPED COUNTRIES
•APPROXIMATELY TWO-THIRDS OF PATIENTS WITH GTPS ALSO EXPERIENCE
LOW BACK PAIN OR OSTEOARTHROSIS OF THE HIP
•IN THEIR OBSERVATIONAL STUDY, SCHAPIRA ET AL. FOUND THAT 91.6% OF
PATIENTS DIAGNOSED WITH GTPS HAD ASSOCIATED CONDITIONS SUCH AS
PERIPHERAL ARTHRITIS, RHEUMATOID ARTHRITIS AND LUMBAR ARTHRITIS.
•FACTORS ASSOCIATED WITH GTPS INCLUDE AGE, FEMALE SEX, OVERWEIGHT,
GAIT DISORDERS AND LOW BACK PAIN
Jens Erik Jørgensen. MScPT Aalborg. 2018
RESULTS
CONSERVATIVE TREATMENT INCLUDES THE FOLLOWING: (ONLY INCLUDED PHYSIO RELEVANT TREATMENTS)
•CORRECTION OF GAIT DISORDERS (E.G., INSOLES TO CORRECT ASYMMETRIC GAIT AND ORTHOPEDIC SHOES FOR
POORLY ALIGNED FEET)
•RELATIVE REST
•MODIFICATION OF PHYSICAL ACTIVITY
•WEIGHT LOSS
•COLD AND HEAT, STRETCHING AND MUSCLE STRENGTHENING EXERCISES.
•THERAPEUTIC EXERCISE TO PROMOTE TISSUE REPAIR
•HOME TRAINING: ECCENTRIC CONTRACTION AND STRETCHING OF THE GLUTEUS MUSCLES AND ABDUCTORS OF
THE HIP.
•ECCENTRIC EXERCISE IS MORE EFFECTIVE THAN REST FOR IMPROVING TENDON PAIN AT VARIOUS ANATOMIC SITES ,
ALTHOUGH NO SPECIFIC STUDIES HAVE BEEN PERFORMED ON THE GLUTEUS MUSCLES;
•TRAINING WITH RESPECT TO THE DISEASE, TREATMENT AND SELF-MANAGEMENT;
•SHOCKWAVE THERAPY.
Jens Erik Jørgensen. MScPT Aalborg. 2018
THE UNDERLYING ETIOLOGY FOR GTPS IS MOST COMMONLY
THE TENDINOSIS OR A TENDON TEAR OF THE GLUTEUS MEDIUS,
MINIMUS OR BOTH AT THE GREATER TROCHANTER; THE
INFLAMMATION OF THE TENDON IS NOT A MAJOR FEATURE
PainManag.(2018)8(1),45–55
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Aalborg. 2018
Studies comparing MRI and ultrasound with
surgical findings for detecting tears of the gluteal
tendons have recently been systematically
reviewed. Sensitivity reported for MRI has been
varied (33–100%).
Ultrasound appears more
consistently sensitive (79–
100%) and has been proposed
as the first-line investigation for
suspected gluteal tendon
disease.
Hodgson et al. The British Journal of Radiology,
85 (2012), 1157–1172
Sensitiviteten siger noget om hvor god hvor god
testen er til fange de personer, der har
sygdommen
Jens Erik Jørgensen. MScPT Aalborg. 2018
Seo K-H, Lee J-Y, Yoon K, Do JG, Park H- J, Lee S-Y, et al . (2 0 1 8) L on g-term outcome of
low-energy extracorporeal shockwave therapy on gluteal tendinopathy documented by
magnetic resonance imaging. PLoS ONE 13(7): e0197460.
Jens Erik Jørgensen. MScPT Aalborg. 2018
RESULTS
•INITIAL NRS (5.9 ± 1.6) SIGNIFICANTLY DECREASED AT IMMEDIATE (2.5
±1.5, P< 0.01) AND LONG- TERM FOLLOW-UP (3.3 ±3.0, P< 0.01),
RESPECTIVELY. SUCCESS RATES WERE 83.3% (IMMEDIATE) AND 55.6%
(LONG-TERM), RESPECTIVELY. THERE WAS NO CORRELATION AMONG
AGE, SYMPTOM DURATION AND NRS.
Jens Erik Jørgensen. MScPT Aalborg. 2018
•ROMPE ET AL. SHOWED THAT A CORTICOSTEROID INJECTION PROTOCOL WAS SIGNIFICANTLY
MORE SUCCESSFUL THAN RESWT AND EXERCISE AT 1 MONTH FROM BASELINE.
•CSI EFFECTIVENESS DECREASED OVER TIME WITH TREATMENT FAILURES OF 49% AND 52% AT 4
AND 15 MONTHS FROM BASELINE, RESPECTIVELY.
•rESWT TREATMENT SUCCESS AT 4-MONTH FOLLOW-UP, HAD SIGNIFICANTLY BETTER RESULTS THAN
CSI.
•AT FIFTEEN MONTHS FROM BASELINE, rESWT AND EXERCISE TRAINING WERE EQUALLY SUCCESSFUL
WITH TREATMENT FAILURES OF ONLY 26% AND 20%, RESPECTIVELY.
ROMPE JD, SEGAL NA, CACCHIO A, FURIA JP, MORRAL A, MAFFULLI N. HOME TRAINING, LOCAL CORTICOSTEROID INJECTION, OR RADIAL SHOCK
WAVE THERAPY FOR GREATER TROCHANTER PAIN SYNDROME. AM J SPORTS MED. 2009;37(10):1981–90.
Jens Erik Jørgensen. MScPT Aalborg. 2018
•FURIA ET AL COMPARED rESWT WITH USUAL TREATMENT,
CONCLUDING THAT rESWT IS A SAFE AND EFFECTIVE METHOD OF
TREATING PATIENTS WITH CHRONIC GTPS, WITH SATISFACTORY
IMPROVEMENT MAINTAINED FOR AT LEAST 1 YEAR.
•(USUAL TREATMENT AS STRETCHING, STRENGTHENING AND PHYSICAL THERAPY MODALITIES)
FURIA JP, ROMPE JD, MAFFULLI N. LOW-ENERGY EXTRACORPOREAL SHOCK WAVE THERAPY AS A TREATMENT FOR GREATER
TROCHANTERIC PAIN SYNDROME. AM J SPORTS MED. 2009;37(9):1806–13.
Jens Erik Jørgensen. MScPT Aalborg. 2018
A. Fearon et al. / Gait & Posture 52 (2017) 237–243
Question: What are the functional differences between people with
greater trochanteric pain syndrome (GT), hip osteoarthritis (OA)
or an asymptomatic population as measured by
walking, Time Up and Go, single leg standing and strength ?
Jens Erik Jørgensen. MScPT Aalborg. 2018
CONCLUSION:
THERE IS A SIGNIFICANT LEVEL OF DYSFUNCTION AND
IMPAIRMENTS ASSOCIATED WITH GT AND HIP OA. AS ACTIVITY
LIMITATIONS DO NOT APPEAR TO BE DIFFERENTIATED BY
STRUCTURAL IMPAIRMENTS, WE SUGGEST THAT PAIN, RATHER
THAN THE UNDERLYING PATHOLOGY MAY BE THE DRIVING
IMPAIRMENT THAT LEADS TO WALKING AND SINGLE LEG
STANDING DYSFUNCTION.
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Aalborg. 2018
Jens Erik Jørgensen. MScPT Aalborg. 2018
Myofascial pain syndrome (MPS) is
defined as a series of sensory, motor,
and autonomic symptoms caused by a
stiffness of the muscle, caused by
hyperirritable nodules in
musculoskeletal fibers, known as
myofascial trigger points (MTP), and
fascial constrictions.
Jens Erik Jørgensen. MScPT Aalborg. 2018
How do shockwaves affect myofascial pain?
It remains unclear how ESWT may affect TrP´s.
Taking as valid the Energy Crisis Hypothesis, and considering the
mechanotransduction effect of ESWT in other diseases it could be
posited that ESWT in MPS may increase:
•Perfusion ( blodgennemstrømning),
•promote angiogenesis (angiogenese = dannelse af nye
blodkar)
•alter the pain signaling in ischaemic tissues caused by the influx
( tilstrømning ) of calcium.
•Substans P
•Analgetisk hyperstimulation ( frigivelse af endorfiner,
sertonin og kortisol som følge af stimulationen
Jens Erik Jørgensen. MScPT Aalborg. 2018
•HOFTEN ?
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 12 (December), 2014: pp 1588-1594
13 cm
10 cm
Jens Erik Jørgensen. MScPT Aalborg. 2018
•LOW-ENERGY SHOCKWAVE THERAPY COULD PROVE USEFUL IN GTPS. HOWEVER,
THE LACK OF WELL-DESIGNED, VALID CONTROLLED TRIALS SHOULD TEMPER THE
ENTHUSIASM SURROUNDING THIS TECHNIQUE. PAIN M ANAG .(2018)8(1),45–55
DET MÅ VI SÅ GØRE NOGET VED J