1. Extracorporeal Shockwave Therapy
Extracorporeal shockwave therapy (ESWT)—also known as acoustic compression, myotripsy, and/or shockwave therapy—has rapidly become the gold standard for the treatment of chronic, calcified, mineralized, and fibrotic tissue stemming from longstanding trauma. The etiology of the traumatic injury can vary from repetitive strain to acute, forceful injury. The more consolidated the tissue, the greater the therapeutic target for shockwave treatments. Therefore, it is not surprising that clinicians are experiencing above average results (Table 1) for enthesopathic conditions or where fibrotic scarring is confirmed.
Strength of Treatment
Personal experience has taught me that care must be applied by the provider in the delivery of the focused sound waves emitted from the probe. There is no mistaking when this device is “on,” and subtlety is not usually an adjective used to describe this technology. One merely has to pass over “abnormal” and/or disrupted tissue for it to be felt by the patient. For example, ESWT along active trigger points or a calcified tendon, such as in calcific supraspinatus tendonitis, where the increased stiffness of the lesion causes the mechanical waves to collide with the target lesion, leads to a painful pressure sensations felt by the patient. One particular device, the PiezoWave by Richard Wolf Co., actually has a sono-isolation function that allows the practitioner to routinely scan over normal or healthy soft tissue with no sensations felt until an area of dysfunction (disorganization) is encountered, at which point the patient describes experiencing nociception, felt as a deep achy sensation.
Ease of Treatment
The ESWT units we have tested and used clinically have been relatively simple to use, with only frequency, intensity, and selection of stand off pads being the decision points.
There is a “duality” or balance between possible clinical benefits and the risk of “aggravating” the target condition. All practitioners should use a shared decision-making paradigm, in which the patient ultimately decides whether to proceed or not. Generally, patients referred for ESWT have chronic conditions. They tend to be tired of their pain and usually are willing to do what they have to do for some pain relief. This treatment has a higher probability than most other treatments to lead to post-treatment discomfort. In fact, it is an expected and desired part of the treatment, signaling initiation of the acute phase of healing. Despite intensive pre-treatment patient education, expect a higher rate of patient complaints of soreness after using ESWT. Soreness can be worse than usual because the use of ice or non-steroidal anti-inflammatory drugs immediately after ESWT treatment is contraindicated.
Manufacturers need to find a way to get this technology into the market at a lower price point than exists today. The true shockwave devices can cost $20,000 to $30,000 or more, making them a serious capital investment and too costly for many practices. The health care system is undergoing significant reform, and more than ever, cost containment is a high priority. There is no reason why this technology cannot be made available at lower cost, without which, my sense is that true market penetration will not be achieved. One of the largest prospective markets for ESWT is physical therapy (PT). ESWT would be a serious capital investment for many practices and given that there is no specific and payable Current Procedural Terminology (CPT) code for ESWT, it is a difficult argument to make that providers should purchase this technology in the absence of a reimbursement option.
Probably due to the multidisciplinary appeal of ESWT, combined with early adoption of the first-generation ESWT technology by the podiatry sector, there is a relatively robust and varied research base. Research support is considered a strength of ESWT because numerous clinical trials are on record (>250) and have been published since this technology emerged in the early 2000s.