ISMST (International Society for Medical Shockwave Treatment)

About ESWT

Consensus statement Recommendations for the use of extracorporeal shockwave technology in medical indications

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Introduction

Building on the experience gained over the past 15 years, the scientific board of the ISMST and experts from National Shockwave Societies around the world, have put together a set of recommendations for the use of shockwave therapy. Purposefully the experts did not apply Cochrane standards for the assessment of the level of evidence. The most recent meta-analyses published by Cochranei shows "platinum evidence" that shockwave treatment has little or no effect at all.

But Cochrane researchers simply cannot ignore the results of several well designed studies from the past which failed to show any efficacy of ESWT for various disorders. By analysing those studies it could be shown that inclusion criteria, treatment parameters or other conditions are afflicted with systemic biases which turn the results of the studies completely into the opposite.

Therefore, as long as the situation is so incoherent the idea of a ranking due to the level of evidence is not reasonable or feasible.

Prerequisites 

In order to prevent improper treatment the following are prerequisites for administering the technology: In addition to a clinical examination, radiological imaging, neurological and/or laboratory-diagnostic tests may be necessary to corroborate the diagnosis. Only a qualified (certified by National or International Societies) physician may use shockwave therapy to treat pathologies, which have been determined by diagnostic testing. For the treatment of bone ailments, a high-energy, focused shockwave with positioning technology is to be used. To treat superficial soft tissue conditions, devices with or without focusing technology may be utilized; close attention must be paid to the depth of penetration of the shockwave source when treating deep tissue structures.

Approved standard indications

Chronic tendinopathies:

  • Plantar fasciitis with or without heel spur
  • Achilles tendon
  • Radial epicondylopathy (tennis elbow)
  • Rotator cuff with or without calcification
  • Patella tendon
  • Greater trochanteric pain syndrome
  • Impaired bone healing function:
  • Delayed bone healing
  • Stress fractures
  • Early stage of avascular bone necrosis (native X-ray without pathology)
  • Early stage osteochondritis dissecans (OD) post-skeletal maturity

Urology:

  • Lithotripsy (extracorporeal and endocorporeal)

Common empirically-tested clinical uses

Tendinopathy:

  • Ulnar epicondylopathy
  • Adductor syndrome
  • Pes anserinus syndrome
  • Peroneal tendon syndrome

Muscular pathologies:

  • Myofascial syndrome (fibromyalgia excluded)
  • Injury without discontinuity

Impaired wound healing

Burn injuries

Salivary stones

 

Exceptional indications/expert indications

Spasticity

  • Early stage osteochondritis dissecans (OD) pre-skeletal maturity
  • Apophysitis (Osgood Schlatter disease)
  • Peyronie’s disease (IPP)

Uses under experimental conditions

  • Myocardial ischemia (extracorporeal/endocorporeal)
  • Peripheral nerve lesions
  • Abacterial prostatitis
  • Periodontal disease
  • Osteoarthritis

The authors group of the DIGEST

Vinzenz Auersperg
Matthias Buch
Ludger Gerdesmeyer
Markus Gleitz
Rolf Rädel
Jan-Dirk Rompe
Wolfgang Schaden
Richard Thiele
Andreas Waubke
Georg Wille

 

The ISMST Managing Board

Roland Hamisultane
Robert Gordon
Sergio Russo
Heinz Kuderna
Vinzenz Auersperg
Wolfgang Schaden
Richard Thiele
Richard Coombs

 

March, 10th, 2008

 

This statement has been voted for publication on the official website of the ISMST by the AGM (annual general meeting) of the ISMST.

Juan les Pins, June 5th, 2008

 

 

Abstracts

Extracorporeal generated shock waves have been introduced for medical therapy approximately 20 years ago to disintegrate kidney stones. Since this time shock waves have changed the treatment of urolithiasis substantially. Today shock waves are the first choice to treat kidney and ureteral stones. A new indication in Urology is the shock wave treatment of IPP where first clinical investigations show promising results. Urology is not the only medical field for shock waves in medicine. Meanwhile shock waves have used in Orthopedics and Traumatology to treat insertion tendinitis, non- or delayed unions, avascular necrosis of the head of femur and other necrotic bone alteration. Another field of shock wave application is the treatment of tendons, ligaments and bones on horses in veterinary medicine. The idea of the shock wave therapy for orthopedic diseases is the stimulation of healing processes in tendons, surrounding tissue and bones. This is a completely different approach compared to urology where shock waves were used for disintegration. This paper gives an overview of basic physical principles of shock waves, history and basic research of shock wave application in medicine.

Introduction and prerequisites and minimal standards of performing ESWT

In order to prevent improper treatment, the following list contents the minimum prerequisites and standard examinations performing ESWT:

  1. Clinical examination
  2. Radiological imaging
  3. Neurological and/or laboratory-diagnostic tests and/or other investigations may be necessary to corroborate the diagnosis.

Only a qualified physician (certified by National or International Societies) may use focused shockwave therapy to treat pathologies, which have been determined by diagnostic testing.

For the treatment on bones, a high-energy, focused shockwave with positioning technology has to be used.

In accordance with most scientific evidence ISMST recommends to use focused generators and high energy levels to treat calcifications.

To treat superficial soft tissue conditions, devices with or without focusing technology may be utilized; close attention must be paid to the depth of penetration of the shockwave source when treating deep tissue structures.

Indications

1.    Approved standard indications
1.1.    Chronic Tendinopathies
1.1.1.    Calcifying tendinopathy of the shoulder
1.1.2.    Lateral epicondylopathy of the elbow (tennis elbow)
1.1.3.    Greater trochanter pain syndrome
1.1.4.    Patellar tendinopathy
1.1.5.    Achilles tendinopathy
1.1.6.    Plantar fasciitis, with or without heel spur
1.2.    Bone Pathologies
1.2.1.    Delayed bone healing
1.2.2.    Bone Non-Union (pseudarthroses)
1.2.3.    Stress fracture
1.2.4.    Avascular bone necrosis without articular derangement
1.2.5.    Osteochondritis Dissecans (OCD) without articular derangement
1.3.    Skin Pathologies
1.3.1.    Delayed or non-healing wounds
1.3.2.    Skin ulcers
1.3.3.    Non-circumferential burn wounds
2.    Common empirically-tested clinical uses
2.1.    Tendinopathies
2.1.1.    Rotator cuff tendinopathy without calcification
2.1.2.    Medial epicondylopathy of the elbow
2.1.3.    Adductor tendinopathy syndrome
2.1.4.    Pes-Anserinus tendinopathy syndrome
2.1.5.    Peroneal tendinopathy
2.1.6.    Foot and ankle tendinopathies
2.2.    Bone Pathologies
2.2.1.    Bone marrow edema
2.2.2.    Osgood Schlatter disease: Apophysitis of the anterior tibial tubercle
2.2.3.    Tibial stress syndrome (shin splint)
2.3.    Muscle Pathologies
2.3.1.    Myofascial Syndrome
2.3.2.    Muscle sprain without discontinuity
2.4.    Skin Pathologies
2.4.1.    Cellulite
3.    Exceptional indications – expert indications
3.1.    Musculoskeletal pathologies
3.1.1.    Osteoarthritis
3.1.2.    Dupuytren disease
3.1.3.    Plantar fibromatosis (Ledderhose disease)
3.1.4.    De Quervain disease
3.1.5.    Trigger finger
3.2.    Neurological pathologies
3.2.1.    Spasticity
3.2.2.    Polyneuropathy
3.2.3.    Carpal Tunnel Syndrome
3.3.    Urologic pathologies
3.3.1.    Pelvic chronic pain syndrome (abacterial prostatitis)
3.3.2.    Erectile dysfunction
3.3.3.    Peyronie disease
3.4.    Others
3.4.1.    Lymphedema
4.    Experimental Indications
4.1.    Heart Muscle Ischemia
4.2.    Peripheral nerve lesions
4.3.    Pathologies of the spinal cord and brain
4.4.    Skin calcinosis
4.5.    Periodontal disease
4.6.    Jawbone pathologies
4.7.    Complex Regional Pain Syndrome (CRPS)
4.8.    Osteoporosis

Contraindications

1.    Radial and focused waves with low energy
1.1.    Malignant tumor in the treatment area (not as underlying disease)
1.2.    Fetus in the treatment area
2.    High energy focused waves
2.1.    Lung tissue in the treatment area
2.2.    Malignant tumor in the treatment area (not as underlying disease)
2.3.    Epiphyseal plate in the treatment area
2.4.    Brain or Spine in the treatment area
2.5.    Severe coagulopathy
2.6.    Fetus in the treatment area