All right. Hello, everybody. My name is Kira. I'm with the AAPMNR staff. I'm going to kind of get us started with some housekeeping here before we get started since it's about time. So just want to state that the views expressed during the session are those of individual presenters and participants and do not necessarily affect the positions of AAPMNR. AAPMNR is committed to maintaining a respectful, inclusive, and safe environment in accordance with our code of conduct and anti-harassment policy available at AAPMNR.org. All participants are expected to engage professionally and constructively. The activity is being recorded and will be made available on the Academy's online learning portal. And an email will be sent after this activity with a link to bring you to the recording and evaluation. For best attendee experience during this activity, please mute your microphone when you're not speaking. And if you do have a question, please use the raise your hand feature and unmute once you're called upon. Or you can use the chat feature to type in your question, but we will be doing questions at the end. So that's about it. Thank you guys for coming and I will hand it off. All righty. Thank you for joining. So my name is Haruki Ishii. I'm one of the clinical assistant professors at NYU Langdon Hospital within the Department of Rehabilitation. And I'll be talking about application of the shockwave on common MSK conditions today. And I would like to thank the AAPMNR for the opportunity for me to present here today. All right. So I have no disclosures. So these are the learning objectives for today's lecture. So to understand the mechanism of action of extracorporeal shockwave therapy in the treatment of common MSK conditions, to review the clinical application of shockwave therapy in MSK disorders, and then to discuss the safety and effectiveness of shockwave in common MSK pathologies, including tendinopathies, OA, and bone stress injuries. So let's start with the very basic question of what is shockwave, right? So shockwave is a non-invasive intervention that creates sound or pressure waves that propagate through a tissue to stimulate interstitial and then extracellular responses. Such biological responses include increased collagen synthesis, cellular proliferation and wound healing, and neovascularization leading to tissue regeneration. So the shockwave force emerged around the 1980s as extracorporeal shockwave lithotripsy. And it is a form of energy that can develop a peak pressure about 1,000 times higher than that of ultrasound. So the shockwave therapy can be subdivided into two types, focal shockwave therapy and then radial shockwave therapy. And the radial shockwave is also referred to as a radial pressure waves. So the focal shockwaves are produced by the generators seen on the left of the screen here, consists of a negative phase and achieve much higher intensity on a target deep in the tissue to be treated. So-called radial waves, which can be seen on the right side of the screen here, are lower intensity pressure waves generated by pneumatic mechanism without a negative phase. So the fundamental difference between the two types of shockwave therapy are illustrated on this figure here. So as you can see, focal shockwaves reach their maximal energy point at the deeper in the body tissues, whereas radial shockwaves have its point of maximal intensity more superficially. So certainly, this observation still depends on the device and energy setting that you use during the treatment. However, the fact remains that the focal shockwaves will still propagate farther and have more impact on tissue located deeper in the tissue, or deeper in the body, sorry. So what's the mechanism of action? So the mechanism of action by which the shockwave produce their therapeutic effect is still not fully understood yet, but shockwaves are thought to have mechanical and cellular effects, improving the tissue healing and outer pain signal. So it has been hypothesized that the biological effects of the shockwave are consequence of the mechanotransduction, where the vibration of the tissues lead to regeneration and healing. Shockwave has also been shown to have effects at the cellular level by triggering the release of ATP for the activation of cell signaling pathways, and also altering the function of the ion shells in the cell membrane. So the curve generated by each shockwave type is reflected in this figure. So with the focal shockwave treatment, the area of the force is much, much smaller. Hence, the energy can be delivered deeper, and there is more pressure developed per square inch of tissue, as you can see here. So the end result of this is that the focal shockwave therapy causes more of a cellular type response. On the other hand, the forces generated by the radial shockwave is distributed over a greater area, and is more beneficial for soft tissue stimulation. And I know this is a bit of a busy slide, but the therapeutic effects of the shockwave include pain reduction, bone healing, and then tissue repair, which are mediated by different mechanisms as shown in this table. I will be going over every little detail that's listed on this table, but I want to pick up some of the key points that you probably should know, how the shockwave basically kind of works to deliver the therapeutic effects. So the shockwaves may cause microcavitation and the release of nitric oxide, which leads to downstream anorexic angiogenesis and then anti-inflammatory effects. It also may increase the collagen synthesis through several mechanisms, including increased TGF-beta-1 and IGF-1, increased IL-6, IL-8, MMP-2, and MMP-9, and there's also an increased glycosaminoglycans as well. In addition to these effects, they can increase the tenosyte proliferation and then osteoporogenitor differentiation and also have an analgesic effect through the stimulation of non-susceptive C-fibers, increase in pain-inviting substances, and also non-susceptive hyperstimulation via the gait control theory. So there are several parameters that can be adjusted with each shockwave treatment, and they are listed here. So these should all be considered when interpreting the literature regarding the effectiveness of the shockwaves. I'll be covering some of them when I'm going through some of the literature later on in the slides. And EFD is probably the most common parameter that gets adjusted with shockwave application, and it's defined as the energy per impulse at the focal point of shockwave. So this is the literature evidence and clinical recommendations for the shockwave parameters. So when looking at the EFD, one would likely want to try to administer as high as the patient can tolerate, but there are certain recommended intensity based on what you're treating patients for. So for example, if you're addressing the nerve-related injuries with the shockwave treatment, you want to consider using the low energy level, which is less than 1.1 millijoule. On the other hand, if you're treating, whether it's a tendon or fascia-related injuries, you want to use the moderate energy level, which is defined as between 0.1 to 0.25 millijoule. And lastly, a lot higher energy level, so greater than 0.25, and most often I use 0.3 to 0.4 for the treatment of the bone-related injuries. And in terms of the impulses that you're going to be delivering during the treatment, you should try to deliver at least 2,000 up to 3,000 shocks, that's 7 to 8 hertz for focus shockwave, and then 12 to 15 hertz with the radial shockwave. You can consider lowering the frequency if too painful for the patient to tolerate the procedures, but certainly you can adjust these numbers according to the patient's response and also what you're treating the patients for. And literature suggests three essentials to start. The treatment, so basically patients come in once a week for three weeks and perform additional treatments if symptoms persist. However, it is important to note that shockwave-induced tissue repair response and thus they require time to achieve their clinical effect. And the literature suggests that the clinical improvement from the shockwave has been reported to occur within three to 12 weeks after the treatment, and the benefits persist for up to two years compared to placebo. So before you consider additional treatment, you want to at least give four to six weeks after the third treatment to see if they had any benefit from the shockwave treatment before considering additional interventions. And when you're applying the shockwave for the treatment, you will target the site of maximal tenderness to palpation, and the procedure can be quite painful. When I use shockwave or when I used to use shockwave, I tried to achieve at least pain level between five to seven to achieve the therapeutic effect of the shockwave. So this can be quite painful for some patients. And I often get asked by the patient that, hey, can we actually try to use lidocaine so that they don't feel anything, right? But this kind of brings a good point of use of anesthesia during the procedure. So HACA et al found that the shockwaves applied under local anesthesia was no more effective than a placebo at 12 weeks follow-up. And other studies such as that of PURIA et al and many others actually show similar results. So even though it is an uncomfortable procedure, it is recommended that the shockwaves are applied without local anesthesia. So as I said, shockwave is a noninvasive procedure, and it is often used when patients fail other conservative treatments, including rest, ice, NSAIDs, or physical therapy. And it is a noninvasive option with minimal side effects, and often allows athletes or patients to continue to participate in their sports or activities for most conditions as pain allows. Therefore, it may be preferred to more invasive treatment options such as corticosteroid injections, tenotomy, or platelet-rich plasma injections, which carry the risk of tendon rupture or require variable amounts of time away from the sports. So in this slide, I listed several different pathologies subdividing to tendon, bone, and muscle pathologies that the shockwaves are used for. And the ones that has asterisks on, so lateral congitis and then plantar fasciopathy are actually FDA approved. And so this table provides the guidance on recommended intensities, pulses, and number of sessions for the main indication of the shockwave in MSK conditions. And this table shows the effectiveness of shockwave therapy for the following pathologies presented by the level of evidence. So the study shows that the best results with shockwave therapy are achieved in patients younger than 60, and with those who have a symptom duration of less than 12 months. So now that we know a little bit about the shockwave and its mechanism of action, I want to specifically talk about the tendinopathy and then shockwave. And before diving into different literature, I want to talk a little bit about the tendinopathy. So tendinopathy is characterized by abnormalities in the microstructure, composition, and sterility of the tendon. And it is a spectrum of changes that happen in damaged and diseased tendons leading to pain and reduced function. Thank you. So a normal tendon is composed of a highly arranged collagen fibers with spore cells, mostly tenosites, aligned along the lengths of the collagen fibers, as you can see pictured in here. However, an altered or diseased tendon consists of a fragmented collagen fibers, which is disorganized, and also accumulation of glycosaminoglycans and increased microvascular associated with a new innervation, which leads to adverse changes in the material properties of the tendon. So this is a fairly old paper, but I actually like it. I'm going to bring it. But in 2008, Cook and Porden proposed that there is a continuum of tendon pathology that has three stages, reactive, tendon disrepair, and then degenerative tendinopathy. So adding or removing load is the primary stimulus that drives the tendon forward or back along the continuum, especially in the early stages. So if the load is modified, this may allow the tendon to return to a previous level structure and capacity within the continuum. However, if there is excessive load applied to the tendons, plus minus other risk factors, this can progress tendon towards the degenerative phase of the model, which is down here. A few years later, so in 2016, their group published a revised paper where they came up with the model called Reactive on Degenerative Tendinopathy. So this refers to clinical cases where the structurally normal portion of the tendon may drift in and out of the reactive response, so going back and forth here. So the degenerative portions of the tendon appear mechanically silent and structurally unable to transplant the tensile load, resulting in the overload in the normal portion of the tendon. So the aim of the treatment for the tendinopathy is to push the tendon into the green section with relatively little pain and good function. So this is where you want to try to achieve or bring the patients back to when you're treating patients with tendinopathy. So tendon structure can be normalized in the early stages of the continuum where rehabilitation or physical therapy can push the tendon up the continuum. However, in the latter stages of the continuum, moving up the continuum may not be possible at that point. So the intervention should be focused in the basically moving the tendon sideways going towards the left of this picture. And it is important to note that the interventions directed solely at pain will not drive the tendon to a positive outcome as they do not address their dysfunction, such as motor inhibition, strength and power deficit, and or tendon load capacity. All right, now I'm gonna be talking a little bit more specific about each tendinopathy that can be treated with shockwave. I didn't pick all of them, but I picked some of the highlights since we have a lot of conditions that we can actually treat with shockwave. So I just wanted to kind of give you some of the highlights. So starting with the rotator cuff tendinopathy. So this was the study done. So it's a program review done in 2020 looking at the shockwave therapy for rotator cuff disease with and without calcification. So this review included 32 randomized control and clinical control trials with more than 2000 patients participated totally. And 25 of the trials looked at the patients with calcific tendinopathy. Five of them looked at the patients with non-calcific tendinopathy. And then two of them looked at the patients with either calcific or non-calcific tendinopathy. And out of 32, 12 of them compared the shockwave to placebo. 11 of them compared the high-dose versus low-dose therapy. And the rest of the studies compared the shockwave with various other interventions. 26 of them looked at the focal shockwave, and then six of them included the radial shockwave as the treatment with various protocols. So essentially what they found was that when comparing the shockwave with placebo at three months follow-up, there are some improvements in the pain and their function scores. However, neither of them met the minimally or minimal clinically importance difference. And what the authors concluded from this review was that there were very few clinical important benefits of shockwave therapy on rotator cuff tendinopathy. However, there were wide clinical diversity, as I discussed briefly, and a variety of treatment protocols which may have underestimated some of the potential benefits that the shockwave can provide if some of the trials tested subtherapeutic doses and thus further testing is needed. So a little bit more recently, in 2024, this review or this review article was published, which included 16 randomized controlled trials with more than 1,000 patients included in these analysis. And what they found was that the shockwave treatment significantly reduces shoulder pain and enhances their function. You know, patients with rotator cuff tendinopathy, except for that their shoulder abduction range of motion did not really change, or there was no difference between the shockwave and then the control groups. They also did some subgroup analysis in this study, where shockwave remains effective in mitigating shoulder pain and enhancing shoulder function, irrespective of the administered energy doses. And also, both radial and focal shockwave groups exhibited superior improvements in the pain score and also the shoulder function depicted by the customary score compared to the control group. So essentially what they concluded was that the shockwave can provide better pain relief, functional recovery, and also maintenance of function in patients with rotator cuff tendinopathy compared to the control group, but the evidence is still limited. So lateral conglutinosis, so this is one of the FDA-approved indications for the shockwave. So this study was done back in 2019, where they compare the effectiveness of the shockwave versus ultrasound. So this meta-analysis of five randomized control trials completed by Yan et al, compared shockwave to ultrasound therapy, which showed a statistical significant improvement in the short-term pain, so at one, three, and six months, and in grip strength at three months in shockwave group compared to the control. However, there was no difference in function at one and three months in the shockwave group compared with the ultrasound group. So this is another study or review article looking at 40 different randomized control trials with closer to 2,500 patients. In the review included, and essentially, this paper looked at the shockwave and five different injection therapies, including corticosteroid, autologous whole blood, platelet-rich plasma, bushland toxin, and then also dextrose prolotherapy for the treatment of the lateral hyponylitis. And just looking at the shockwave, what they found was that the shockwave outperformed placebo for medium-term pain relief and also was ranked as the most optimal short- and then medium-term grip strength recovery compared to others. Moving on to the lower extremity tendinopathy, so starting with the proximal hamstring tendinopathy. So in this study, Chio et al compared concerted management, which included NSAIDs, physical therapy, and an exercise program to a radial shockwave. So the patient received the treatment once a week for four weeks, and 2,500 shocks were delivered at EFD 0.18 millijoule for the treatment of proximal hamstring tendinopathy in a randomized controlled trial of 40 professional athletes. So they found a significant improvement in pain and in function at three months in shockwave group compared with the concerted management group, with 85% of the patients in the shockwave group achieved at least 50% pain reduction. And most strikingly in this paper, what they found was that about 80% of athletes who were treated with shockwave returned to pre-injured level of sports participation by three months, with 0% of those in the concerted treatment group returned to sports at three months. So it's a huge difference there. Moving on to gluteal tendinopathy. So there are a couple of studies looking at the gluteal tendinopathy treatment with both radial and then focal shockwave. So I'm gonna start with the radial shockwave studies and then kind of move on to the focal shockwave. So the first study that I looked at was the FURIA et al. So they assessed the utility of the radial shockwave. They only actually did one session of the shockwave treatment for these patients with 2,000 shockwaves with four bars for greater drug-induced pain syndrome. And essentially they showed improved short and long-term outcomes compared with the baseline with 76% of the athletes who received the shockwave returning to sports within one week to three months. The study done by Rampe et al. also show long-term superiority of the radial shockwave. For this study specifically, they actually did sessions three times. So once a week for three weeks with three bars and then impulses or the shocks of 2,000 shocks delivered for each treatment. And then it seems like patient did better compared with the corticosteroids at the 15 months follow-up period. And Raman assessed the utility of the focal shockwave this time, which was given once a week for three weeks with 2,000 shocks delivered at the EFD 0.2 module. And what they found was that the shockwave treatment resulted in an improved pain at two months and improved function at six months when compared with the sham treatment. And the other study also showed a improved pain reduction at two and six months with focal shockwave when compared to ultrasound therapy. And with this study, the patient received treatment once a week for three weeks with 1,800 shocks delivered at the EFD 0.15. And this was a randomized control trial as well. So looking at the patella tendinopathy, so Zorver et al compared to the focal shockwave treatment. So three weekly sessions, EFD of 0.07 to 11.7, like a plus minus 11.7 module. So there was a quite a big difference in terms of the energy level that they were giving for these patients. And the impulses were delivered at 2,000 shocks to placebo to a treatment in seasoned athletes, right? So these athletes included volleyball, basketball, and handball players. So of the 127 symptomatic athletes, 62 were eligible for the study. So they were randomized into two groups, shockwave or the placebo equally. And what they found was that there was a significant, simply more athletes who noted subjective symptom improvement at one week following the shockwave treatment. However, there was no difference in pain and function at 12 and then 22 weeks. So there was not much of the effect of the shockwave treatment with this specific study at 12 and 22 week mark, even though the athletes noted some subjective symptom improvement at one week. So in terms of the Achilles tendinopathy, so Ramson et al compared the focal shockwave, again, three sessions every one to two weeks with EFD of 0.12 to 0.51, which I feel like it's a little bit too much for the treatment of the tendons, to be honest. And then the shocks were about 2,000 shocks every session to a sham treatment in a patient with a chronic mid-portion Achilles tendinopathy and a figure on the left side. So this is the figure that I'm gonna be talking about a little bit. Those individual improvement in the AOFAS score in relation to pre-treatment score. So there was a greater improvement in the intervention group, which is represented with the blue diamonds here than the control group, which is represented in red diamonds. The figure right next to it also shows a weekly pain score with various activities. And they found that there was an improvement in pain in both control and then intervention group at eight and in 12 weeks. So in general, as we know, insertional Achilles tendinopathy is historically more difficult to treat than mid-portion tendinopathy. So Zhang et al actually looked specifically for the treatment of the insertional Achilles tendinopathy with shockwave. So they found that of those who received the radial shockwave so this was five weekly sessions, EFD of 0.06 to 0.1 millijoules with the impulse of 2000 shocks. And those who self-reported to be sports active had better five-year pain and functional outcomes suggesting that athletes may have better response to shockwave than the general population. Additionally, the same author concluded that the use of shockwave did not have any effect on the sonographic presence of the intra tendinous calcification which you can see here. So there's not much of difference between the two pictures. So between 5.2 and 4.96 and neovascularization in the patients with insertional Achilles tendinopathy after the treatment. And lastly, plantar fasciopathy. So this is the other FDA approved indication for the shockwave. And so basically this was a meta-analysis study including nine studies involving about 1000 patients looking at the shockwave treatment for the chronic plantar fasciitis. And what they found was that the shockwave had higher improvement rates than placebo group and both focal and then radial therapies had greater therapeutic success in pain relief than the placebo. However, they also noted that there was a significant heterogeneity observed in the radial shockwave therapy group versus placebo. So in conclusion, what they suggested was that the focal shockwave therapy can relieve pain in chronic plantar fasciopathy or fasciitis as an ideal alternative option if they continue to have pain after other concern management has been failed. So I'm gonna be covering a little bit more in depth in terms of the tendinopathies. So this study included a total of 384 patients who were diagnosed with a tendinopathy in general, both upper and lower extremities. And out of which 326 patients were randomized into a shockwave intervention groups and then 58 patients of them were in the control group. And in terms of the control group, they did not really define the treatment for these tendinopathies. I'm not 100% sure what they actually did, but in the end, what they found was that the pain function and quality of life of these patients improved after shockwave treatment compared to the people in the control group. And this is a narrative review study done by Borton looking at the efficacy of the combined shockwave and exercise on tendinopathy. And some of the key findings from the study were, one, eccentric exercise combined with shockwave is feasible and it may be more effective than either alone for Achilles tendinopathy and then lateral aconititis. Secondly, isotonic or eccentric exercise combined with shockwave is more effective than either alone for rotator cuff tendinopathy. And this was particularly true when calcification exists. And lastly, shockwave does not provide any additional effective eccentric exercise for rotator tendinopathy, therefore either treatment in isolation is recommended at this time, with eccentric exercise being the most recommended treatment. And in this narrative review, two studies evaluated the use of shockwave in the military population for lower extremity injuries, specifically in the treatment of MTSS and implanted fasciitis. And both studies had favorable outcomes in the use of shockwave. And the reminder of the studies predominantly included athletes. So the majority of the studies demonstrated an improvement in pain and return to activity using shockwave. And among these studies, two studies using PRP as a treatment arm identified similar short-term outcomes compared to shockwave for Achilles and pituitary tendinopathy. So this was the study done by Adam Tamportes' group who looked at the use of shockwave for athletes and physically active individuals. So this systemic review included 56 studies with more than 1800 athletes or physically active individuals. And what they found was that the shockwave treatment alone was effective in plantar fasciitis, lateral hip onritis, and proximal hamstring tendinopathy, and was effective as an adjunct to exercise treatment in MTSS and pituitary tendinopathy. All right, now we're gonna be moving on to bone stress injuries. So briefly, bone stress injury is a common overuse injury that can result in prolonged time away from sport. So excessive demand on the bone with a spectrum ranging from a stress reaction to stress fracture is what's defined as a bone stress injury. And the gold standard for clinical evaluation with bone stress injuries is still an MRI. So with grade one BSI, you're gonna see a periosteal edema on T2-weighted imaging with a normal bone marrow on T1 and T2. Once it goes to grade two, you're gonna see a periosteal and bone marrow edema on T2 imaging. With grade three, you're gonna still see a periosteal edema on T2. However, there is a corresponding dropout on T1 and lastly, grade four, you're gonna see a visible fracture line, which is commonly referred to as a stress fracture. So Hotzinger reported the first case of stress fractures treated with Chalkwave back in 1999 at the ISMST meeting in London. So he studied the role of the MRI in the diagnosis of multiple stress fractures of the tibia and then treated a case with high energy Chalkwaves with good results, but what's the science behind it, right? So Chalkwaves increase the endogenous production of the growth factors, nitric oxides, and then free radicals that result in an increased healing process. Specifically looking at the bone, there is a clear effect in neovascularization, periosteal stimulation and osteoinduction. This final outcome is useful in the treatment of delayed unions or delayed unions, avascular necrosis and stress fractures. And looking at the mechanotransduction effect of the Chalkwave using high energy Chalkwaves, there is a clear stimulation of vascularity as well as the osteoblast differentiation from the mesenchymal stem cells and inactive cells. There's also a clear effect on the periosteal cells that contribute to cell migration and the development of calcists in healing impaired bone. So Garcia et al evaluated the effectiveness of the Chalkwave in a military population with MTSS. So this was the study that was included with one of the narrative review article that I briefly went over. So this was a single blind randomized control study in 42 subjects. So there were 33 men and nine women with unilateral chronic MTSS. And these subjects were normally assigned to either one session of focus Chalkwave. So 1500 pulses were given at 0.2 millijoule plus a specific exercise program or the exercise program alone. So essentially what the study showed was that the patients in the intervention group were able to run longer with a mean running time of 17 minutes and 33 seconds compared to four minutes and 48 seconds in the control group. Also the mean VAS after running was 2.17 in the Chalkwave group. And then it was 4.26 in the exercise only group. And lastly, the Chalkwave group had a significantly higher modified roles and a monthly score where greater than 80% of the patients rated the treatment outcome as excellent or good. Whereas only about 37% of the patients in the exercise only group rated the same way. So this was another study done by Moretti looking at the Chalkwave in the treatment of the stress fractures. So they included 10 male elite and sub-elite soccer players who had a delayed union or non-union tibia, tibial fracture or fifth metrosexual stress fractures. So these athletes received three to four sessions of Chalkwave with low to middle or medium energy level with 4,000 shocks delivered at each treatment. And what they found was that the Chalkwave treatments was effective in pain relief and bony union and allowed them to return to full competition at 10 weeks to 24 weeks after the treatment with one patient requiring a repeat treatment to achieve bony union. And Takiero also studied five athletes with stress fractures that did not respond to conservative management back in 2007. and he used a very high energy level 0.29 to 0.4 millijoule of EFD was two to 4,000 shocks delivered in one session and was able to significantly reduce the recovery time to three to six months in these athletes. So kind of covering other muscle injuries before I talk about osteoarthritis with shockwave. So this was the study done by Morgan et al, who conducted the study to compare layoff times achieved by treating acute muscle injuries in elite football players with a multimodal therapy approach that included a specific protocol of almost daily radial extracorporeal shockwave therapy. So there was a total of 20 acute muscle injuries of which eight were labeled as type 1A, which is muscle tightness injuries, five were type 2B, which is muscle strain, four were type 3A, which is partial muscle tear injuries, and then three of them were contusions. So the in vitro analog scale scores are marked by the red dots. I don't know if you guys can actually see this because it came out pretty small, but essentially the scores are marked by red dots. So zero being no pain, 10 being maximal pain, and the player's status by blue dots, right? So one means that they are injured, two is in rehabilitation, three is they're back in training, and then four is fully fitted or returned to play at that point. And diagram A through S represent the treatments with a radial shockwave, whereas diagram T, so the last one was the patient who was treated with focal shockwave therapy. So what they found was that in this study was that the players were able to return at the mean of 3.3 days for type 1A muscle injury, 6.2 days for type 2B, and then 13 days for type 3A muscle injuries after the treatment with radial shockwave. And Oster et al essentially looked at the chronic muscle injuries and then treatment with the shockwave. So they included eight amateur athletes with chronic muscle injuries, and these athletes received a low energy shockwave with PT where they had an improvement in pain, muscle strength, and Tegner score at the end of the treatment that was at around six to eight weeks. In the meantime, to return to sports in these patients were about 8.1 weeks after the first shockwave treatment. All right, moving on to osteoarthritis. And specifically, I'm talking about Neo-A just because there are a lot of studies done or looking at it for the Neo-A, and I couldn't find a lot of studies in terms of the other types of the osteoarthritis. But in general, shockwave was proposed as a treatment option for the Neo-A for several years at this point now. And Zell et al were the first to report the application of shockwave in Neo-A in humans. So they were doing a lot of animal studies as well, which demonstrated patient safety, pain relief, and then functional recovery. So to find the most appropriate anatomical region of the Neo-A for applying shockwave in a preclinical study in rats, Wang et al conducted a study and they found that the shockwave treatment on the medial tibial subcondyle bone produced better results than the shockwave that was applied on the lateral and other location in the early Neo-A. So Ann et al summarized the potential role of the shockwave in treating OA in this diagram. So basically what they said was that the shockwave could possibly promote the cartilage regeneration by activating chondrocytes and then decrease the number of osteophytes. It can also increase osteocytes activity and decrease the CGRP, sensory nerve fibers in the subcondyle bone. On top of that, shockwave could also alleviate chronic inflammatory activities in the whole joint through down-regulating inflammatory cytokines. And overall, shockwave could reverse the pathology of OA progression to some extent, is what they concluded. So this was the study done in 2023 by Cho and et al, and they included 18 subjects with mild Neo-A who are enrolled and randomized to one of two treatment groups, either active or sham. And patients in the experimental group received 0.05 mJ total energy with 1,000 pulses weekly for three weeks, so three sessions total. And subjects were assessed before, immediately after, and then one month after the last treatment. So both the experimental and then control groups actually improved in terms of the OA symptoms, as you can see in this table here. But the height of the supercalar fusion decreased with time course in the experimental group, and that was more significant compared to the control group at the follow-up. And this is a randomized control study by Cho et al, comparing the effectiveness of focus and radial shockwave treatment for the Neo-A. So there were 42 patients randomly assigned to one of the two groups. And compared with the baseline participants of the both groups reported significant improvements in all the outcomes measured during the study at the end of four and eight weeks of treatment. However, the results for the focal shockwave were superior to the radial shockwave in terms of the VAS score, LUMEX score, and then the distance in the six minute walk. So basically what they concluded in this study was that the focal shockwave treatment may actually have more beneficial than the radial shockwave treatment for the Neo-A. So the aim of this study was to compare shockwave therapy with other treatment modalities for the treatment of the Neo-A. And what they found in this study was that there is a significant improvement in both pain, pain reduction and functional improvement compared to placebo, corticosteroid, hyaluronic acid, medication, and then ultrasound in the shockwave group. And interestingly, there was significant difference between shockwave and PRP in pain reduction, but not in functional improvement. So it seems like functionally both patients who received shockwave and PRP achieved the same functional levels, but pain reduction was more in the shockwave group. So this was the study Cisco review article done by Wang. And then essentially they included nine articles. And then the results showed that the shockwave group had significant improvement in pain relief compared with a control group through 12 months based on LUMEX and VAS scores. And compared with the baseline level, the participants had significant improvement in pain relief at most follow-up points. So one weeks to 12 months based on LUMEX and VAS scores. And also the patient showed significant improvement in physical function at six and then 12 months follow-up when compared with the control group and for a follow-up one to 12 months when compared with the baseline level. And additionally, only minor complications were observed after the shockwave treatment. So shockwave itself has been shown to be a relatively safe procedure. The vast majority of the studies have found no significant adverse effects or events during or after shockwave applications. Some of the adverse effects that you can encounter with a shockwave treatment could include pain, skin irritation, nerve irritation. But like I said, there was no major adverse events that was reported in the literature, including tendon rupture or hematoma. Some of the control indications for the shockwave is included here, but those patients who have a poorly controlled coagulopathies or acute infection, you shouldn't be providing the shockwave treatment. Those who are pregnant or those who have a complete tendon rupture, you shouldn't be considering the shockwave as a treatment options. And also in a pediatric populations, you wanna avoid a direct application of the shockwave to the growth plate, especially if it's not closed. So you wanna make sure that you don't do that. For example, like Oshkosh ladders, if their growth plate is still open, you probably should be avoiding applying the shockwave one because it's very painful, but also it can stop the growth essentially. And in terms of the post-procedural guidelines, so like I said, it is a very simple procedure. So like I said, it is generally believed that shockwave can be safely used as a treatment option for in-season athletes without necessitating time away from sport, right? So pain may increase slightly on the day of the procedures, but they can often continue activities as tolerated as long as the pain level is less than three out of 10. And if the athletes can rest based on the timing in their sports season, that is probably recommended. But if they need to continue, you can certainly continue the activities without hindering the effect of the shockwave. And shockwave likely works best when combined with adequate rest and an optimal rehabilitation protocol. So it is not considered a substitute, but more of a supplementation for the physical therapy. And only a few studies have examined efficacy of concurrent physical therapy and shockwave treatment, but these studies have shown good efficacy of combined treatment. So you can certainly continue analgesic meds such as Tylenol as needed if the pain is bad, especially after the protocol. However, I generally recommend avoiding NSAIDs during and after treatments. So the use of concurrent NSAIDs and other analgesics is infrequently described in the literature, so it is hard to draw a conclusion from it. But there is one study that discontinued NSAIDs and analgesics for two weeks before and four weeks after the shockwave treatment, but there is not additional evidence to support this. But I usually recommend at least not taking the NSAIDs or anti-inflammatory for two weeks prior to the treatment, and then at least two weeks, maybe up to four weeks after the treatment is over. So take-home points. So one, shockwave is a safe treatment option for peripheral MSK conditions. Treatment of shockwave requires no to minimal time away from sports or other activities, and pain reduction functional improvement has been shown or has been seen in different MSK pathologies as you saw during the lecture today. And there is no single optimal shockwave protocol that has been identified, so certainly other future studies need it to find the best protocols for each conditions that you're treating. And then again, this is not a substitute, but more of a supplement for other conservative management. So certainly don't use the shockwaves just as a sole treatment for the patients, but certainly add it to the physical therapy if they're not responding well to the PT or other conservative management. So these are some of the references I have. I'll stop sharing my screen, but if you guys have any questions or anything, please let me know. All right, so one of the questions that's in the chat, so which training do you recommend? So in terms of the training, so I actually did a lot of shockwave treatment or training during the fellowship from the attending, but also you can reach out to the company because sometimes they do some training sessions as well. So you can certainly get a certification or at least get a couple of training sessions to make sure that you can feel comfortable. But for those who are in training, whether you're residents, fellows, PA, MPs, you can certainly get a training from the attending that you're working with. And then certainly I think that's how I actually learned how to apply the shockwave treatment for the patients. So those are some of the stuff that you can certainly do, but you can certainly reach out to the company and then they are more than happy to do a workshop to get those kinds of training for the trainee. Thanks for the lecture, Dr. Ishii. A quick question for you. I know you mentioned how like for, you'll initially start with like three treatments once a week for three weeks and then follow up with them, you said like about four to six weeks afterwards. When do you decide, I guess, what's your next steps? Like say they are getting some improvement, maybe not 100% better. What's your typical like subsequent treatment protocol if you want to consider it again? Sure. So I don't think there's a good literature in terms of like how many additional sessions you should be considering for the patients for those who did not achieve 100% improvement from shock, like first three sessions of shockwave, right? So it becomes more anecdotal to me, but if they have at least 50% improvement from the first three sessions, I would consider additional sessions to see if I can get that rest of the 50%. However, if they didn't achieve that 50% improvement after four to six weeks from that three sessions, then I would consider maybe other modalities, including PRP, Tenex, and other more invasive treatment, I would say. But I would at least give four to six weeks before you decide to move on to other treatments or not, but 50% is my cutoff point, at least. Makes sense, thanks. And how often you can repeat shockwave. So in terms of the sessions, you can certainly repeat more, you know, fairly frequently, but like I said, if they achieve, you know, 100% improvement after three sessions, and hopefully the effects of the shockwave last anywhere from one to two years, you probably don't want to consider doing or repeating those procedures within those one to two years. But once the pain comes back, and if they don't respond to physical therapy, I would certainly consider repeating the therapy or the sessions for those patients. But I've seen shockwave given probably up to like eight to 10 times from the initial treatment as well. So certainly there is a couple of different variables as well, and also if you're treating bilateral, right? So some people have bilateral, I don't know, glutendinopathies, and I certainly have done application of the shockwave bilaterally simultaneously. So you don't really have to do one and then other, or like a PRP, you may want to wait, you know, you don't want to consider doing bilateral PRP injection with the glutes, just because it could be one painful, they may not get the most benefit out of it, just because they can't really do a lot of exercises with that, but for the shockwave, I definitely done, you know, whether unilateral or bilateral treatment simultaneously, and you don't really have to give any sort of a timeframe between treating one or the other, so. So what the code, okay. In terms of the billing questions, so the code that you can use is 0101-T, is the one that I use for the coding, but this is typically not covered as far as I know. So NYU, and then at Emory, where I trained previously, we were charging 200 for a session. So usually, you know, we charge about 600 initially, and then if they need additional sessions, then you charge 200 for a session that they need it. Honestly, if there's anyone in the group that does it differently, you can certainly chime in, but that's how I build it during my training, so. Okay, and regarding the types of the shockwave, so it depends. Usually, I wanna use focus for the tendon-related or bone-related issues. I do recommend using radial for the muscle-related. So radial more for soft tissue, focus for tendons or bones, right, because they can actually propagate the wave deeper to the tissues. So certainly, I actually combine both sometimes. So if, let's say I'm treating either Achilles tendinopathy or plantar fasciitis, I apply the focal shockwave on the tendons and plantar fascia, but then I also use radial to apply that in the calf region to loosen up those calf muscles, because sometimes that can be contributing to their symptoms. So certainly, you can use both, but if you're specifically treating tendons, focal is better. For the bones, usually you wanna do a focal shockwave, not radial. For a couple of different reasons, one, radial shockwave is probably too painful for the patient to tolerate, and also for the focal, you wanna use higher energy level for the stress fractures or nonunion. So certainly, I would recommend using focal for that kind of pathology. Any other questions or comments or? Good question. So for the specificity management, I'm not sure if people actually use shockwave for the specificity management. I didn't look into that, actually. I'm guessing it will be radial, but I'm not 100% sure, actually, on the literature. So I have to do a little bit of digging in terms of the specificity management. I've encountered in literature for spine-related issues, but again, I didn't look into it too much because I haven't seen it in the clinic. That's much of the use of the shockwave for the spine-related issues, but it seems like there are some literature on the spine-related pain with the shockwave, but it seems like you need to have more sessions. So one of the tables that I had, I think listed about eight sessions as average for the spine-related pain, but you're going to use a lower level focal shockwave. So that's what I saw on the spine, but not for the specificity, so I'm not 100% sure on that. And I have a card that you can use for the Unhealing as well. You build it differently and then I'm not an expert on the Unhealing, but certainly the Shockwave can be used for the Unhealing or Delayed Unhealing as well. But I can still hang around for another 15 minutes or so if you guys have any questions or anything, but if not, I can probably give you guys about 15 minutes of time. But if you guys have any last minute questions, let me know. And thank you for listening.

extracorporeal shockwave therapy

musculoskeletal conditions

tendinopathies

osteoarthritis

pain reduction

focal shockwaves

radial shockwaves

plantar fasciitis

lateral epicondylitis