1. SWISS DOLORCLAST APPLICATIONS FOR PODIATRY

2. HISTORY
EMS/Dolorclast was the first company to develop Lithotripsy
Extracorporeal Shockwave Therapy
(ESWT) was first used to treat kidney stones
Since 1990 (ESWT) has been used for a variety of orthopaedic applications.
More recently, it is used for treating wound ulcers, lymphodema, burns and cellulite

3. Indications for RSWT® Tennis elbow (Epicondilitis humeri radialis)
Subacromial pain syndrome
Golfer‘s elbow (epicondylitis humeri ulnaris)
Greater trochanteric pain syndrome
Patellar tip syndrome
Medial tibial stress syndrome
Achilles tendinopathy
Plantar fasciopathy

4. MECHANISMS
The procedure accelerates the body's own healing mechanisms by:-
Generating impulses of high energy, high pressure sound waves that travel through skin to stimulate healing.
It is effectively changing a chronic condition to an acute condition.

5. Radial extracorporeal shock wave therapy RSWT®

6. Gloria Allery & Val Bryce
Gloria Allery & Val Bryce 6

7. RSWT®: basic physics (3) - cavitation
Which part of shock waves mediates their biological efffects on tissue?
"A significant tissue effect is cavitation consequent to the negative phase of the wave propagation."
(Ogden et al., 2001)

8. RSWT®: see shock waves on high speed movie:
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9. RSWT®: basic physics - cavitation
Cavitation bubbles
Wave front
Secondary
shock waves
Hydrophone
(used to trigger
a high-speed
camera)
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Applicator 9 9

10. SCIENTIFIC BACKGROUND
ESWL can trigger a variety of effective actions
Release more substance P
Inhibits the COX11 enzyme
Activates cellular defenses
Hyper stimulates nerve fibres

11. RSWT RANDOM CONTROL TRIALS WITH POSITIVE OUTCOMES
Chronic plantar fasciopathy
Gerdesmeyer et al., Am J Sports Med 2008; 36:
Chow and Cheing, Clin Rehab 2007;21:
Greve et al., Clinics 2009; 64:
Midportion Achilles tendinopathy:
Rompe et al., Am J Sports Med 2007;35:
Rompe et al., Am J Sports Med 2009;37:
Insertion Achilles tendinopathy:
Rompe et al., Am J Bone Joint Surg 2008;90:52-61
Medial tibial stress syndrome:
Rompe et al., Am J Sports Med 2009 [Epub Sep 23]
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12. PROBLEMS WITH DIABETIC FOOT
Diabetes= Worldwide= over 200million
Qld = over 200,000
Over 1 million diabetic amputations year worldwide
Most common diabetic admissions
Foot ulcers = more than 15%
Amputations = more than 1-3%

13. STANDARD FOOT ULCER MANAGEMENT
Control infection
Improve blood supply
Optimise wound healing environment
Protect wound from trauma

14. TREATMENT
ESWT in conjunction with standard therapies for off loading foot pressure
Padding
Insoles
Orthotics
Footwear- sandals boots, casts, splints
Walking aids, crutches, walking sticks, wheelchairs

15. Case Study
This patient was treated at a Hairmyres Hospital, Scotland, and had a large diabetic foot ulcer. This had been surgically debrided and had also had larvae therapy. It was not responding to treatment and there was a real chance that the patient would need a lower leg amputation.
The patient was treated with ESWT over a period of six months during which there was full healing. On average he was treated once every 2.5 weeks.

16. Large diabetic foot ulcer- March 2010,prior to treatment

17. 24th AUGUST TH October 2010

18. References
[1] R. Saggini, A. Figus, A. Troccola, V. Cocco, A. Saggini, and N. Scuderi. Extracorporeal shock wave therapy for management of chronic ulcers in the lower extremities. Ultrasound Med Biol, 34(8):1261– 1271, August 2008.
[2] W. Schaden, R. Thiele, C. Kolpl, M. Pusch, A. Nissan, C. E. Attinger, M. E. Maniscalco-Theberge, G. E. Peoples, E. A. Elster, and A. Stojadinovic. Shock wave therapy for acute and chronic soft tissue wounds: a feasibility study. J Surg Res, 143(1):1–12, 2007.
[3] A. M. Larking, S. Duport, M. Clinton, M. Hardy, and K. Andrews. Randomized control of extracorporeal shock wave therapy versus placebo for chronic decubitus ulceration. Clin Rehabil, Feb 2010.

19. [4] J. Dumfarth, D. Zimpfer, M. Vögele-Kadletz, J. Holfeld, F
[4] J. Dumfarth, D. Zimpfer, M. Vögele-Kadletz, J. Holfeld, F. Sihorsch, W. Schaden, M. Czerny, S. Aharinejad, E. Wolner, and M. Grimm. Prophylactic low-energy shock wave therapy improves wound healing after vein harvesting for coronary artery bypass graft surgery: A prospective, randomized trial. Ann Thorac Surg, 86(6):1909–1913, December 2008.
[5] C. Wang, Y. Kuo, R. Wu, R. Liu, C. Hsu, F. Wang, and K. Yang. Extracorporeal shockwave treatment for chronic diabetic foot ulcers. J Surg Res, 152, 96–103 (2009).

20. RSWT®: summary Physical mechanisms of action understood
Wave propagation
Cavitation
Molecular and cellular mechanisms of action understood
Immediate pain relief by depletion of substance P
Blockade of neurogenic inflammation
Change of gene expression in adult stem cells towards healing 20

21. Efficacy and safety demonstrated in various RCTs
Happy patients
Efficacy and safety demonstrated in various RCTs
Evidence-Based Medicine Level 1
Fast (3 x 5 min treatment) with immediate benefit
Negligible side effects when applied properly (skin reddening)
No injections, no cortisone, no surgery!
No doping!

22. A treatment modality becomes successful when...
we know how it works
we know that it works
we know why it works
your patients become enthusiastic about it!
Enthusiastic patients – successful practice!