As a physiotherapist I am an avid believer of the patient needing to play an active role in their treatment, which is why the sceptic in me wondered whether I was best suited taking on the Shockwave service for Body In Motion. However, after researching more into this evidence based practice, there were plenty of reports suggesting good clinical outcomes for a number of musculoskeletal pathologies, with the main body of supportive research for that of chronic tendinopathies.
I‘m not here to do a sales pitch or go into depth about the mechanisms of action, but more so to give you feedback on what I’ve seen over the past 10 months in clinic at Body in Motion, Adam’s Centre for High Performance.
1. Best outcomes are seen in those patients who continue to play an active role in their treatment. I always inform the patient not to ‘rely’ on Shockwave to fix their injury, but to see it as part of their treatment in which they need to continue to work on other contributing factors (stiffness, weakness, movement control…etc) and ultimately for a tendon- the need to load it.
2. Seeing Shockwave as ‘hitting the reset button’ or ‘providing a window of opportunity’. This is how I describe it to my patients who struggle with pain and the difficulty they have associating exercise with helping their symptoms, as ‘exercises are too painful, so I don’t do them’. This is a crucial part of treatment in order to gain long term benefits. I have seen some very immediate responses to pain and stiffness of the tendon (some immediate in clinic, others weeks down the line), but education as to the need to continue their rehabilitation is of utmost importance for long term gains.
1. Rotator cuff tendinopathies (namely supraspinatus insertional and calcific)- immediate change to pain response and movement dysfunction in the athletic and non athletic population. With all the shoulders (n=4) showing immediate changes in pain and movement within the first session, which has continued to carry over. Painful arc and empty can testing being much less irritable on retest. Additional treatment: manual therapy and tendon loading.
2. Achilles tendinopathies (insertional to proximal)- the majority of these patients do well however there is no real pattern as to the time frame of improvements. The best outcome I had was a 70 year old lady who had pain and weakness for over a year, which lead to the inability to heel raise or walk day to day. Within 4 weeks of Shockwave (and physiotherapy) her pain had settled in order to allow her to strengthen her lower leg, 3 months later she heel walked out of the clinic doors.
3. Lateral and medial epicondyalgia- Overall good response in short and long term. Follow up at 12 weeks, showed nearly everyone had improved to a level at which day to day function was pain free, if not resolved.
4. Proximal hamstring, patella and quadriceps tendons- only experienced to date in the athletic population which had positive outcomes and allowed continuation of training and sport participation
5. Plantar fascia- I have had a number of plantar fascia patients referred for Shockwave and this is the main pathology which has had varied results. Some patients have reported no change at 12 weeks, and others have reported complete symptom resolution. For those who have improved, the main improvements appear to be a number of weeks down the line.
My own personal experience and potential insight would be the importance of the other contributing factors of plantar fasciopathies, i.e. body weight, physical activity levels, general health, inability to offload and/or appropriately load. Shockwave for this diagnosis in my experience is only effective if the patients are compliant with other self management strategies, and finding the correct balance of load/stress through the plantar fascia.
Some Questions I Continually Reflect On:
1. How much is enough? The main body of research recommends 3-5 treatments, 1 week apart. In clinic, I advise a minimal of 3 and have used up to 6 sessions in some patients. I am still uncertain as to how much is enough and have seen better outcomes with treatments less than a week apart and around 3-5 sessions in total.
2. How chronic is chronic? Although the research suggests best outcomes for chronic tendinopathies, there have been a couple of athletic patients which showed early signs of tendon related pain, at which i used Shockwave and showed immediate changes to pain and function (namely shoulders and achilles). If the patient has trialed normal conservative means of addressing their pain and function, and struggle to show improvements, early Shockwave intervention from my personal experience may be of benefit.
3. When do the effects of Shockwave occur? The main body of research suggests long term gains around 12 weeks, of which I relay this to the patient. In my experience I have seen some immediate responses to symptoms, and others which have only started to show improvements around 6+ weeks. On reflection this may be due to a number of different reasons e.g. tendon size, tendon loading, acute vs chronic, etc.
No I don’t think I am, my clinical outcomes over the past months far outweigh my initial skepticism. As with the research, there are still many unknowns and variables which account for the differences in clinical effectiveness.
The changes to short term pain response and subjective reports of tendon stiffness are the main findings from my clinical experience.
For the patients I see, it is ‘another tool in the toolbox’, an adjunct to treatment of which I would use alongside manual techniques and the active role the patient partakes.
At Body In Motion, we offer Shockwave at:
ACC $ 60 per treatment
Private $250 for 3 session bundle, $85 per additional treatment