Page 286 - WSAVA2018
P. 286

 25-28 September, 2018 | Singapore
J. Van Dyke1
1CRI, Faculty, Wellington, USA
Diplomate American College of Veterinary Sports Medicine and Rehabilitation
Wellington, Florida USA
Therapeutic plans generally involve a combination of manual therapies (joint mobilizations and soft tissue mobilizations), physical modalities (laser, therapeutic ultrasound, e-stim, shockwave), and therapeutic exercises. The modalities are generally used to prepare the tissues for the manual therapies and therapeutic exercises. Physical modalities should never be the sole therapeutic method applied to any patient.Therapeutic parameters for each modality are chosen based upon the acuity of the injury, so the therapist must be well versed on the definitions of the acute, subacute, and chronic phases of healing.Extracorporeal shock wave therapy is also known as high energy focused sound wave therapy. This is a high energy pressure wave,
or impulse, produced by supersonic craft, explosions, lightning, or other extreme phenomena that create sudden, huge changes in pressure. This is essentially a controlled mini-explosion creating energy that we can focus for treatment. The device has a ‘trode’ head in which a spark is generated, the energy from this spark is reflected off of a surface and then focused through the trode head’s bulb. The depth of penetration is determined by the thickness of this bulb.Shock waves are rapid, high energy sound waves characterized by an extremely rapid rise time or ‘pressure front’, followed by a slight negative pressure dip that causes cavitation, and resulting in a clearly defined focal area in which the energy is concentrated. There are four types of shock wave device: Electrohydraulic, electromagnetic, piezo- electric, and radial pressure wave. Electrohydraulic devices have peak pressures of 70Mpa, rise times
of nanoseconds, and create true shockwaves at all settings. Electromagnetic devices have a peak pressure of 20MPa, rise times measured in microseconds, and create true shockwaves at high energy settings only. Piezo-electric devices have peak pressures of 15MPa, rise times in microseconds, and create true shockwaves
at high energy settings only. This group is used for lithotripsy. Radial pressure wave devices have a peak pressure of 0.4MPa, rise times in milliseconds, and they do not produce a shock wave at any setting. The energy is completely dissipated at 0.5 to 1.0cm of depth. These devices are marketed as ‘painless shock wave devices, requiring no sedation’.
Shock waves stimulate release of many cytokines including nitric oxide, VEGF, PCNA, TGF-b1, and BMP2, leading to a brief inflammatory phase, vasodilation, neovascularization, endothelial cell proliferation, tissue healing, and osteogenesis. ESWT causes decreased inflammation via downregulation of TNF-a and IL-
10, increased bone and tissue healing via increased secretion of BMP2, TGF-b, VEGF, PCNA, and eNOS, and decreased bone via release of serotonin in the dorsal horn of the spinal cord, leading to descending inhibition. Additional medical effects of ESWT can be disruption
of biological biofilm, resulting in a bactericidal effect, decreased cartilage degradation, and a temporary analgesic effect, lasting 3-4 days in one equine study. Studies have revealed beneficial effects of ESWT in treating delayed and non-union fractures, leading to
76% success in healing delayed unions (as compared
to 79% success with re-operation). Used preemptively, a significant decrease was found in the incidence of non- unions in high risk fractures. In a fracture healing study
in canine fracture gap models, the use of ESWT lead to significantly greater callus and significantly more cortical bone at 12 weeks post-op. In a clinical canine study reported in VCOT in 2002, four of 6 dogs with non-union fractures were treated with ESWT. Three of the 4 treated dogs healed.
ESWT is used to treat osteoarthritis as well as fractures. A study reported in VCOT in 2005 showed a trend over the 14 weeks of treatment toward improved range of motion with no change in peak vertical force (PVF) in the treated group while the control group showed a significant loss of PVF. Another study in 2010 reported a significant increase in PVF in elbow OA patients treated with ESWT. This magnitude of change in PVF was similar to that seen in patients treated with NSAIDs. A study reported in Vet Surgery in 2012 showed a significant decrease in patellar ligament thickening at 6 and 8 weeks post-surgery in TPLO patients treated with ESWT. Cauda equina cases treated with ESWT resulted in an 87.5% positive response with a median duration of 13.6 months. A study out of Tufts University in 2015 revealed excellent short-term results in treating dogs with chronic lameness due to shoulder disease. Another study published in Vet Record in 2016 looked at ESWT and therapeutic exercise for supraspinatus tendinopathies. 85% of these cases had good or excellent outcomes in both short term and long term follow up. Equine studies have shown decreased lameness and improved ROM
2 months post ESWT for carpal joint osteoarthritis.

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