SWISS DOLORCLAST APPLICATIONS FOR PODIATRY

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

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

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.

Radial extracorporeal shock wave therapy RSWT®

Gloria Allery & Val Bryce 28.11.2011 Gloria Allery & Val Bryce 6

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)

RSWT®: see shock waves on high speed movie: Notizen: ____________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8

RSWT®: basic physics - cavitation Cavitation bubbles Wave front Secondary shock waves Hydrophone (used to trigger a high-speed camera) Notizen: ____________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Applicator 9 9

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

RSWT RANDOM CONTROL TRIALS WITH POSITIVE OUTCOMES Chronic plantar fasciopathy Gerdesmeyer et al., Am J Sports Med 2008; 36: 2100-2109 Chow and Cheing, Clin Rehab 2007;21: 131-141 Greve et al., Clinics 2009; 64: 97-103 Midportion Achilles tendinopathy: Rompe et al., Am J Sports Med 2007;35:374-381 Rompe et al., Am J Sports Med 2009;37:463-470 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] Notizen: ____________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 11

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%

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

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

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.

Large diabetic foot ulcer- March 2010,prior to treatment

24th AUGUST 2010 5TH October 2010

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.

[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).

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

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!

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!