What is the origin of ESWT?

The type of shockwave therapy we use, then, is specialized to specifically help treat musculoskeletal conditions. 

What conditions can you treat with ESWT?

When is ESWT considered as a treatment for these sorts of conditions?

Shock Wave Therapy is generally considered when the following criteria are met:

• When patient has a diagnosis that is considered to be responsive to ESWT.

• When simpler and less expensive treatment alternatives have failed or aren't
        appropriate for some reason.

• When surgery or other more invasive treatments are alternatives.

• When the patient fully understands the procedure.

• When there are no known contraindications to the procedure.

When can't you use ESWT? 

ESWT is not typically used in the presence of bone tumours, certain metabolic bone conditions, and certain nerve or circulation disorders.  ESWT isn't typically used in pregnant patients and locations of an open growth plate, (where the bone is still growing).  It's not currently used in areas where an infection is present, (though there is some early research suggesting ESWT may actually help with infection).  It also shouldn't be used in conditions or locations where gas or air is present in the body, (rare in the locations where ESWT is typically used)--or for other conditions as determined by your doctor.

How effective is Focused ESWT?

The answer to this question depends upon which study you read, what methods were used in the study, how "success" is measured in the study, the patients selected to be included in the study, the condition being treated, and the machine being used. 

While there are some studies (usually quoted by an insurance company trying to find a way to justify not paying for ESWT treatment) that suggest that shockwave hasn't been proven to be effective, the vast majority of recent studies suggest that shockwave is highly effective.  For example, over 70 studies were presented at the 2006 international shockwave seminar in Brazil, and over 80 were presented the year before in Vienna--and this doesn't even include the numerous published findings in the medical literature. 

Assuming you have an injury appropriate to extra-corporeal shockwave technology treatment, most recent independent studies suggest somewhere between a 65% and a 95% "success" range, with values around 80% being the most commonly cited number.  And it's important to note that most of these studies have success rates as determined by the patient, himself, in terms of pain and function.

We find that our results with the highly accurate piezoelectric technology, are at least this successful.  The most important factor in getting a good result with ESWT appears to be in selecting appropriate patients most likely to benefit from this technology.  However, we can't predict which patients will respond successfully to ESWT and which ones won't.

How fast does ESWT work?

We find that many patients get an initial degree of improvement almost immediately following treatment.  This effect is usually (but not always) temporary, and is associated with an anesthesia effect from the hyperstimulation of the tissue from the ESWT. 

It takes several days for injuries to begin to heal, and many patients see an improvement before the end of the second week.  Depending upon your diagnosis, the healing process may take several weeks or even months to be completed, but pain relief often precedes the completion of the healing process. 

How safe is ESWT?

The basic technology involved with extracorporeal shockwave technology has been used for decades now on quite literally millions of people.  The technology has been used most extensively in Europe, particularly the German-speaking countries, where this technology originates.  In all its use, ESWT of the musculoskeletal system has been found to have virtually no serious side-effects.  In fact, even mild side effects like tingling, aching, redness, or bruising are relatively rare, modest and short-lived. 

Further, effects like these appear to be more common with higher energy treatments, particularly those from earlier generations of ESWT technology than that which we use.  We'll discuss more about the different ESWT technologies  below. 

How does ESWT work?

Simply put, extracorporeal shockwaves stimulate certain components within the body so the body is able to heal.  And ESWT is able to accomplish this even in chronic cases, when the body has demonstrated a previous unwillingness or inability to do so by itself.

In addition to stimulating the healing process, ESWT seems to have a direct effect on nerves, diminishing pain. 

Many traditional therapies--such as anti-inflammatory medications, steroid injections, physiotherapy, massage, acupuncture, and so forth--can assist the body during the early, acute phase of an injury.  However, they are much less effective in assisting the body to heal when an injury becomes chronic.  As an example, many patients can relate to a history where a steroid injection (like cortisone) seemed to be effective in resolving pain early in their healing process, but subsequent injections were much less effective.  This isn't really surprising when you realize that a chronic-state, degenerative injury isn't likely to respond well to a medication designed to affect an acute-phase, inflammatory condition.

What makes ESWT unique is that it is one of the very few technologies in any field of medicine that seems to work best when an injury reaches the chronic, non-healing state.  ESWT appears to be able to jump start the healing process in chronic, non-healing injuries and move them back into the acute phase of healing. 

How do the physics of ESWT promote tissue healing?

While investigations are still being conducted to more fully understand the precise mechanism behind ESWT's effects on injured tissues, the picture is becoming much clearer. 

True ESWT produces a very strong energy pulse (5-100 MPa) for a very short length of time, (approximately 10 milliseconds).  The energy pulse quite literally breaks the sound barrier, and this is what creates the shockwave.
To the right is a photograph of a plane flying faster than the speed of sound and creating shockwaves.  Shockwaves produced by an extracorporeal shockwave machine are identical, only on a smaller scale.  One difference with the shockwaves our machine is able to produce is that the shockwave is generated, controlled, and focused precisely.

• ESWT also diminishes pain.  It does so in two ways.  First, as mentioned above, ESWT initially diminishes pain through what is known as hyperstimulation anesthesia.  This is where the nerves sending signals of pain to the brain are stimulated so much that their activity diminishes, thereby decreasing or eliminating pain. This effect is usually, (but not always), short lived. 
   

• ESWT is also believed to diminish pain over longer periods of time through the stimulation of what is known as the "gate-control" mechanism, where nerves can be stimulated to "close the gate" to pain impulses sent to the brain.  It is sometimes thought of as activating a sort of "reset" button that recalibrates pain perception.
  
  Interestingly, and in apparent support of this theory, it was demonstrated by research presented at the 2005 conference in Vienna that using anesthesia with ESWT alters the sensor input - motor output balance of nerve fibres, inhibiting the pain-killing effect of ESWT. 
   
  In other words, ESWT appears to be most helpful for patients who are not anesthetized.   (This explains why some some early studies where anesthesia was used before the administration of extracorporeal shockwave therapy did not get results as good as what is found in patients where no anesthesia is used.)
  
  As the piezoelectric version of shockwave we use does not require anesthesia, this serves as one explanation as to why piezoelectric shockwave works so well.

While ESWT is used on a wide variety of body tissues and medical conditions (see the What conditions can you treat with ESWT? section above), the effects of shockwaves are best documented in areas of changes in tissue density, such as where tendon attaches to bone (enthesiopathies) and where bone attaches to ligaments (desmopathies).  For this reason, it is very effective for painful connective tissue pain in such locations as the foot, knee, hip, elbow, and shoulder.

Are there different forms of shockwave therapy?

While there are numerous shockwave machines on the market today, they are all based on one of four basic shockwave (or shockwave-like) technologies.  Listed in the order in which they were introduced in Canada, they are:

• Electrohydraulic shockwave (such as the HMT OssaTron machine)

• Electromagnetic shockwave (such as the Sonocur and Dornier Epos machine)

• Radial pressure wave (such as the Dolorclast system)

• Piezoelectric shockwave (such as the machine we use, the Piezoson by Wolf).

What's the difference between these forms of shockwave therapy?

Tissue Depth Penetration: 

As you might imagine intuitively, being able to aim shockwaves directly on the desired tissues and only the desired tissues is generally considered to be superior to not being able to direct the shockwaves to the specific injured tissues.

Electrohydraulic, electromagnetic, and piezoelectric shockwave can all be aimed and delivered past the skin and down to different tissue depths, allowing for delivery of the therapeutic waves to the injured tissue. 

Radial pressure waves are applied to the skin only, and must dissipate to the tissues from there.  They are therefore not able to be aimed to different tissue depths.    Deeper tissue injuries are therefore more difficult to treat with radial shockwave. 

Focus Area: 

A third characteristic to consider is how precisely the energy waves are able to be focused onto the injured tissue and away from uninjured tissues.  The tighter the focus area, the more precisely the shockwaves can be delivered to specific tissues, and the less energy is wasted in areas not requiring treatment.

Not only does this mean a greater concentration of therapeutic energy on the specific injured tissues, it also means less trauma to the surrounding uninjured tissues. 

As alluded to above, the piezoelectric technology we use has, by far, the tightest focus area of any competing technology in the world. 

For instance, even at maximum energy level, the focus area for the Piezoson 100, (the machine we use), is 1.3mm x 1.3mm x 4.2mm.  (This equates roughly to 1/20th of an inch x 1/20th of an inch x 1/6th of an inch.) 

In comparison with other machines in North America, the focus area for the Ossatron is 8.7mm x 8.7mm x 67.6mm; the focus area for the Sonocur is 4.8mm 4.8mm x 48.3mm and for the Epos it's 2.9mm x 2.9mm x 22.0mm.  (Radial pressure waves cannot be focused at all.)

(Source for these statistics, the German site on physical parameters of extracorporeal shock wave therapy technologies:  http://stosswellentherapie.org/fach/vergl.html) 

As these statistics make clear, the piezoelectric technology is the most accurate ESWT technology on the market.  Treatment is more precisely directed at injured tissues and the least traumatic to uninjured tissues surrounding the site being treated. 

However, because piezoelectric technology is so precise, it needs to be applied carefully and precisely to the correct tissues.  This is why we don't hire ESWT technicians to perform the therapy.  We only have doctors applying the treatment.  This is actually the law in many jurisdictions in Europe, but the exception in North America, where technicians perform most ESWT treatments in the vast majority of facilities. 

Energy Level: 

Another important differentiating characteristic is how high an energy output the machine produces.  In fact, this characteristic is commonly used in marketing various machines. 

For instance, you'll see many websites touting the benefits of their machine being either "high energy" or "low energy".  Facilities with "high energy" machines claim, for example, that their technology is superior because only one treatment is typically required and the technology has been around longer.  Facilities with "low energy" machines advertise that it doesn't require anesthesia and it's cheaper. 

While there is some truth to each of these claims, the larger question is frequently not mentioned.  That is to say, the question that should be asked is what is better at actually treating a particular condition?  High energy or low energy? 

Before we can answer this question, you should know that the energy level of a machine is actually a fairly complicated subject and it deserves some discussion.  

For instance, you'd think that the energy produced by a machine would be a pretty clear-cut characteristic.  But there are several different--and confusing--ways to measure energy.  For example, you could consider the amount or type of energy produced by the machine, the amount or type of energy delivered into the body, the amount or type of energy delivered into the focus area, the amount or type of energy delivered to a central point inside the focus area, or the amount or type of energy present at a certain radius from that central focus point. 

Each of these characteristics is important to the scientists studying various characteristics of ESWT machines, and different manufacturers and scientists use different definitions of "energy". 

As you might expect, so many variables make it rather confusing to both patients and physicians.  After all, even doctors aren't sure what type of energy is most important when judging which technology is a better in which to invest.  

For the purposes of this discussion, we'll concentrate on the most common standardized measurement of energy in the field, something called the "energy flux density", expressed in millijoules per millimeter (mJ/mm²).. 

Energy flux density can be defined as the amount or concentration of energy in the focus area.  In other words, this is the amount of therapeutic energy being delivered to the injured tissue.  The physics of the other measures of energy are interesting, but we feel this is the characteristic in which most patients and physicians are interested. 

Now even when we've defined what we mean by an energy level and defined the unit of measurement, you should know that different authors use different cut-off measurements to define "high energy" and "low energy".  One author's "high energy" setting may only qualify as a "low energy" setting in another author's opinion.  So the terms "high energy" and "low energy" are rather imprecise and arbitrary.  (This demonstrates why the marketing of "high energy" and "low energy" machines is somewhat dubious.)

For the purposes of this discussion, we'll define low energy here as less than 0.27 mJ/mm² , medium energy as 0.27 mJ/mm² to 0.59 mJ/mm² , and high energy as anything over 0.60 mJ/mm².  These are frequently-used cut-off points, but do keep in mind that other practitioners, researchers, manufacturers, and websites may use different values. 

So now that we've defined what energy is, what's considered high, medium, or low energy, let's get back to the question of what energy settings are better to treat a specific injury.

The answer that seems to becoming more clear in research is that both high energy settings and low energy settings have their indications. 

For instance, certain tissues (like bone) appear to respond better to higher energy settings.  Conditions like avascular necrosis and delayed unions and pathological calcifications are examples of conditions that are typically thought of as being more responsive to higher intensity settings.  In addition, the original medical application for shockwaves, the treatment of kidney stones, too, seem to be most effective with higher energy settings.

However, other tissues (like tendons and other more sensitive structures) typically require lower energy settings, as research indicates that these they may be damaged by higher-intensity settings. 

Complicating matters further, what does a patient do when both hard and soft tissues need to be treated for a single injury, as is often the case?  For example, what if a patient has both a bone spur and a soft tissue injury like fasciitis or tendonitis?  Is it better to go with a so-called "high energy" machine or a "low energy" machine?

The good news is that it doesn't have to be an either-or proposition.  The beauty of the piezoelectric ESWT technology we use is that it covers the energy spectra employed by the other technologies. 

For instance, piezoelectric ESWT can be applied in energy levels as low as .05 mJ/mm²--obviously well into the lowest levels of energy--and it can be raised as high as 1.48 mJ/mm²--an energy level well above even the classic "high energy" machines. 

In other words, in terms of the amount of energy applied in the focus area, (the so-called "energy flux density"), piezoelectric technology can be delivered in energy doses as low as virtually any other competing technology and as high or higher than virtually any other technology.

Further, piezoelectric technology can be readily adjusted to any energy level, depending upon the specific condition and indication of each individual case.  And as mentioned above, the energy can be precisely focused to the specific depth required.

Our patients don't have to compromise for a single energy range or a specific tissue type.

And because the machine we use is so precise, we can use high energy settings in areas very close to the most sensitive tissue structures.  This allows the piezoelectric technology noticeable advantages to machines with much less precise focus areas.   

Anesthesia Requirements:

The energy the machine produces also affects the need for anesthesia (whether local, general, or spinal) or IV sedation.  All things being equal, it's obviously preferable for the patient not to have to go through anesthesia or sedation. It's not only safer, it's also less expensive. 

Beyond the issues of safety and expense, though, there is mounting evidence that the use of anesthesia diminishes the effectiveness of ESWT.  Specifically, the use of anesthesia with ESWT alters the sensory input - motor output balance of nerve fibres, which seems to be why anesthesia diminishes the pain killing effect of ESWT. 

So unlike other so-called "high-energy" machines, the piezoelectric technology does not typically require anesthesia--even at high energy settings.  And further, this means it's more likely to work than versions requiring anesthesia.

Which is the best version of shockwave therapy? 

There is a natural tendency for practitioners to feel some bias towards the form of technology which they use personally. 

However, we can tell you that when Shockwave Therapy - BC was formed, all these different technologies were available to us, and we had the opportunity to examine each of them.  We've even examined and investigated many machines not available in North America.
 

How do I know which version of shockwave therapy is being offered at a facility? 

Many facilities don't go into much detail about the different versions of ESWT technology.  Perhaps they may feel it doesn't matter to the patient or   that the information is too technical for most patients.  But if you're having significant pain and are searching for answers, if you're curious which machine may be most applicable to your condition, we feel this is the sort of information that we find a lot of patients seek.  If the facility you're considering isn't clear about what version of ESWT technology they're using and you wish to know, you should ask.

Where can I get the best, most up-to-date form of focused ESWT?

At present, the only site we know of in British Columbia or in Western Canada offering Piezoson 100 ESWT is at our facility in Surrey, British Columbia near Vancouver.  While this technology has been around for many years in Europe and in Canada for nearly two years, it is not yet available in the United States or in many other countries around the world. 

For this reason, we welcome patients from any area who are seeking this newest of ESWT technology.  Overnight or longer stays can be arranged at some of the recommended hotels near our facility.  

We can be contacted at:

For more maps and directions to our location, please follow the following link. 

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