The expert consensus of skeletal muscle disease extracorporeal shock wave therapy in China (1)
Since the literature reported in the early 1990s that the application of extracorporeal shock wave technology to promote fracture healing, reports on the treatment of musculoskeletal diseases at home and abroad have gradually increased, and have become a research hotspot. In recent years, through continuous research and improvement, this technology has become a new therapy, extracorporeal shock wave therapy (ESWT). Due to its minimally invasive, safe, and effective characteristics, this therapy has been widely used in the clinical treatment of musculoskeletal diseases.
In recent years, ESWT has developed rapidly and accumulated a large number of new treatment experiences and research results. In October 2016, the International Society of Shockwave Medicine updated the ESWT indications and contraindications. In order to further promote the standardized application of ESWT and promote the development of shock wave medicine, experts of the Shockwave Medical Committee of the Chinese Research Hospital Association and the Chinese Society of the International Shockwave Medical Association discussed the Expert Consensus of extracorporeal shock wave therapy for musculoskeletal diseases (first edition). Revisions were made to increase the indications of ESWT, supplement the clinical application guidelines corresponding to the indications, and adjust some of the treatment parameters.
ESWT Physical Characteristics and Biological Effects
Shockwave is a kind of sound wave with mechanical properties that is caused by the extreme compression of the medium caused by vibration, high-speed motion, etc., which can cause the pressure, temperature, density and other physical properties of the medium to jump. The physical characteristics of ESWT include: 1 mechanical effect, that is, the effect generated at the interface of different tissues after the shock wave enters the human body; 2 the cavitation effect, that is, the cavitation bubbles of micro gas present in the liquid between tissues are vibrated under the action of shock waves. .
When the intensity of the shock wave exceeds a certain value, the effect of growth and collapse occurs; 3 The thermal effect, that is, the effect of the shock energy is continuously absorbed by the tissue during the propagation of the shock wave in the living body.
1.1 Describe the physical parameters commonly used for shock waves
The shock wave pressure distribution measurement requires different physical parameters, the main parameters include: shock wave energy, pressure field and energy flow density.
1.2 Shock wave source generation method and transmission form
1.2.1 Way of production
a. Electro-hydraulic shock wave source;
b. Piezoelectric shock wave source;
c. electromagnetic shock wave source;
d. Pneumatic ballistic shock wave sources.
1.2.2 Transmission Form
The transmission form of shock wave energy can be divided into focusing, diverging, flat wave, horizontal focusing and so on.
1.3 Shock Wave Biological Effects
A. Repair and reconstruction of tissue damage;
B. Tissue adhesion and release;
C. Dilation of blood vessels and angiogenesis;
D. Analgesia and nerve endings closure;
E. High-density tissue lysis;
F. Inflammation and infection control.
ESWT Indications, Contraindications and Adverse Reactions
2.1 ESWT Indications
Bone tissue diseases: delayed fracture healing and nonunion, adult femoral head necrosis, stress fractures;
Soft tissue chronic injurious diseases: supraspinatitis, epiphyseal epicondylitis, patella epicondylitis, plantar fasciitis, Achilles tendinitis, long biceps tendonitis, trochanteric bursitis of the femur, and the like.
2.1.2 Relative indications
Osteoarthritis, bone marrow edema, osteochondritis of the tibial tubercle, osteochondral bone injury of the talus, tenosynovitis, subacromial bursitis, presacral bursitis, tendonitis, snapping hip, tendon, muscle strain, wrist Syndrome, osteonecrosis (necrosis of bone, necrosis of talus, necrosis of scaphoid bone), osteoporosis, etc.
2.2 ESWT Contraindications
2.2.1 Overall Factors
(1) Hemorrhagic disease: patients with coagulopathy may cause local tissue hemorrhage, and ESWT should not be performed in patients with untreated, uncured or incurable bleeding disorders;
(2) Patients with thrombosis: This group of patients is forbidden to use ESWT so as to avoid thromboembolism detachment and serious consequences;
(3) Children with growth pain: The painful sites of children with growth pain are mostly located near the epiphysis. To avoid affecting the development of callus, ESWT should not be performed.
(4) Patients with severe cognitive impairment and mental illness.
22.214.171.124 Relative Contraindications
1) The following diseases are relatively contraindicated when using high-energy focused shockwave therapy machines, while low energy shockwave therapy machines are not completely restricted by the following contraindications:
2) Patients with severe arrhythmia;
3) Patients with severe hypertension and poor blood pressure control;
4) Install pacemaker patients;
5) Malignant tumors have metastasized to multiple patients;
6) pregnant women;
7) Patients with sensory dysfunction;
2.2.2 Local Factors
Tendons, fascial tears, and severely damaged patients;
Those with extracorporeal shock wave focus on brain and spinal cord tissue, large blood vessels and important nerve trunks, lung tissue;
Patients with bone defects > 2 cm of nonunion;
Patients with leakage of synovial fluid: it is easy to cause exudation of joint fluid;
2.3 Adverse reactions of ESWT
Local hematoma, purpura, and spotting hemorrhage at the treatment site;
Increased pain in the treatment site;
Local numbness, acupuncture, and loss of sensation in the treatment site.
ESWT energy selection and positioning method
3.1 ESWT Energy Selection
The key to shock wave therapy is to apply appropriate energy to the exact site. Use appropriate energy and select the exact site to directly determine the treatment effect of the disease. The energy is too low to achieve the therapeutic effect, and the energy is too high to produce adverse reactions. According to the energy level, the shock wave is divided into three levels: low, medium, and high: the low energy range is 0.06 to 0.11 mJ/mm2, the medium energy range is 0.12 to 0.25 mJ/mm2, and the high energy range is 0.26 to 0.39 mJ/mm2. It can be converted into energy flow density according to the different energy parameter range and conversion method provided by the equipment manufacturer.
According to ESWT energy division: low energy and medium energy are mostly used for the treatment of soft tissue chronic injury diseases, cartilage injury diseases and superficial nonunion; high energy is used to treat deeper bone nonunion and delayed fracture healing and stocks Osteonecrosis and other osteogenic disorders.
According to the transmission mode of ESWT wave source, focusing shock wave and horizontal focus shock wave are used to treat nonunion and fracture delayed healing, femoral head necrosis and other osteoblastic disorders and deeper osteochondral lesions; divergent shock waves are commonly used. In the treatment of chronic soft tissue injury diseases, superficial bone and cartilage injury diseases and relieve muscle spasms; flat-wave shock waves are used in the treatment of superficial chronic soft tissue injury diseases, wound ulcers and scars.
3.2 ESWT positioning method
1 Accurate positioning is a prerequisite for good efficacy of ESWT. Commonly used localization methods include surface anatomical landmarks combined with pain point location, X-ray localization, ultrasound positioning, and magnetic resonance imaging (MRI) combined with anatomical landmarks on the body surface.
2 The combination of body surface anatomical landmarks and pain points is based on the location of the patient's pain points and local anatomical landmarks. It is often used in the positioning of chronic soft tissue injury diseases, such as epiphyseal patella, external epicondylitis of the humerus and so on.
3 X-ray localization is to couple the treatment point with the second focal point of the focused shock wave therapy machine through an X-ray machine, which is mainly used for the positioning of bone tissue diseases, such as non-union of bone and necrosis of the femoral head.
4 Ultrasound positioning is to determine the localization method of the treatment site through ultrasound examination. It can be used for the positioning of bone and soft tissue diseases, such as long biceps tendonitis, Achilles tendinitis, supraspinatitis and so on.
5 MRI combined with body surface anatomical landmark positioning is based on the MRI imaging findings and local anatomical landmarks of patients. It is often used to locate bone and cartilage diseases, such as talus bone cartilage injury, bone marrow edema, and stress fractures. When positioning, the treatment site should avoid brain and spinal cord tissue, large blood vessels, and important nerve trunks and lung tissue, and should avoid shielding the internal fixation.