Fokusert vs radial trykkbølgebehandling. Schmitz 2015

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2 Am J Sports Med 2017

3 Fokusert vs radi trykkbølgebehandling Schmitz 2015

4 Fokusert ESWT Bør ha billeddiagnostikk for å sikte seg inn mot antatt smertefokus Fokuserer energien på et punkt dypt i vevet Lavt-middels-høyt energinivå Radi ESWT Enklere å bruke, man treffer et stort område Energien spres ut over (høyest energinivå der proben møter huden) Lavt-middels energinivå Genererer ekte sjokkbølger Genererer lydbølger som ikke tilfredsstiller kriteriene for å kles sjokkbølger

5 Bakgrunn Mange fysioterapeuter bruker veiledet trening sammen med trykkbølgebehandling Rompe et fant at pasienter med akillessenelidelser som fikk reswt i tillegg til veiledet trening hadde bedre resultater enn de som kun fikk veiledet trening Rompe et, Am J Sports Med, 2009 Engebretsen et sammenliknet reswt og veiledet trening hos pasienter med subacromie smerter og fant at veiledet trening hadde best effekt på smerte og funksjon etter 18 uker, men begge gruppene ble signifikant bedre Engebretsen et, BMJ, 2009

6 Veiledet trening Best dokumenterte behandling for subacromie skuldersmerter Bygger på en grundig funksjonsvurdering og deretter individuelt behandlingsopplegg med avlæring av dysfunksjon og veiledet trening i form av aktive skulderøvelser Har vist effekt på smerte og funksjon Kuhn 2009, Haik 2016

7 Metode Randomisert, dobbelt-blind studie Pasienter: Med subacromie skuldersmerter i minst tre måneder Mellom 25 og 70 år

8 Metode 2 grupper: A: Veiledet trening og reswt B: Veiledet trening og sham reswt Blinding: Pasientene og le som var involvert i studien var blindet for sham eller reswt med unntak av behandlende fysioterapeut Oppfølging: Kontroll på baseline, 12 og 24 uker Utflsmål: SPADI (The shoulder pain and disability index) skår (0-100)

9 Pasientkarakteristika Sham reswt (n=74) Ekte reswt (n=69) Alder (SD) 46,0 (9,9) 47,6 (10,9) Kvinner (%) 41 (55,4) 37 (53,6) SPADI baseline (SD) 51,8 (17,4) 51,9 (16,7)

10 SPADI Resultater Begge gruppene ble signifikant bedre Gj. snittlig forskjell 0.7, 95% CI -6.9 to 8.3, p= reswt Sham A B C D E F G Baseline 12 weeks 24 weeks

11 SPADI Subgruppeanyse på pasientene med kk over 5 mm i rotator cuff (n=23 x 2) reswt gruppen ble signifikant bedre enn sham gruppen, gj snittlig forskjell -12.5, 95% CI to - 0.8, p= reswt Sham A B C D E F G Baseline 12 weeks 24 weeks

12 Eksplorativ subgruppeanyse på pasientene som trodde de hadde fått ekte vs pasientene som trodde de hadde fått sham behandling: De som trodde ble signifikant bedre enn de som ikke trodde Gj snittlig forskjell 10.3 poeng, 95% CI 2.3 to 18.2, p=0.012

13 Subacromie smerter med kk Author Year Articl Intervention Control Result es Wu YC High-energy ESWT Control group (L-ESWT, reswt, laser, sham, TENS, UGN) The most effective treatment for improvement in CMS was H-ESWT Arirachakaran et feswt and reswt Placebo ESWT improved CMS and VAS significantly when compared to placebo. Louwerens JK et High-energy ESWT (feswt) Baseline parametres ESWT significantly improved shoulder function compared to baseline Bannuru High and low-energy feswt and reswt Placebo ESWT is more effective than placebo and may result in complete resorbtion of the ccification Verstraelen FU et High-energy ESWT (feswt) Low-energy ESWT H-ESWT showed significantly greater improvement in CMS than L-ESWT Speed CA et feswt Placebo Consistent level 1 evidence for effectiveness of ESWT Speed CA et reswt Placebo Less robust evidence. One RCT reported effectiveness of reswt over placebo Ioppolo F et feswt and reswt Placebo ESWT reduce pain and increase function, and dissolve ccifications Huisstede B et reswt Placebo or no treatment Moderate evidence Huisstede B et reswt Sham Moderate evidence Lee SY et feswt or reswt Sham There is consistet evidence of midterm effectiveness of ESWT Storheim K et el feswt Sham or low-energy ESWT Evidence grade B for the effectiveness of high-energy feswt Storheim K et reswt Sham Evidece grade A for effectiveness Vavken et ESWT Control (diff treatments or placebo) ESWT is effective for treating cc tendonitis of the shoulder

14 Subacromie smerter med kk Author Year Articl Intervention Control Result es Wu YC High-energy ESWT Control group (L-ESWT, reswt, laser, sham, TENS, UGN) The most effective treatment for improvement in CMS was H-ESWT Arirachakaran et feswt and reswt Placebo ESWT improved CMS and VAS significantly when compared to placebo. Louwerens JK et High-energy ESWT (feswt) Baseline parametres ESWT significantly improved shoulder function compared to baseline Bannuru High and low-energy feswt and reswt Placebo ESWT is more effective than placebo and may result in complete resorbtion of the ccification Verstraelen FU et High-energy ESWT (feswt) Low-energy ESWT H-ESWT showed significantly greater improvement in CMS than L-ESWT Speed CA et feswt Placebo Consistent level 1 evidence for effectiveness of ESWT Speed CA et reswt Placebo Less robust evidence. One RCT reported effectiveness of reswt over placebo Ioppolo F et feswt and reswt Placebo ESWT reduce pain and increase function, and dissolve ccifications Huisstede B et reswt Placebo or no treatment Moderate evidence Huisstede B et reswt Sham Moderate evidence Lee SY et feswt or reswt Sham There is consistet evidence of midterm effectiveness of ESWT Storheim K et el feswt Sham or low-energy ESWT Evidence grade B for the effectiveness of high-energy feswt Storheim K et reswt Sham Evidece grade A for effectiveness Vavken et ESWT Control (diff treatments or placebo) ESWT is effective for treating cc tendonitis of the shoulder

15 Subacromie smerter uten kk Author Year Article s Intervention Control Result Steuri R et ESWT Uncertain effect Speed CA et feswt (no studies on reswt was found) Sham or low-dose There is limited evidence of inefficiacy Bannuru R et feswt Sham or low-dose The evidence was inconclusive Huisstede B et feswt Sham, low-dose or radiotherapy No evidence for effectiveness was found Storheim K et feswt Sham No evidence for effectiveness

16 Subacromie smerter uten kk Author Year Article s Intervention Control Result Steuri R et ESWT Uncertain effect Speed CA et feswt (no studies on reswt was found) Sham or low-dose There is limited evidence of inefficiacy Bannuru R et feswt Sham or low-dose The evidence was inconclusive Huisstede B et feswt Sham, low-dose or radiotherapy No evidence for effectiveness was found Storheim K et feswt Sham No evidence for effectiveness

17 Andre tilstander Later epikondylgi Author Year Articles Intervention Control Result Speed et feswt (lowdose) Storheim et Storheim et Sham reswt Subtherapeutic dose Mixed evidence Evidence grade B for effect feswt Evidence grade A for inefficiacy Trochanter tendinitt Author Year Articles Intervention Control Result Korakakis V et Manu-Babu et (including non-rcts) (including non- RCTs) feswt ESWT Achilles tendinopati Author Year Articles Interventio Korakakis V et Korakakis V et Manu-Babu et Al-Abbad H et Speed CA et n 1 reswt on insertion AT 2 reswt and feswt at mid/mixed 4 reswt and feswt 6 reswt and (includin feswt g non- RCTs) Cortison, no treatment Contr ol Sham Sham Result Low level evidence to support ESWT Moderate evidence for effectiveness Low level of evidence supports reswt Very low level of evidence supports reswt and feswt Conflicting evidence Satisfactory evidence for the effectiveness 2 feswt Sham Evidence of benefit but further research is warranted (sml study populations) Patellar tendinitt Author Year Articles Intervention Control Result Korakakis V et Manu-BAbu et Larsson M et 2017 feswt Sham Moderate-level evidence suggests no difference between feswt and sham (including non-rcts) ESWT ESWT may be an effective intervention ESWT No treatment Limited evidence supports ESWT Plantar fasceitt Author Year Articles Intervention Control Result Lou et feswt and reswt Speed CA et High-energy feswt Sham ESWT is effective in releiving pain Level 1 evidence for benefit Speed CA et reswt Level 1 evidence for benefit Yin MC et feswt and Sham Strong evidence for effectiveness reswt Zhiyun et feswt Sham Strong evidence of effectiveness Aqil et feswt and Sham ESWT is safte and effective reswt Chang KV et feswt Sham Evidence for effectiveness Chang KV et reswt Sham Evidence for effectiveness Storheim K et feswt Sham, cortison, low-energy feswt Conflicting evidence

18 Oppsummering ESWT (både radi og fokusert) kan vurderes for pasienter med subacromie smerter med kk i rotator cuff, evt i tillegg til veiledet trening ESWT anbefes ikke for de med subacromie smerter uten kk For andre msk tilstander er det manglende og/eller sprikende evidens, med unntak av plantar fasceitt (hvor det ser ut til å ha effekt)