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Shockwave therapy in musculoskeletal treatmentMgr. Ondrej ProuzaPhysiotherapist BTL medical consultant Shockwave therapy Ondrej Prouza2Shockwave therapy contentsContents of presentation:Shockwave Therapy– physical principles technologyShockwave Therapy – medical backgroundShockwave Therapy clinical demoShockwave therapy Ondrej Prouza33Biophysical backgroundShockwave therapy Ondrej Prouza44Shockwave therapy Ondrej Prouza5Shock wave is atransient acoustic waveUnique opportunity to transmit high energy for longdistancesFirst observation – Second World WarFirst technicalinterest in 1966 Dornier Aircraft Labs5Biophysical backgroundShockwave therapy Ondrej Prouza66Picture by Shriwastava, J.Biosci., March2005Shockwave therapy Ondrej Prouza7Shockwaves in medicineShockwave is an acoustic wave which carries its´ high energy to the painful spotand provokes healing and repair processesMain fields of application: OrthopedicsRehabilitationSport medicineOther veterinary, aesthetics, urology, dermatology Most common applications:Shoulder tendonitisAchillodyniaHeel spur calcar calcanei Lateral epicondylitisShockwave therapy Ondrej Prouza8Terminology Low energyshockwaveRadial shockwavetherapyPressure pulsetherapyAcoustic wavetherapy All refer to onetherapy defined by: Shape of the pulse Energy1 5 bar = 0.15–0.47 mJmm2EFDShockwave therapy Ondrej Prouza9Energy Flux Density vs Pressure in BarsEnergy flux density00,050,10,150,20,250,30,350,40,450,51,5 2 2,5 3 3,5 4 4,5 5Pressure (Ba r)Energy fl ux densi ty (mJ mm2)15 m m fo ku s9 m m m u ltifo kus15 m m m u ltifoku sShockwave therapy Ondrej Prouza10SWT TECHNOLOGIESShockwave therapy Ondrej Prouza11 1985 Extracorporeal Shock Wave LithotripsyESWL kidney stones disintegration11The beginnings..Shockwave therapy Ondrej Prouza12121990 First applications inmusculoskeletal apparatus1999 – Radial schockwaveprinciple introduced2011: more than 1000 clinical studieswidely accepted therapy in rehabilitation orthopaedicsurgeryEmerging new fieldsclinical indications1993 1997 TODAYFrom history to presentShockwave therapy Ondrej Prouza13SHOCKWAVE TECHNOLOGIESShockwave therapy Ondrej Prouza1414Radial = BTL pneumatic principle Focused:Electrohydraulic principle Electromagnetic principle Piezoelectric principleRadial vs. Focused principleShockwave therapy Ondrej Prouza15Radial vs Focused devices•Differences in size, cost per therapy and treatment and in the procedure..•Both the same shape of the pulse and clinicall effect when equal energies are usedShockwave therapy Ondrej Prouza16Radial vs focused principleRadial: • Designed for superficial treatment• Clinically focused• No anesthesia, no analgesics• Higher comfortof the therapy• Low costs of the unit = faster reimburstmentFocused:• Developed to reach internal organs• Xray or ultrasoundguided• Anesthesia necessary• Costs per unit, treatmentShockwave therapy Ondrej Prouza17More of terminologyESWT vs. RSWT• ESWT=Extracorporeal Shockwave therapy= applied outside of the body, treatment of musculoskeletal apparatus• RSWT=Radial Shockwave therapy • RSWT is ESWTShockwave therapy Ondrej Prouza18Radial, pneumatic principleby BTLProjectileisaccelerated by high pressure pulse Hits the transmiter, emits the SWSemifocused, focused and trigger tip18Radial Shockwave DevicesApplicators Transmitters:• 9 mm – for acupuncture points and for more accurate applications (finger joints)• 15 mm – universal transmitter for all applications• Focused 15 mm – for more targeted applications ( deep trigger points)Shockwave therapy Ondrej Prouza20Shockwave energy What energy is still meaningful?Litothriptors, HE focused shockwaves, radial acoustic waves :Shockwave therapy Ondrej Prouza21SHOCKWAVE THERAPY – BIOLOGICAL EFFECTSShockwave therapy Ondrej Prouza2223ESWT – effects generally Tissue regeneration and repairNeovascularization and angiogenesisAnalgesia, myorelaxationCalcific deposits reabsorptionShockwave therapy Ondrej Prouza23Promptand longlasting analgesic effect Extracorporeal shockwaves induce the expression of ATF3 and GAP43 genes in rat dorsal root ganglion neuronsMurata et al., Auton.Neurosci.,2006Initiation and acceleration of tendon healing process involving collagen and glycosamino glycan GAGproduction.Significant increase in degraded collagen and GAGlevels shortly after treatment. After 6 weeks, metabolism Decreased significantly as GAG levels were lower than in untreated controls. Bosch et al., EquineVet J., 200724SHOCKWAVE THERAPY – BIOLOGICAL EFFECTS I.Shockwave therapy Ondrej Prouza24Stimulation of local metabolism, neovascularisation, osteogenesis and bone remodellingIn adult hip necrosis, significant increase in vWF, platelet endothelial cell adhesion molecule, VEGF, proliferation cell nuclear antigen PCNA levels was observed in patients undergoing SWT prior to total hip arthroplasty.Wang et al., Rheumatology,2004Resorption of calcium depositscaused by tensile part of shockwave Cosentino R et al., Ann Rheum Dis, 200325SHOCKWAVE THERAPY – BIOLOGICAL EFFECTS II. Shockwave therapy Ondrej Prouza25ESWT – Biological mechanism in the tissue Wang 2005Shockwave therapy Ondrej Prouza26 27Immediate effectsLocal increase of microcirculation Immediate myorelaxationImmediate and strong analgesiaESWT Effects on the Tissue I.Shockwave therapy Ondrej Prouza27 28„Shockwave effects“Stimulation of activity of osteoblasts– increase of osteogenesisStimulation of production of collagen by fibroblasts acceleration of healing processesLigament and bone neovascularizationESWT Effects on the Tissue II.Shockwave therapy Ondrej Prouza28 29Analgesia how does it act?inhibition of spasminhibition of nociceptive fibres Gate mechanismendorfines and serotonine releaseacceleration of substance PwashoutESWT Effects on the Tissue III.Substance P: excitation mediator, stimulates nociceptive nervous fibres, supports resorption of oedema andsecretion of histamineantiinflammatory effects of swtShockwave therapy Ondrej Prouza29Repair of the mechanical destruction caused by shockwave „hammer“ or just startup of healing processes?Mechanical model„ minor mechanical destruction causes repair reactions“Biomechanical modelShockwave therapy and healing – the conceptShockwave therapy Ondrej Prouza30Shockwaves in the cell mechanotransductionCells sensetheir physical surroundings through mechanotransduction=translating mechanical forces into biochemical signalssuch aschanges in intracellular calcium concentration or by activating diverse signalling pathways.In turn, these signals adjust cellularand extracellular structure.This mechanosensitive feedback modulates cellular functionsas diverse as migration, proliferation, differentiation and apoptosis, a thoughcrucial for organ development and homeostasis.Mechanotransduction gone awry Diana E. Jaalouk and Jan Lammerding, 2009Shockwave therapy Ondrej Prouza31SHOCKWAVES IN THE TISSUEWhat cell are involved in this reaction?Specific cells activation: Neovascularization pericytes Osteoblasts osteogenesis Fibroblasts collagen productionSupported by vasodilatationShockwave therapy Ondrej Prouza32SWT effects on tissue WANG 2005 Shockwave therapy Ondrej Prouza33 34Most Frequent Indications?Pain in muscles, insertions, TendonsGroin pain AchillodyniaBack painPlantar fascitis Patellar tendinopathy jumper´s kneeEpicondylitis tennis elbowCalcificationsHeel spur (calcar calcanei)Tendinosis calcarea Long tendon ofbiceps calcificationShockwave therapy Ondrej Prouza34Shoulder tendonitis – Xray documentation Moreover, efficacyof ESWT in calcifying shoulder tendonitis was proved in 70% patients Cosentino R et al., Ann Rheum Dis, 200335Shockwave therapy Ondrej Prouza3536Before treatmentAfter 3 SWT sessions, 1500 pulses at 3 bars per session Impingement sy Xray proved calcification–clinical example Shockwave therapy Ondrej Prouza36 37Trigger points treatmentFrozen shouldersyndromeCoxarthrosis, gonarthrosisArthrosis of small finger jointsMuscle spasticityAcupuncturepoints stimulationScarsMOST FREQUENT INDICATIONS II.Shockwave therapy Ondrej Prouza37Unusuall clinical experience6 moths old forefinger extensors incision injuryrigid and prominent scar tissuefirst IP joint fixedin 30° flexion position4SWT applications with 2.5 Bars intensity the scar reformed, ROM full extensionand 100° flexion Shockwave therapy Ondrej Prouza38Shockwaves in sports medicineWhat are the greatest deals of sports medicine?Quick recovery and fast returnto sport activity and training Symptoms asociated with injury – pain, swelling, muscle spasm Shockwave therapy Ondrej Prouza39Shockwaves in sports medicineWhat is the main effectivity of shockwaves?Pain relief Muscle relaxationLocal microcirculation increaseHealingprocesses enhancement and speedingShockwave therapy Ondrej Prouza40Sports medicine most frequent indicationsThree indication groups, is SWT for all?Chronic pain and overuse syndromesAcute pain minor injuriesback pain, muscle distensions, minor ruptures Serious injuriescomplete ruptures, fractures Shockwave therapy Ondrej Prouza41Shockwaves in sport – new indications I.„Overuse“, chronic subacute disordersEpicondilitisJumper´s kneeAchillodyniaChronic back painShoulder tendinitisHuge variety depending on the type of sports activityUnique efficiencyShockwave therapy Ondrej Prouza42Shockwaves in sport – new indications II. Acute injuries or postsurgicalstatusesMuscle and tendon strains– distensions and partial rupturesLigaments sprains– distorsionsAcute vertebrae blockageRegeneration support Postsurgical or post imobilization healingenhancement Shockwave therapy Ondrej Prouza43CLINICAL EXPERIENCE – MUSCLE RUPTURE AFTER ESWT THERAPY Acute muscle rupturetreated with ESWT (1st, 7th and 14th day)Shockwave therapy Ondrej Prouza44Shockwaves in sport – therapeutic procedureSupport with other available therapies – healing and antioedematory effectLaserafter and between the sessions Lymphatic drainageThermopositive therapyMagnetotherapy maximum frequency of the sessions UltrasoundElectronalgesiaCryotherapy or spa proceduresShockwave therapy Ondrej Prouza45Emerging fields otherDermatology, Aesthetics: CelluliteScarsDiabetic ulcersUrology, veterinaryShockwave therapy Ondrej Prouza46SWT IN SPASTICITY TREATMENTOnose, T. EXTRACORPOREAL SHOCKWAVE THERAPY FOR SPASTICITY MANAGEMENT, IN CHILDREN WITH CEREBRAL PALSY,2010Servodio F,et Al. Unfocused shock wave therapy for focal spasticity in the infantile cerebral palsy:Evaluation of results through computerised gait , 2008Amelio E, Mangnotti P Effect of Extracorporeal Shock Wave Therapy on Spastic Hypertonia “7th International Symposium on Experimental Spinal Cord Repair and Regeneration”, Brescia, Italia, 2009SWT can decrease all types of muscle hypertoniaLocal muscle hypertonus or spasmPartial hypertonus – TrpMuscular spasticitycaused by neurological disorderShockwave therapy Ondrej Prouza47SWT SUMMARYChronicor semichronic conditions – non comparable resultsMuscle, soft tissue and bone healing process startupNo harm of the tissue, only anabolic processes provedLongterm followup efficiency about 7080%in main indications36 sessionsusually maximumNecessary to follow regimen restrictions and contraindicationsAlternative to surgeryShockwave therapy Ondrej Prouza48SWT AND OTHER CLINICAL MODALITIES Shockwave therapy Ondrej Prouza49Reduction of side effects and support of desired clinical resultLaser therapy– more intense healing support in chronic inflammationElectrotherapy– to support analgesic effectLymphatic drainage– sports medicine – regeneration and oedema removalMagnetotherapy – acceleration of bone and cartilage healingSWT AND OTHER CLINICAL MODALITIES Shockwave therapy Ondrej Prouza50Synergic Effect of SWT Laser CombinationBiostimulation– physiologically different supportive effect of SWT Antiswelling and anti–inflammatoryeffect support of healing dg associated with inflammation to reduce possible side effects of SWT = shorter interval between sesions : 45 daysRevascularization= both effects of SWT and laser Shockwave therapy Ondrej Prouza51Rest therapy after treatment? Stretching and postisometrical relaxation during or immediately after treatmentInstruct patient to do stretching and postisometrical relaxationbetween sessions i.e. elbow tendinopathiesActive training up to 40% of the muscle capacity, starting from 2nd dayRegional stabilization and dysbalance correctionsSWT AND OTHER CLINICAL MODALITIES – ACTIVE TRAININGShockwave therapy Ondrej Prouza52RELATIVESkindefects– relative, some studies show improvement i.e. in DM ulcerTBCTumordiseases Fever, flu or other infectious diseaseApplication in the area of varicesApplication just above the nerve Application on certain tissues (eyes and periorbital area, myocardium, spinal cord, gonads, kidneys, liver)53CONTRAINDICATIONS OF ESWT Shockwave therapy Ondrej Prouza53CONTRAINDICATIONS OF ESWT Application of therapeutic X rays within last 6 weeksPharmacotherapy by corticosteroids within last 6 weeksSensational deficite in the treated areaDisc hernia or protrusion ABSOLUTEBlood coagulation disorders, anticoagulation treatmentPregnancyAbdominal or frontal pelvic applicationShockwave therapy Ondrej Prouza54 55Possible Temporary Side EffectsTemporary hyperhypo sensitivityErythemaPetechiaHaematomaOedemaMost of the patients never experience any of these side effectsCan be maximally reduced in combination with other therapies e.g. Lasertherapy, magnetotherapyShockwave therapy Ondrej Prouza55DISCUSSION
Shockwave therapy in musculoskeletal treatment Mgr Ondrej Prouza Physiotherapist & BTL medical consultant Shockwave therapy contents Contents of presentation: Shockwave Therapy– physical principles & technology Shockwave Therapy – medical background Shockwave Therapy - clinical demo Shockwave therapy / Ondrej Prouza Biophysical background Shockwave therapy / Ondrej Prouza 3 Shockwave therapy / Ondrej Prouza 4 Biophysical background Shock wave is a transient acoustic wave Unique opportunity to transmit high energy for long distances First observation – Second World War First technical interest in 1966 Dornier Aircraft Labs Shockwave therapy / Ondrej Prouza 5 Picture by Shriwastava, J.Biosci., March 2005 Shockwave therapy / Ondrej Prouza 6 Shockwaves in medicine Shockwave is an acoustic wave which carries its´ high energy to the painful spot and provokes healing and repair processes Main fields of application: Orthopedics Rehabilitation Sport medicine Other /veterinary, aesthetics, urology, dermatology / Most common applications: Shoulder tendonitis Achillodynia Heel spur /calcar calcanei/ Lateral epicondylitis Shockwave therapy / Ondrej Prouza Terminology Low energy shockwave Radial shockwave therapy Pressure pulse therapy Acoustic wave therapy All refer to one therapy defined by: Shape of the pulse Energy - bar = 0.15–0.47 mJ/mm2 EFD Shockwave therapy / Ondrej Prouza Energy Flux Density vs Pressure in Bars Energy flux density 0,5 Energy flux density (mJ/mm2) 0,45 15 m m fo ku s m m m u ltifo ku s 0,4 15 m m m u ltifo ku s 0,35 0,3 0,25 0,2 0,15 0,1 0,05 1,5 2,5 3,5 4,5 Pressure (Ba r) Shockwave therapy / Ondrej Prouza SWT - TECHNOLOGIES Shockwave therapy / Ondrej Prouza 10 Shockwaves in sport – new indications I „Overuse“, chronic subacute disorders Epicondilitis Jumper´s knee Achillodynia Chronic back pain Shoulder tendinitis Huge variety depending on the type of sports activity Unique efficiency Shockwave therapy / Ondrej Prouza 41 Shockwaves in sport – new indications II Acute injuries or post-surgical statuses Muscle and tendon strains – distensions and partial ruptures Ligaments sprains – distorsions Acute vertebrae blockage Regeneration support Post-surgical or post imobilization healing enhancement Shockwave therapy / Ondrej Prouza 42 CLINICAL EXPERIENCE – MUSCLE RUPTURE AFTER ESWT THERAPY Acute muscle rupture treated with ESWT (1st, 7th and 14th day) Shockwave therapy / Ondrej Prouza 43 Shockwaves in sport – therapeutic procedure Support with other available therapies – healing and anti-oedematory effect Laser /after and between the sessions/ Lymphatic drainage Thermopositive therapy Magnetotherapy /maximum frequency of the sessions / Ultrasound Electronalgesia Cryotherapy or spa procedures Shockwave therapy / Ondrej Prouza 44 Emerging fields - other Dermatology, Aesthetics: Cellulite Scars Diabetic ulcers Urology, veterinary Shockwave therapy / Ondrej Prouza 45 SWT IN SPASTICITY TREATMENT SWT can decrease all types of muscle hypertonia Local muscle hypertonus or spasm Partial hypertonus – Trp Muscular spasticity caused by neurological disorder Onose, T EXTRACORPOREAL SHOCKWAVE THERAPY FOR SPASTICITY MANAGEMENT, IN CHILDREN WITH CEREBRAL PALSY, 2010 Servodio F,et Al Unfocused shock wave therapy for focal spasticity in the infantile cerebral palsy: Evaluation of results through computerised gait , 2008 Amelio E, Mangnotti P Effect of Extracorporeal Shock Wave Therapy on Spastic Hypertonia - “7th International Symposium on Experimental Spinal Cord Repair and Regeneration”, Brescia, Italia, 2009 Shockwave therapy / Ondrej Prouza 46 SWT SUMMARY Chronic or semi-chronic conditions – non comparable results Muscle, soft tissue and bone healing process start-up No harm of the tissue, only anabolic processes proved! Long-term follow-up efficiency about 70-80% in main indications 3-6 sessions usually maximum Necessary to follow regimen restrictions and contraindications! Alternative to surgery Shockwave therapy / Ondrej Prouza 47 SWT AND OTHER CLINICAL MODALITIES Shockwave therapy / Ondrej Prouza 48 SWT AND OTHER CLINICAL MODALITIES Reduction of side effects and support of desired clinical result Laser therapy – more intense healing support in chronic inflammation Electrotherapy – to support analgesic effect Lymphatic drainage – sports medicine – regeneration and oedema removal Magnetotherapy – acceleration of bone and cartilage healing Shockwave therapy / Ondrej Prouza 49 Synergic Effect of SWT & Laser Combination Biostimulation – physiologically different supportive effect of SWT Antiswelling and anti–inflammatory effect support of healing - dg associated with inflammation to reduce possible side effects of SWT = shorter interval between sesions : 4-5 days Revascularization = both effects of SWT and laser Shockwave therapy / Ondrej Prouza 50 SWT AND OTHER CLINICAL MODALITIES – ACTIVE TRAINING Rest therapy after treatment? Stretching and post-isometrical relaxation during or immediately after treatment Instruct patient to stretching and post-isometrical relaxation between sessions /i.e elbow tendinopathies/ Active training up to 40% of the muscle capacity, starting from 2nd day Regional stabilization and dysbalance corrections Shockwave therapy / Ondrej Prouza 51 CONTRAINDICATIONS OF ESWT RELATIVE Skin defects – relative, some studies show improvement i.e in DM ulcer TBC Tumor diseases Fever, flu or other infectious disease Application in the area of varices Application just above the nerve Application on certain tissues (eyes and periorbital area, myocardium, spinal cord, gonads, kidneys, liver) Shockwave therapy / Ondrej Prouza 52 53 CONTRAINDICATIONS OF ESWT Application of therapeutic X - rays within last weeks Pharmacotherapy by corticosteroids within last weeks Sensational deficite in the treated area Disc hernia or protrusion ABSOLUTE Blood coagulation disorders, anticoagulation treatment Pregnancy Abdominal or frontal pelvic application Shockwave therapy / Ondrej Prouza 53 Possible Temporary Side Effects Temporary hyper/hypo- sensitivity Erythema Petechia Haematoma Oedema Most of the patients never experience any of these side effects Can be maximally reduced in combination with other therapies e.g Lasertherapy, magnetotherapy Shockwave therapy / Ondrej Prouza 55 54 DISCUSSION Shockwave therapy / Ondrej Prouza 55 [...]... indications 1993 Shockwave therapy / Ondrej Prouza 1997 TODAY 12 12 SHOCKWAVE TECHNOLOGIES Shockwave therapy / Ondrej Prouza 13 Radial vs Focused principle Radial = BTL pneumatic principle Focused: Electrohydraulic principle Electromagnetic principle Piezoelectric principle Shockwave therapy / Ondrej Prouza 14 14 Radial vs Focused devices •Differences in size, cost per therapy and treatment and in the procedure...The beginnings 1985 Extracorporeal Shock Wave Lithotripsy /ESWL/ kidney stones disintegration Shockwave therapy / Ondrej Prouza 11 11 From history to present 1990 - First applications in musculoskeletal apparatus 1999 – Radial schockwave principle introduced 2011: more than 1000 clinical studies widely accepted therapy in rehabilitation & orthopaedic surgery Emerging new fields&clinical indications... • Anesthesia necessary • Costs per unit, treatment Shockwave therapy / Ondrej Prouza 16 More of terminology ESWT vs RSWT • ESWT=Extracorporeal Shockwave therapy= applied outside of the body, treatment of musculoskeletal apparatus • RSWT=Radial Shockwave therapy • RSWT is ESWT!!! Shockwave therapy / Ondrej Prouza 17 Radial Shockwave Devices Radial, pneumatic principle by BTL Projectile is accelerated... secretion of histamineanti-inflammatory effects of swt Shockwave therapy / Ondrej Prouza 29 28 Shockwave therapy and healing – the concept Repair of the mechanical destruction caused by shockwave „hammer“ or just start-up of healing processes? Mechanical model „ minor mechanical destruction causes repair reactions“ Biomechanical model Shockwave therapy / Ondrej Prouza 29 Shockwaves in the cell mechanotransduction... proved in 70% patients Cosentino R et al., Ann Rheum Dis, 2003 Shockwave therapy / Ondrej Prouza 34 35 Impingement sy & X-ray proved calcification–clinical example Before treatment Shockwave therapy / Ondrej Prouza After 3 SWT sessions, 1500 pulses at 3 bars per session 35 36 MOST FREQUENT INDICATIONS II Trigger points treatment Frozen shoulder syndrome Coxarthrosis, gonarthrosis Arthrosis of small finger... Lammerding, 2009 Shockwave therapy / Ondrej Prouza 30 SHOCKWAVES IN THE TISSUE What cell are involved in this reaction? Specific cells activation: Neovascularization - pericytes Osteoblasts - osteogenesis Fibroblasts - collagen production Supported by vasodilatation Shockwave therapy / Ondrej Prouza 31 SWT effects on tissue / WANG 2005 / Shockwave therapy / Ondrej Prouza 32 Most Frequent Indications?... Indications? Pain in muscles, insertions, Tendons Groin pain Achillodynia Back pain Plantar fascitis Patellar tendinopathy - jumper´s knee Epicondylitis - tennis elbow Calcifications Heel spur (calcar calcanei) Tendinosis calcarea Long tendon of biceps calcification Shockwave therapy / Ondrej Prouza 34 33 Shoulder tendonitis – X-ray documentation Moreover, efficacy of ESWT in calcifying shoulder tendonitis... part of shockwave Cosentino R et al., Ann Rheum Dis, 2003 Shockwave therapy / Ondrej Prouza 24 25 ESWT – Biological mechanism in the tissue Wang 2005 Shockwave therapy / Ondrej Prouza 25 ESWT Effects on the Tissue I Immediate effects Local increase of microcirculation Immediate myorelaxation Immediate and strong analgesia Shockwave therapy / Ondrej Prouza 27 26 ESWT Effects on the Tissue II Shockwave. .. GAP-43 genes in rat dorsal root ganglion neurons Murata et al., Auton.Neurosci.,2006 Initiation and acceleration of tendon healing process involving collagen and glycosamino- glycan /GAG/ production Significant increase in degraded collagen and GAG levels shortly after treatment After 6 weeks, metabolism Decreased significantly as GAG levels were lower than in untreated controls Bosch et al., EquineVet J.,... tip Shockwave therapy / Ondrej Prouza 18 18 ApplicatorsTransmitters: • 9 mm – for acupuncture points and for more accurate applications (finger joints) • 15 mm – universal transmitter for all applications • Focused 15 mm – for more targeted applications ( deep trigger points) Shockwave energy What energy is still meaningful? Litothriptors, HE focused shockwaves, radial acoustic waves : Shockwave therapy