ISMST - 2014 Presentation Final Presentation
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Transcript of ISMST - 2014 Presentation Final Presentation
Kenneth Craig, Bradley Takai, Daniel Poratt
Presenter: Kenneth CraigMedical Director Kompass Health Associates
Kompass OrthoShock Centre of Extracorporeal Shockwave Therapy & Research
Auckland, New Zealand
Medical shockwaves a treatment option for complex / neuropathic pain
syndromes?
A compilation of case reports 2012 – 2014
Conflict of Interest Declaration
Royalties & stock options – NONE
Consulting Income – NONE
Research & Education Support – NONE
Other support - NONE
AIM
To discuss and invite more research in this area
Complex / Neuropathic Pain
-
(Dorkin et.al., 2003 & 2007; Ducreux et.al., 2006; Costigan et al., 2009; Nielson et.. al, 2008; Staud et.al., 2008; Tracey & Mantyh, 2007; Treede et. al., 2008).
Introduction
Poorly understood
Maladaptive
Abnormal sensory perception
Multifactorial propagation
Indocile to most interventions
(Mainly symptomatic control)
Severe impactPeripheral hyperalgesia,
allondynia
2ndary
hyperalgesia &
allondynia
Peripheral /
Central
Ectopic
activity
To find an effective homeostatic disease modifying treatment modality that is:
Non-invasive
Systemically neutral
Economically viable
The Need
ESWT?
The Answer
Our Case Series
Brief Case Description
Gender Male (n=5); Female (n=7)
Age (Mean) 44 yrs; Y(14yrs) / E (70yrs)
Inciting Event Trauma (n=10) – CRPS1; Infection (n=2) - Neuropathic
Region of Interest Foot & Ankle (n=10); Knee (n=2)
Mean Disease Duration 16 months
P & S Hyperalgesia n=12
P & S Allondynia n=12
Emotional Distress n=12
Management
Primary analgesia & NSAID’s
Secondary analgesics (TCA’s / Anticonvulsants)
Opioid analgesia (Tramadol / oxycodone)
Physical therapy
Counselling + alternative therapies (ie hypnotherapy)
Baseline Investigations
General history taking
Psychometric
POP 3 (20 pt questionnaire)
Subjective Pain (0 – 10)
Physical Index (% of Mobility; ADL; Vitality)
Affective Index (% of Emotional status & Fear)
Neuropathic
questionnaireDN4
Clinical tests DermaTemp; NeuroTip; Monofilament; Cotton-brush
Physical assessment Passive / Active ranges & movement observation
EducationPain education
Technology education
Material s & Methods
Phamacogenic
s
All discontinued prior to Tx and remained throughout
Device Electrohydraulic (MediSpec)
Treatment # 4 at 1 week intervals
Impulse # 1500 / Tx (500 impulses over each region)
EFDL 0.08mj/mm² (initial 2); 0.10 – 0.14mj/mm² (3rd- 4th)
Tx regions Primary & secondary regions, and along neural course
0
1
2
3
4
5
6
7
8
9
10
Baseline Week 6 Week 12 Week 24
Pain (VAS)
DN4
Results
Positive response: n=10 (trauma induced)
VAS Pain score: (8.87) to 2 at w24
DN4 Score: (6.7) to 0 at w24
Results
0
10
20
30
40
50
60
70
80
90
Pre Tx Week 6 Week 12 Week 24
Physical Index
Affective Index
Physical Index: (53.47) to 2.77 at w24
Affective Index: (85.49) to10.22 at w24
Discussion
n=2 non-respondents – infection incited (unchanged from onset)
n=10 CRPS - Abnormal pain symptoms & sensitivity settled
No adverse complaint to-date (n=12)
Discussion: Rational for Application
(Bee & Dickenson, 2008; Costigan et al., 2009; Keller et.al., 2007; Koban et. al., 2003; Kohno et.al., 2005; Matsuzawa-Yanagida et.al., 2008; Miraucourt et.al., 2007; Pearl, 2007; Schattschneider
et.al., 2006; Schloz et.al., 2007; Vera-Portocarrerro et.al, 2006; ).
Peripheral abnormaly (Increased
nociceptive barrage, aberrant
inflammatory, immunological interactions
etc.)
Central abnormaly (sensitisation &
aberrant inflammatory, immunological
interactions etc.)
Reduced descending inhibition
Reduced inhibitory polarisation modulators
Neuro-transcription (pain memory)
Nutritive vessel hypoxia =
small fiber damage
ESWT proposed mechanics of action:
Modulates inflammatory substances
Modulates immune response
Improves perfusion – hypoxic correction
Regenerative and restorative capacity
Unique stimulus – cognitive capturing / arousing
Certainly more research is warranted
Future Direction & Conclusion
Continue to monitor these cases
Research collaboration with pain
centres (ie TREND / TARPS)
More measurable Tx. outcomes
(dorsaVi) to help expand recognition
and use of ESWT
Certainly worthwhile investigating
THANK YOU
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