Research is not intended to subjugate, penalize, or reward us; rather, it serves as a method to enhance and advance our knowledge. However, integrating our existing knowledge and clinical practices with research findings can be both rewarding and affirming when evidence supports our actions as the 'right' choice. Conversely, it can also be disruptive and uncomfortable when it reveals that we may be mistaken.

 

We can feel a deep sense of satisfaction when we are proven right - our brains pleasure centres predictably respond to self-affirming information (1). When I read a study that confirms me... I mean, ah, my knowledge... I can imagine my figurative tail wagging, like Ellie's response to "you're such a good girl ❤️"

 

 

 

Of course the opposite is true when we receive information that contradicts our prior knowledge and actions. 

 

"It is well documented that people seek to maintain a positive self-view and that threats to perceived self-competence across many domains are met with resistance (1)." 

 

"...negative feedback is also known to generate negative emotions such as frustration and anxiety that may lead to a decline in intrinsic motivation." (3)

 

All knowledge seeking healthcare practitioners will meet this resistance, and the choice of whether or not to oppose it. We should aim to oppose research through critical appraisal research based on:

• its methods, strengths and limitations
• its context among other relevant research findings

We should avoid opposing it based on:

• our cognitive biases and emotional response to it
• We should anticipate this will be the case when we read something that contradicts our present knowledge and clinical approach.

 

So let me give you a real-world example I am presently faced with after reading this study:

 

Does shockwave therapy lead to better pain and function than sham over 12 weeks in people with insertional Achilles tendinopathy? A randomised controlled trial

 

Preface: I have used Shockwave Therapy in Clinical Practice for 14 years; Focused SWT for 11 years and Radial Shockwave Therapy for 3 years.

 

The studies conclusion: 

"The addition of radial extracorporeal shockwave therapy to recommended exercise and education did not result in improved pain and function or other outcomes compared to sham at 6 or 12 weeks among people with insertional Achilles tendinopathy."

I encourage you to read the full text, including the supplementary material, which you can download, that defines the exercise / loading program and activity modification in response to pain and progress.

 

In the following text, I will share my past use of SWT in clinical practice, my cognitive and emotional response to reading this study, and my plan for future action.

 

Part 1: My historical use of SWT in Clinical Practice

 

My primary method of treating tendinopathies is based on activity modification, building tendon load tolerance and capacity, and where necessary, improving movement quality, stability, stamina and strength. Depending on the tendon and general health of the patient, lifestyle factors can also play an essential role. 

 

I have used Shockwave Therapy as an adjunct and secondary therapy, predominantly for chronic tendinopathies. My indications for SWT include:

 

New Patients: Chronic tendinopathy of >6 months duration. Failed response to past good primary conservative care (emphasis added, because sadly, this is uncommon). If past care is deemed unsatisfactory, follow existing patient protocol.

 

Existing Patients: Failed response to 3 months of primary conservative care. If patient has been non responsive to treatment at 6 wks and 12 wks, a detailed re-exam to confirm the correct diagnosis, discuss compliance to care, lifestyle factors, strategic mistakes in loading.

 

Part 2: Past Research and Experience Using SWT

 

For the sake of this discussion, I will keep this focused to the Achilles Tendon. 

My anecdotal experience suggests that in chronic tendinopathy that does not respond sufficiently to primary conservative care, SWT can have significant effects on outcomes. In my opinion, the primary mechanisms of SWT are likely related to its impact on the physiology of pain. There seems to be a period during and shortly after SWT whereby the patients response to load is improved, thereby improving our efforts to improve strength, tolerance and capacity, through exercise rehabilitation.

"Application of ESW resulted in a selective, substantial loss of unmyelinated nerve fibers." (8)

"The application of extracorporeal shockwaves caused a statistically significant decrease in the mean number of neurons immunoreactive for substance P within the dorsal root ganglion L5 of the treated side compared with the untreated side, without affecting the total number of neurons within this dorsal root ganglion." (9)

 

Again anecdotally, I have observed significant changes in the appearance thickening and swelling after shockwave therapy, that had not transpired with prior care. This also jives with the limited evidence we have on the mechanisms of SWT.

 

Here are some other studies for your reference, that have mostly supported use of SWT as an adjunct therapy for achilles tendinopathy.

"This review suggests that ESWT is a safe and effective modality for treating midportion Achilles tendinopathy. ESWT reduces pain and improves function in those with midportion Achilles tendinopathy. The best available evidence suggests that a combination of ESWT with eccentric exercises and stretching may be even more effective than ESWT alone. Further research is required to confirm this and to determine the optimum ESWT treatment protocol." (5)

 

"Recently published data have shown the high evidence of efficacy of extracorporeal shock wave therapy in chronic Achilles tendinopathy. Randomized placebo controlled trials have confirmed excellent results with regards to function and pain. So far no differentiation can be done between different treatment modalities such as application pressure, energy flux density or frequency. Further studies have to focus on this missing evidence to further improve the outcome after ESWT. Shock wave therapy as published up to day seems to be the most effective option in chronic Achilles tendinopathy." (6)

 

"extracorporeal shock wave treatment improved the symptoms of insertional and non-insertional AT, and the Insertional AT patients experienced better clinical outcomes compared with non-insertional AT patients." (7)

 

Part 3: My cognitive and emotional response

 

My first response was concern - "is my approach wrong; am I wasting good resources using SWT?" 

 

My second response was confusion - "this doesn't jive with my experience; what am I missing? Am I attributing SWT mechanisms where there were other explanations or mechanisms defining the patients outcome?"

 

My process when I read research abstracts or conclusions that contradict my current knowledge is to dive into the full text. Having a solid understanding of the research methods helps me determine the weight I will ultimately give to the study.

 

In this case, I will point out that I am familiar with one of the authors work (Malliaris) and have taken continuing education through both him, and the like minded Jill Cook. I am aware that Malliaris has used SWT in practice for several years with a similar approach to my own. In reading the supplementary material I am satisfied and confident the control and treatment group received good primary care via exercise and activity modification. The study was powered well. The sham treatment was reasonable, but perhaps there were insufficient - from my experience the average practitioner would perform of 3-6 treatments, depending on the chronicity and severity of the condition, and the response to treatment.

 

I think most practitioners and indeed this study states insertional achilles tendinopathy tend to be more challenging to manage than mid-tendinopathy. It is interesting that prior opinions of SWT were in favour of its treatment for insertional tendinopathies. The evidence to date mostly contradicts this. 

 

I have to admit that I do like my protocol for using SWT. It is focused on activity modification and gradual, symptom monitored response to loading. It incorporates whole body and local movement parameters, including addressing stability, strength, and load tolerance, according to a best-evidence approach. And frankly, when you've thrown everything and the kitchen sink at it, I'd rather try SWT than some other more invasive (surgery), risky (cortisone), or equally unproven intervention (dry needling, other injections).

 

My personal experience and professional opinion is that the vast majority of chronic tendinopathies only become and continue to be chronic due to shitty loading protocols (either not enough, or progressions that are too much and too fast). When this is well in place and the outcome remains poor, we must consider alternative diagnoses and reconsider lifestyle factors (diet, hormonal, sleep, stress) as bigger than anticipated culprit.

 

This study does however give me pause, and reminds me to be patient and persist with exercise and activity based interventions for a minimum of 12 wks before jumping ship. It also reminds me to communicate effectively and continuously with my patients, to ensure they are compliant, understand and follow the loading protocols well.

 

In summary, maybe I was being unnecessarily dramatic. I don't completely suck. I just partially sucked. This is a good thing, to get better for the next day.

 

References:

 

1. David K. Sherman, Geoffrey L. Cohen. The Psychology of Self‐defense: Self‐Affirmation Theory, Advances in Experimental Social Psychology, Academic Press,
Volume 38, 2006, Pages 183-242, ISSN 0065-2601, ISBN 9780120152384, https://doi.org/10.1016/S0065-2601(06)38004-5.