title: In-vitro cell treatment with focused shockwaves-influence of the experimental setup on the sound field and biological reaction.
abstract: BACKGROUND
  To improve understanding of shockwave therapy mechanisms, in vitro experiments are conducted and the correlation between cell reaction and shockwave parameters like the maximum pressure or energy density is studied. If the shockwave is not measured in the experimental setup used, it is usually assumed that the device's shockwave parameters (=manufacturer's free field measurements) are valid. But this applies only for in vitro setups which do not modify the shockwave, e.g., by reflection or refraction. We hypothesize that most setups used for in vitro shockwave experiments described in the literature influence the sound field significantly so that correlations between the physical parameters and the biological reaction are not valid.
  
  
  METHODS
  To reveal the components of common shockwave in vitro setups which mainly influence the sound field, 32 publications with 37 setups used for focused shockwave experiments were reviewed and evaluated regarding cavitation, cell container material, focal sound field size relative to cell model size, and distance between treated cells and air. For further evaluation of the severity of those influences, experiments and calculations were conducted.
  
  
  RESULTS
  In 37 setups, 17 different combinations of coupling, cell container, and cell model are described. The setup used mainly is a transducer coupled via water to a tube filled with a cell suspension. As changes of the shockwaves' maximum pressure of 11 % can already induce changes of the biological reaction, the sound field and biological reactions are mainly disturbed by use of standard cell containers, use of coupling gel, air within the 5 MPa focal zone, and cell model sizes which are bigger than half the -6 dB focal dimensions.
  
  
  CONCLUSIONS
  Until now, correct and sufficient information about the shockwave influencing cells in vitro is only provided in 1 of 32 publications. Based on these findings, guidelines for improved in vitro setups are proposed which help minimize the influence of the setup on the sound field.
authors.affiliation: Chair of medical engineering, RWTH Aachen University, Pauwelsstraße 20, Aachen, 52074 Germany.
authors.forename: Kristin
authors.initials: K
authors.lastname: Dietz-Laursonn
authors.affiliation: Department of Anatomy and Cell Biology, RWTH Aachen University, Wendlingweg 2, Aachen, 52074 Germany.
authors.forename: Rainer
authors.initials: R
authors.lastname: Beckmann
authors.affiliation: Richard Wolf GmbH, Pforzheimer Straße 32, Knittlingen, 75438 Germany.
authors.forename: Siegfried
authors.initials: S
authors.lastname: Ginter
authors.affiliation: Chair of medical engineering, RWTH Aachen University, Pauwelsstraße 20, Aachen, 52074 Germany.
authors.forename: Klaus
authors.initials: K
authors.lastname: Radermacher
authors.affiliation: Chair of medical engineering, RWTH Aachen University, Pauwelsstraße 20, Aachen, 52074 Germany.
authors.forename: Matías
authors.initials: M
authors.lastname: de la Fuente
keywords: ESWT; Experimental setup; In vitro; Review; Shockwave; Shockwave parameters; Therapy