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ESWT Discussion with Dr. David Zuckerman

Posted by Duane E on 2/02/00 at 00:00 (015391)

Thank you for your efforts to answer some of my questions. It is obvious from your post, that the ESWT you perform with the Orbasone is substantively different from orthotripsy(TM) performed with the OssaTron. As I mentioned before, having competing technologies is to everyone's benefit. Ultimately, with such differences in performance, one system should dominate the treatment of plantar fasciitis. Everyone on this board who has had ESWT, has had it performed with the OssaTron. The comparison of the two technologies and procedures will be beneficial to those deciding which system to use.

(1) Your nerve block procedure requires more detail for me to fully understand it. You list three nerves, and an area of the foot to block. Since some of the nerves run quite a distance, (e.g., the posterior nerve roots enter the spinal column), please state the injection site and the amount of anesthetic used for each site.

(2) Please state the type of anesthetic used. What I'm asking for here, is the analgesic compounds, their concentrations in the carrier fluid, and the composition of the carrier fluid.

(3) The 18kV energy setting on the Orbasone does not appear to produce the same shock strength or focal size as the same setting on the OssaTron. Please supply the following information so an accurate comparison of the two devices may be performed.
(3a) What is the focal size?
(3b) What is the range of energy settings?
(3c) At the 18kV setting, what is the focal energy in mJ? What is the focal pressure in MPa?
(3d) What is the operating frequency range of the Orbasone? Is it programmable?

(4) What is the frequency schedule that you use to administer the 3000 shocks in the initial session?
(4a) Are all the shocks administered at 18kV?

(5) I am familiar with Dornier, Siemens, Storz Medical and HMT, but not MIP. Could you supply the words to this acronym? Do they have a web site?

(6) You mentioned one of your ESWT patients had some 'subjective' pain when he cleared the snow for one hour. Many on this board are familiar with this type of pain. Can you ask your patient to post on this web site so we may objectively discuss his experience?

(7) Nicole V.R. states that the treatment cost of $1800 is not covered by insurance. My insurance will cover any FDA approved treatment. Please discuss.

(8) Please address issue number (2) from my post made on Jan. 31, 2000 about the energy required for altering bone.

Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/02/00 at 00:00 (015395)

I will answer some the questions that have you asked me.
1. I am using 1% lidocaine plain with 0.5 Marcaine plain total ten cc's

2. foot and ankle.

3. 3a i was told but I will have to ask. At the time I had them show me the focal point because I wanted to beable to see this in my mind's eye I have been doing alot of minimial incision foot surgery for heel spurs in the past twent years where I remove the spur without seeing this. I can palpation the
medial tubercle of the heel and I can picture the length and width,
So I want to make sure that the pain treatment focal point is covering
the entire width of the medial tubercle. I do know with the two positions that I am using I am covering the entire medial tubercle which is where the plantar aponeurosis ( plantar fascia
), Abductor hallucis, Flexor digiti brevis,and Quadratus plantae muscle insert
3c Will have to find out. It was explained to me that the amount of pressure was in bars. The person who trained me had over two thousand
EWST procedure experience. He had a PHD in biophysic and Laser. At the
time of the training I was more interested in two things Learing where the focal point was at all times. There were many ways to learn this and different treatment methods. He told me with this machine 3000 shocks at 18kv was a very good start. You must remember the treatment results will be different because you have different levels of clinical skill, different levels of diagnostic skills, there are going to be so many factors that just looking at what is the kv,
what is the pressure etc doesn't matter. I learned along time ago that one doctor can be the same thing and another can be the same thing one lives and doesn't . The point is that this just isn't about a procedure done with the Orbasone, Osstran. This is done by a doctor. This procedure is an art and a science. Probaby more of an art with alot of experience in treating the human foot.
I will tell you by talking with John W. They both have the ability to
do exactly the same thing with amount of shocks KV.
5. Very brief but go to http://www.norlandmedical for the press release

6. working on this. This gentleman doesn't use e-mail etc. He is a working man. I am working this part out.

7. This is FDA approved for chronic pain managment, as per Norland Medical. AS you know there is some disagreement by companies about this. I can understand John W feelings . I would feel the same. He has given me good advice. I told him that if the Orbasone isn't around then I will be using the Osstran. He promised me I would be one of the first installations. I hope that the Orbasone at this time isn't stopped I have patients that need help!
Could you tell me your insurance plan. I will talk to them. If you get one company to pay then there is some little hope that more will.
The law states in New Jersey that insurance companies have to pay for any procedure that is medically necesssary,but you have to go to court to enforce this.

8. According to John W. he tells me that in order to treat avascular necrosis with good results you probaby have to go to 22kv with 6-8
shocks. In my opinion and from a scientific approach, when ever you have increase circulation to the soft tissue and at the medical tubercle where the four tendon-muscle layer insert such as with EWST
you are going to have some demineralizatin of bone, now that is only my opinion. This could be proven but what is the point. In foot this
isn't important to have this happen with EWST. I have read that in the shoulder they had de-calification of bone in the shoulder treatment. I think that there is literature in either http://www.orthotripsy.com or a healthronic link. If it really important let me know.

So I am typing better this message board has given me practice.Oh!
MIP is Minimial Invasion Products. They in Germany.

I hope that I anwered more of your questions. I was thinking that I hope that other doctors don't tryto increase kv power without understanding bone density and bone quality. You could fracture the heel pain if you are just any doctor who has no expertise in treating
heel pain and bone problems of the foot and ankle. So doctors don't
do anything I just stated without talking to me please.

Thanks


Re: ESWT Discussion with Dr. David Zuckerman

Duane E on 2/03/00 at 00:00 (015439)

Thank you for your answers. The more information I look at, the more differences I see between the OssaTron and the Orbasone. When the pertinent information has been gathered, I'll post a comparison of the two technologies. You stated that the Orbasone has been FDA approved (per Norland Medical) for the treatment of chronic pain. This is different from being FDA approved to use for orthopedic lithotripsy. However, that does not mean that the Orbasone has any less value to patients.

(1) and (2) Am I correct to assume that you first inject 5cc of the anesthetic into the ankle site, and later the remaining 5cc into the heel site?

(3a) to (3d) Waiting for answer.

(4) and (4a) Waiting for answer.

(5) The http://www.norlandmedical.com site would not display. I tried going through the link at Wilburn Medical and got the same result. I did find some brief information (including a picture) about the Orbasone at: http://www.norland.com , but no press release.

(6) Hope to hear from him or some of your other ESWT patients.

(7) Nicole V.R.'s post on Jan. 31, 2000 stated the treatment was not covered by insurance. Her source was a Philadelphia television station's news report.

(8) Since there is no literature supporting the changing of bone structure at the energies you currently operate the Orbasone; you might want to consider changing what is on your web site to a statement of your opinion. I consider this issue closed.


Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/03/00 at 00:00 (015462)

This is a very brief note. I just came back from the hospital. My father the first generation of Podiatrists is going to have heart by pass surgery, so there my be silence from me for some time.
I will research the literature . I though there was bone changes in animal studies. I still think that there are but i would have to order a three phase bone scan post-op. I wouldn't want this done. So I guess at this time I can't prove this. Will work on the rest of your questions. I will invite you to visit my office and see the Orbasone in action. You do have alot of information and I am aways open. If you have no problem you can either call or fax the name of your health insurance company and my staff will see if the ESWT treatments are covered or not. I don't know how you feel about giving out this information but I understand if you don't want to. I am in the process of contacting alot of companies but according to Norland Medical no insurance coverage. This to me seems reasonable due to the fact that alot of insurance policies limit coverage in the foot.
I am really diappeared that John W. pulled the word OrthotripyTM out form under me. I am going to have to re-educate the entire world who knows the this word. Could some one put in good word for me. This is going to take alot of time and work. I do have a better word that I guess I am going to have to trade mark. If anyone knows John W well talk to him . We are on the same side. I can understand not letting a company such as Norland Medical but that's not me. I am a doctor trying to explain this procedure to patients so that I can help them.
Any help would be greatly appreciated.
Thanks!!!

Re: ESWT Discussion with Dr. David Zuckerman

Nicole V.R. on 2/03/00 at 00:00 (015479)

As I have been chosen to go to Toronto for an OssaTron treatment, I called my podiatrist for his opinion. He says the ESWT will become more popular in the U.S. shortly, and one of his associates will be renting a machine within the next two weeks. (I'm not sure of the name of the machine or therapy he will be using)Even so, no insurance company has yet to cover the cost of the treatment. I called my insurance company, which requested a pre-cert from my pod., but the pod. said more likely than not it wouldn't be covered at this time. Hopefully in the future, insurance companies will catch on. I'm glad his associate is choosing to do this, because I was a bit concerned about the possibility of complications from the Orthotripsy, and not having a way to follow up.

Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/03/00 at 00:00 (015481)

Is the name of your Podiatrist Dr. Jack Gorman???

Re: ESWT Discussion with Dr. David Zuckerman

Duane E on 2/04/00 at 00:00 (015485)

Thank you for your efforts.

PRELIMINARY ANALYSIS:

*From the information that you have supplied, it is very apparent that the ESWT you perform with the Orbasone is not the same as that performed with the OssaTron.

*I do not see the Orbasone and the OssaTron as head-to-head competitors. As they are currently used to treat plantar fasciitis, they appear more as complimentary devices in a spectrum of ESWT treatment options. It is quite possible that the Orbasone and the OssaTron may have some areas of overlapping capability. I would need more information to make that determination.

*The Orbasone may have its niche in the treatment of foot problems as does the OssaTron. What we need to see, are studies which show the efficacy of treating plantar fasciitis with the Orbasone.

Best wishes for your father with his heart surgery.

Re: ESWT Discussion with Dr. David Zuckerman

John h on 2/04/00 at 00:00 (015503)

i think the ossatron can only be operated under the supevision of an othopedic surgeon in canada. is this true or not? will poditrist be an authorized user in the U.S. if approved by fda?

Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/04/00 at 00:00 (015506)

The orbasone is FDA approved. anyone who is liscensed to practice in the United States can perform any procedure on the human foot and ankle. The same is true in Canada. I know one podiatrist who was looking at the osstran but the cost was too much. The cost of the osstran I believe is about $750,000 in Canadian money. In addition Healthronics is paid for every procedure that is performed. The orthopedic docs in Canada don't own the machine last time I talk to them . The osstran is very expensive. You may want to ask John W.
if they still get money for every procedure. This is probaby the best way to keep the cost down for each procedure and in my opinion is very fair. You must realize the money it takes to get a device approved by the FDA. It in the millions.

Re: ESWT Discussion with Dr. David Zuckerman

Nicole V.R. on 2/04/00 at 00:00 (015508)

I've never met Dr. Gorman. He is an associate of my podiatrist, Dr. Jones. Small world, huh?

Re: ESWT Discussion with Dr. David Zuckerman

Dr. Zuckerman on 2/04/00 at 00:00 (015515)

Dr. Gorman was my mentor. He taught podiatry the use of the CO2 laser many years ago. I have offered to bring the orbasone to his office
when ever he needs the machine and feels it will help any of his patients.
At this time and until the special travel case has been made , I have made arrangements for any of his patients traveling arrangement to my office from his office. We have a van that will be available to his patients to and from our offices. This of course is through the direction of Dr. Gorman. Travel time is under one hour

Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/09/00 at 00:00 (015636)

Dear Duane,

I don't understand why you say that the machine are different when it comes to treating plantar fasciitis -heel spur. It is my understanidng that the osstran is using a mid range EWST level of treatment for this in the foot. Do you know the amount of MPa at the focal point when using the osstran. I believe they use 18kv at 1600
shock waves. I believe that the true way to make a machine comparison is to know what is the force in pounds per squard inch at the focal point of treatment. Do agree with this method to try and compare the machine. I still need that the machine type is only secondary. The doctor and his experience in knowing when and why to use ESWT should be the primary choice by the PF patients, but that another day of discussion. I am really starting to learn and enjoy you imput so please continue to teach me.


Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/02/00 at 00:00 (015395)

I will answer some the questions that have you asked me.
1. I am using 1% lidocaine plain with 0.5 Marcaine plain total ten cc's

2. foot and ankle.

3. 3a i was told but I will have to ask. At the time I had them show me the focal point because I wanted to beable to see this in my mind's eye I have been doing alot of minimial incision foot surgery for heel spurs in the past twent years where I remove the spur without seeing this. I can palpation the
medial tubercle of the heel and I can picture the length and width,
So I want to make sure that the pain treatment focal point is covering
the entire width of the medial tubercle. I do know with the two positions that I am using I am covering the entire medial tubercle which is where the plantar aponeurosis ( plantar fascia
), Abductor hallucis, Flexor digiti brevis,and Quadratus plantae muscle insert
3c Will have to find out. It was explained to me that the amount of pressure was in bars. The person who trained me had over two thousand
EWST procedure experience. He had a PHD in biophysic and Laser. At the
time of the training I was more interested in two things Learing where the focal point was at all times. There were many ways to learn this and different treatment methods. He told me with this machine 3000 shocks at 18kv was a very good start. You must remember the treatment results will be different because you have different levels of clinical skill, different levels of diagnostic skills, there are going to be so many factors that just looking at what is the kv,
what is the pressure etc doesn't matter. I learned along time ago that one doctor can be the same thing and another can be the same thing one lives and doesn't . The point is that this just isn't about a procedure done with the Orbasone, Osstran. This is done by a doctor. This procedure is an art and a science. Probaby more of an art with alot of experience in treating the human foot.
I will tell you by talking with John W. They both have the ability to
do exactly the same thing with amount of shocks KV.
5. Very brief but go to http://www.norlandmedical for the press release

6. working on this. This gentleman doesn't use e-mail etc. He is a working man. I am working this part out.

7. This is FDA approved for chronic pain managment, as per Norland Medical. AS you know there is some disagreement by companies about this. I can understand John W feelings . I would feel the same. He has given me good advice. I told him that if the Orbasone isn't around then I will be using the Osstran. He promised me I would be one of the first installations. I hope that the Orbasone at this time isn't stopped I have patients that need help!
Could you tell me your insurance plan. I will talk to them. If you get one company to pay then there is some little hope that more will.
The law states in New Jersey that insurance companies have to pay for any procedure that is medically necesssary,but you have to go to court to enforce this.

8. According to John W. he tells me that in order to treat avascular necrosis with good results you probaby have to go to 22kv with 6-8
shocks. In my opinion and from a scientific approach, when ever you have increase circulation to the soft tissue and at the medical tubercle where the four tendon-muscle layer insert such as with EWST
you are going to have some demineralizatin of bone, now that is only my opinion. This could be proven but what is the point. In foot this
isn't important to have this happen with EWST. I have read that in the shoulder they had de-calification of bone in the shoulder treatment. I think that there is literature in either http://www.orthotripsy.com or a healthronic link. If it really important let me know.

So I am typing better this message board has given me practice.Oh!
MIP is Minimial Invasion Products. They in Germany.

I hope that I anwered more of your questions. I was thinking that I hope that other doctors don't tryto increase kv power without understanding bone density and bone quality. You could fracture the heel pain if you are just any doctor who has no expertise in treating
heel pain and bone problems of the foot and ankle. So doctors don't
do anything I just stated without talking to me please.

Thanks


Re: ESWT Discussion with Dr. David Zuckerman

Duane E on 2/03/00 at 00:00 (015439)

Thank you for your answers. The more information I look at, the more differences I see between the OssaTron and the Orbasone. When the pertinent information has been gathered, I'll post a comparison of the two technologies. You stated that the Orbasone has been FDA approved (per Norland Medical) for the treatment of chronic pain. This is different from being FDA approved to use for orthopedic lithotripsy. However, that does not mean that the Orbasone has any less value to patients.

(1) and (2) Am I correct to assume that you first inject 5cc of the anesthetic into the ankle site, and later the remaining 5cc into the heel site?

(3a) to (3d) Waiting for answer.

(4) and (4a) Waiting for answer.

(5) The http://www.norlandmedical.com site would not display. I tried going through the link at Wilburn Medical and got the same result. I did find some brief information (including a picture) about the Orbasone at: http://www.norland.com , but no press release.

(6) Hope to hear from him or some of your other ESWT patients.

(7) Nicole V.R.'s post on Jan. 31, 2000 stated the treatment was not covered by insurance. Her source was a Philadelphia television station's news report.

(8) Since there is no literature supporting the changing of bone structure at the energies you currently operate the Orbasone; you might want to consider changing what is on your web site to a statement of your opinion. I consider this issue closed.


Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/03/00 at 00:00 (015462)

This is a very brief note. I just came back from the hospital. My father the first generation of Podiatrists is going to have heart by pass surgery, so there my be silence from me for some time.
I will research the literature . I though there was bone changes in animal studies. I still think that there are but i would have to order a three phase bone scan post-op. I wouldn't want this done. So I guess at this time I can't prove this. Will work on the rest of your questions. I will invite you to visit my office and see the Orbasone in action. You do have alot of information and I am aways open. If you have no problem you can either call or fax the name of your health insurance company and my staff will see if the ESWT treatments are covered or not. I don't know how you feel about giving out this information but I understand if you don't want to. I am in the process of contacting alot of companies but according to Norland Medical no insurance coverage. This to me seems reasonable due to the fact that alot of insurance policies limit coverage in the foot.
I am really diappeared that John W. pulled the word OrthotripyTM out form under me. I am going to have to re-educate the entire world who knows the this word. Could some one put in good word for me. This is going to take alot of time and work. I do have a better word that I guess I am going to have to trade mark. If anyone knows John W well talk to him . We are on the same side. I can understand not letting a company such as Norland Medical but that's not me. I am a doctor trying to explain this procedure to patients so that I can help them.
Any help would be greatly appreciated.
Thanks!!!

Re: ESWT Discussion with Dr. David Zuckerman

Nicole V.R. on 2/03/00 at 00:00 (015479)

As I have been chosen to go to Toronto for an OssaTron treatment, I called my podiatrist for his opinion. He says the ESWT will become more popular in the U.S. shortly, and one of his associates will be renting a machine within the next two weeks. (I'm not sure of the name of the machine or therapy he will be using)Even so, no insurance company has yet to cover the cost of the treatment. I called my insurance company, which requested a pre-cert from my pod., but the pod. said more likely than not it wouldn't be covered at this time. Hopefully in the future, insurance companies will catch on. I'm glad his associate is choosing to do this, because I was a bit concerned about the possibility of complications from the Orthotripsy, and not having a way to follow up.

Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/03/00 at 00:00 (015481)

Is the name of your Podiatrist Dr. Jack Gorman???

Re: ESWT Discussion with Dr. David Zuckerman

Duane E on 2/04/00 at 00:00 (015485)

Thank you for your efforts.

PRELIMINARY ANALYSIS:

*From the information that you have supplied, it is very apparent that the ESWT you perform with the Orbasone is not the same as that performed with the OssaTron.

*I do not see the Orbasone and the OssaTron as head-to-head competitors. As they are currently used to treat plantar fasciitis, they appear more as complimentary devices in a spectrum of ESWT treatment options. It is quite possible that the Orbasone and the OssaTron may have some areas of overlapping capability. I would need more information to make that determination.

*The Orbasone may have its niche in the treatment of foot problems as does the OssaTron. What we need to see, are studies which show the efficacy of treating plantar fasciitis with the Orbasone.

Best wishes for your father with his heart surgery.

Re: ESWT Discussion with Dr. David Zuckerman

John h on 2/04/00 at 00:00 (015503)

i think the ossatron can only be operated under the supevision of an othopedic surgeon in canada. is this true or not? will poditrist be an authorized user in the U.S. if approved by fda?

Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/04/00 at 00:00 (015506)

The orbasone is FDA approved. anyone who is liscensed to practice in the United States can perform any procedure on the human foot and ankle. The same is true in Canada. I know one podiatrist who was looking at the osstran but the cost was too much. The cost of the osstran I believe is about $750,000 in Canadian money. In addition Healthronics is paid for every procedure that is performed. The orthopedic docs in Canada don't own the machine last time I talk to them . The osstran is very expensive. You may want to ask John W.
if they still get money for every procedure. This is probaby the best way to keep the cost down for each procedure and in my opinion is very fair. You must realize the money it takes to get a device approved by the FDA. It in the millions.

Re: ESWT Discussion with Dr. David Zuckerman

Nicole V.R. on 2/04/00 at 00:00 (015508)

I've never met Dr. Gorman. He is an associate of my podiatrist, Dr. Jones. Small world, huh?

Re: ESWT Discussion with Dr. David Zuckerman

Dr. Zuckerman on 2/04/00 at 00:00 (015515)

Dr. Gorman was my mentor. He taught podiatry the use of the CO2 laser many years ago. I have offered to bring the orbasone to his office
when ever he needs the machine and feels it will help any of his patients.
At this time and until the special travel case has been made , I have made arrangements for any of his patients traveling arrangement to my office from his office. We have a van that will be available to his patients to and from our offices. This of course is through the direction of Dr. Gorman. Travel time is under one hour

Re: ESWT Discussion with Dr. David Zuckerman

Dr. David Zuckerman on 2/09/00 at 00:00 (015636)

Dear Duane,

I don't understand why you say that the machine are different when it comes to treating plantar fasciitis -heel spur. It is my understanidng that the osstran is using a mid range EWST level of treatment for this in the foot. Do you know the amount of MPa at the focal point when using the osstran. I believe they use 18kv at 1600
shock waves. I believe that the true way to make a machine comparison is to know what is the force in pounds per squard inch at the focal point of treatment. Do agree with this method to try and compare the machine. I still need that the machine type is only secondary. The doctor and his experience in knowing when and why to use ESWT should be the primary choice by the PF patients, but that another day of discussion. I am really starting to learn and enjoy you imput so please continue to teach me.