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Sonorex......bad effects

Posted by Trish on 10/25/00 at 23:52 (031303)

I had 5 Sonorex treatments......3 in Feb./Mar. this year, and 2 more in June. It has not really helped me. Unfortunately, I have experienced a bad side effect.....PERSISTENT pain closer to the arch than the heel. Even hurts when I am at rest. This started immediately after the 1st treatment, but I thought it would just go away. Some days it's worse than others. The Dr. and technician had no advice for me. I just wanted to warn people that although it has been stated that shockwave therapy has no risks (except financial), that has NOT been my experience.

Re: Sonorex......bad effects

David Lowy on 10/26/00 at 11:51 (031341)

Dear Trish,
I'm sorry to hear that you are experiencing some pain. Has the pain 'moved' from where it originally was? Or, do you feel it in both the arch, and the heel. Where is the pain worse? Can you still find a painful spot in the heel.
Let me know, and maybe we can get to the bottom of this.
Sincerely,
David Lowy
Sonorex Therapy Center

Re: Sonorex......bad effects

Trish on 10/26/00 at 21:40 (031415)

Well, I still have heel pain, but the pain closer to the arch is more intense, so is 'stealing the show' if you know what I mean....

Re: Sonorex......bad effects

Heidi on 11/01/00 at 12:53 (031763)

Post:
Hi Trish,

My name is Heidi and I use ESWT in my clinic for chronic pain. I have never had anything like what you have gone through happen in my clinic and I want to ensure that it never does. We use in-line ultrasound here in our clinic to ensure that we are exactly on the pain path and so as not to cause damage elsewhere. Did the clinic you went to use in-line ultrasound???

Why did you have such a long period of time between your first three treatments and your last two? Did they bring you back b/c you had not had any improvement? Did you have any improvement after the first couple of treatments??

Please write back and let me know what you can. I would love to be able to not only help you, but ensure that nothing like this ever happens to my patients.

I hope to hear from you soon
Heidi
Translation:
Hallo Trish,

Mein Name ist Heidi und ich verwende ESWT in meiner Klinik für die chronischen Schmerz. Ich gehabt nie alles wie, was Sie geschehen in meiner Klinik durchgemacht und ich sichergehen möchte, daß sie nie. Wir verwenden Inline-Ultraschall hier in unserer Klinik, um sicherzugehen, daß wir genau auf dem Schmerzpfad sind und damit, Beschädigung nicht anderwohin zu verursachen. die Klinik, die Sie gingen, Inline-Ultraschall zu verwenden???

Warum hatten Sie solch einen langen Zeitabschnitt zwischen Ihren ersten drei Behandlungen und Ihren letzten zwei? Holten sie Ihnen zurück b/c, das Sie keine Verbesserung gehabt? Hatten Sie irgendeine Verbesserung nach den ersten Paaren von Behandlungen??

Schreiben Sie bitte zurück und informieren Sie mich, was Sie können. Ich lieben, zu können, Ihnen nicht nur zu helfen, aber sicherstelle, daß nichts so überhaupt meinen Patienten geschieht.

Ich hoffe, von Ihnen Heidi bald zu hören


Re: Sonorex......bad effects

Trish on 11/01/00 at 17:17 (031777)

Post:
No, they did not use ultrasound. The reason there was a delay between the two sets of treatments was that 6 weeks after the first 3 treatments, I had no improvement, so the Doctor did not recommend further treatment. Then, after about another month, there was some noticeable improvement, so the Doctor thought that 2 additional treatments might be of benefit.
Translation:
Nr., verwendeten sie nicht Ultraschall. Der Grund dort war eine Verzögerung zwischen den zwei Sets von Behandlungen war, daß 6 Wochen nach den ersten 3 Behandlungen, ich keine Verbesserung hatte, also der Doktor nicht weitere Behandlung empfahl. Dann nach ungefähr einem anderen Monat, gab es etwas wahrnehmbare Verbesserung, so der gedachte Doktor, daß 2 zusätzliche Behandlungen vom Nutzen sein konnten.


Re: Sonorex......bad effects

David Lowy on 11/02/00 at 11:56 (031825)



Re: Sonorex......bad effects

David Lowy on 11/02/00 at 12:12 (031826)

Post:
Re-posted per Scott R. due to message board error

Heidi,
You infer by your post that using inline ultrasound insures that you are on the correct pain path. Using ultrasound, how do you determine that you are on the exact point of pain? Do you 'see' the pain on the ultrasound, or do you go by patient feedback that you are on the specific point of pain? Who is interpreting the ultrasound at your clinic? Is it a physician? Is it a radiological technician, or a physiotherapist?
Having treated over 1000 patients at our Vancouver clinic in 12 months, and having the Workers' Compensation Board of British Columbia send their patients and fund randomized studies, I, as can the WCB, attest to the fact that ultrasound is not the key to success. Proper patient selection and hitting the exact point of pain is the key....as I'm sure you'll agree.
As you know, the energy levels that the Sonocur uses, are so low, and the focalpoint of the wave is so specific (5 sq mm), that tissue damage does not occur as far away from the treatment point that Trish talks about. Treating pf, as was done in Trish's case, does not mean that there might be other pathology that is not treatable by the Sonocur....ie...if a patient has tendinitis in one area of the shoulder and arthritis in another. Treating the tendinitis is not going to make the arthritis go away.
The results that you posted are impressive. I am pleased to tell you that we have experienced similar results with our patients, even though we don't use ultrasound at Sonorex.
Sincerely,
David Lowy
Vice President, Canada
Sonorex Therapy Centers http://www.sonorex.com
Translation:
Re-bekanntgegeben pro Scott R. wegen des Meldung Brettfehlers

Heidi, schließen Sie durch Ihren Pfosten, daß das Verwenden des Inline-Ultraschalls versichert, daß Sie auf dem korrekten Schmerzpfad sind. Mit Ultraschall wie stellen Sie fest, daß Sie im genauen Punkt der Schmerz sind? ' sehen ' Sie die Schmerz auf dem Ultraschall, oder gehen Sie durch geduldiges Feedback, daß Sie im spezifischen Punkt der Schmerz sind? Wer deutet den Ultraschall an Ihrer Klinik? Ist es ein Arzt? Ist es ein radiologischer Techniker oder ein Physiotherapeut? behandelnd über 1000 Patienten an unserer Vancouverklinik in 12 Monaten und habend das Brett Ausgleich der Arbeiter von britischer Kolumbien, senden Sie ihre Patienten und die randomisierte Kapital studiert, I, wie das WCB kann, zur Tatsache bezeugen Sie, daß Ultraschall nicht die Taste zum Erfolg ist. Korrekte geduldige Auswahl und das Schlagen des genauen Punktes der Schmerz ist das Schlüssel....as, das ich sicher bin, daß Sie zustimmen. Wie Sie wissen, sind die Energiestufen, die das Sonocur benutzt, so niedrig, und das focalpoint der Welle ist (5 Quadrat-Millimeter) so spezifisch, daß Gewebebeschädigung wie weit nicht weg mit vom Behandlungpunkt auftritt, dem Trish sich befaßt. PF zu behandeln, wie im Fall Trishs getan wurde, bedeutet nicht, daß es andere Pathologie geben konnte, die nicht durch das Sonocur....ie... umgänglich ist, wenn ein Patient Tendinitis in einem Bereich der Schulter und der Arthritis in anderen hat. Das Behandeln des Tendinitis wird nicht die Arthritis weggehen lassen. Die Resultate, die Sie bekanntgaben, sind eindrucksvoll. Ich freue mich, Ihnen zu erklären, daß wir ähnliche Resultate mit unseren Patienten erfahren haben, obwohl wir Ultraschall nicht bei Sonorex verwenden. Aufrichtig zentriert Vizepräsident Davids Lowy, Therapie Kanadas Sonorex http://www.sonorex.com


Re: Sonorex......bad effects

Heidi on 11/10/00 at 11:52 (032440)

Message Number 32441
dumb and dumber View Thread
Posted by john h on 11/10/00 at 11:53


yesterday i bought a new pair of Rockport Pro walking shoes. I inserted my two piece birkentsock inserts in them and at the end of the day thought these are the best shoes i have worn and my feet really feel good. when i got home after work i discovered i had only put the insert into the right shoe. the left shoe in which i had removed the insert that came with the shoe had nothing in it at all. the bed was perfectly flat and very hard. what is this all about? a placebo effect?

Re: Sonorex......treatment philosophy

David Lowy on 11/16/00 at 13:23 (032855)

>
Thanks for your question about the use of ultrasound in the
focusing of shock waves administered during ESWT for orthopaedic
indications. As an experienced ESWT technician, I know you are aware of many of the points set out below, but I have written them out for the benefit of others on this board.

As you know, shock wave therapy was first used to treat kidney stones. Since high energy shock waves were used, anesthesia was necessary and the stones were focused with flouroscopy, x-ray, and in some devices with ultrasound. Initial orthopaedic use was for pseudoarthroses (non-unions) which also required high energy shock waves, anesthesia, and imaging to see the ends of the affected bones. Thus, the initial ESWT devices used were modified kidney stone lithotripters with imaging devices. Since these used higher energy and were painful, anesthesia was necessary. Since anesthesia was required, imaging devices were necessary to allow the
operator to focus the shock waves. This model was used by manufacturers to produce newly developed devices specifically for orthopedic applications.

When it became clear that lower energy shock waves were effective in
treating tendinopathies and other conditions of near bone pain, it became possible to treat patients without anesthesia. These newly developed devices also incorporated the use of ultrasound for imaging. Initially, this was used to identify calcium deposits, such as calcific tendinitis of the shoulder, to focus the shock waves on these areas. As the use of shock waves became more frequent and as operators became more experienced with the use of lower energy anesthesia free devices, it became less important to use ultrasound to treat tendinopathies. Sonorex has developed a 'clinical focusing' technique technique which does not use ultrasound or other imaging device. The reasons for this are clinical. In the treatment of tendinopathies, several criteria must be met to achieve maximum results: 1) patients must be properly selected, 2) the exact area of pathology must be treated, and 3) adequate shock wave energy must be given to effect the physiological changes which result in pain relief and long term healing.
Patient selection should be limited to those who have well defined
pain 'trigger points' and in whom other unusual pathology has been ruled out by appropriate imaging studies. If pain is not well localized, the patient will often not have desirable treatment results. Therefore, only those who meet this criteria should be treated. Ultrasound or other imaging devices cannot see ' pain ' nor can they identify these trigger points.
They should initially be identified by palpation to give a
general idea of their location. Shock waves, at the lowest energy setting, should then be applied to this area until the patient indicates that indeed this is the site of their pain. If this area cannot be identified precisely with the patients feedback upon shock wave application, then the patient should not be treated. Using this method, it has become clear that the ability to elicit pain in the exact area of the patient's complaint is a good predictor of treatment response. An experienced technician can precisely focus the shock waves using the patient's feedback and adjusting
the shock head accordingly. The depth is adjusted by changing the amount of fluid in the coupling bellows of the machine. During treatment, after every 200-400 shocks the shock head should be refocused using the patients feedback to make absolutely sure the patient's pain is duplicated and that the entire well localized painful area is thoroughly treated.
Treatment energy levels are increased as per protocol and at the patient's tolerance.

ESWT is a procedure used to relieve pain and promote healing. In
order to accomplish this, the shock wave energy must be delivered to the exact area of pathology. Sonorex believes that the best way to do this is to focus treatment only on those areas of identifiable pain. It is only in this way that one can be sure that the area of pathology which causes the pain can be treated. Examples: A patient may have a heelspur and plantar fasciitis. With ultrasound, the heelspur may be identified and treated, but it is well known that the area of plantar fascia which causes pain may or may not be associated with the heelspur. It is our feeling that treatment of the exact painful area identified with the shock wave application itself
is much better than focusing on the heelspur which may not treat the exact site of pathology. Similiarily, if one has calcific tendinitis of the shoulder, this calcification may or may not be associated with the exact painful area. Therefore, focusing on the area of calcification with ultrasound or other imaging device may again not treat the exact painful area of pathology. Indeed, dependence upon ultrasound imaging in these conditions and focusing upon these anatomical sites may actually decrease the effectiveness of ESWT by missing the painful pathological site. It is for these reasons that we feel 'clinical focusing' is desirable.

You asked about applying shock waves to bone. Once again, it is
important to treat the paient's painful area, even if it is near or at the bone surface, such as a tendon insertion. Epicondylitis of the elbow, for example, is frequently at such an insertion. It is necessary therefore to treat near or on the bone to adequately treat this condition. Lower energy shock waves are not harmful to bone.

In Europe, especially Germany, most users employ ultrasound focusing.
By using ultrasound, the practitioners are able to increase their charge for this procedure. In addition, they are able to keep this technology under the control of those who have specific ultrasound training. Certainly the manufacturers have an interest in keeping ultrasound on their devices since they can obviously charge more for their machines.

We at Sonorex have a philosophy that ultrasound is not necessary
for the treatment tendinopathies, and that clinical focusing actually has significant diagnostic and therapeutic advantages. In addition, we are able to provide this service at a lower cost since it is not necessary to expend capital to purchase ultrasound units. In addition, it is not necessary that our treatment technicians be registered and certified in the use of ultrasound which is required in most provinces such as Ontario under the Radiological Technicians Act. This too allows us to provide this service more cost effectively.
In your experience, what do you 'see' on the ultrasound that you are using while performing ESWT? Who is interpreting the ultrasound during the procedure?

We thank you for you interest in the 'clinical focusing' technique
which we at Sonorex have developed. We wish you well at Bayshore and are pleased that you are involved with this exciting new technology. Should you have further questions, please contact us at 1-877-766-6287.

Please forgive the lengthy response.
Sincerely,
David Lowy
VP, Canada
Sonorex Therapy Center http://www.sonorex.com

Re: Sonorex......bad effects

David Lowy on 10/26/00 at 11:51 (031341)

Dear Trish,
I'm sorry to hear that you are experiencing some pain. Has the pain 'moved' from where it originally was? Or, do you feel it in both the arch, and the heel. Where is the pain worse? Can you still find a painful spot in the heel.
Let me know, and maybe we can get to the bottom of this.
Sincerely,
David Lowy
Sonorex Therapy Center

Re: Sonorex......bad effects

Trish on 10/26/00 at 21:40 (031415)

Well, I still have heel pain, but the pain closer to the arch is more intense, so is 'stealing the show' if you know what I mean....

Re: Sonorex......bad effects

Heidi on 11/01/00 at 12:53 (031763)

Post:
Hi Trish,

My name is Heidi and I use ESWT in my clinic for chronic pain. I have never had anything like what you have gone through happen in my clinic and I want to ensure that it never does. We use in-line ultrasound here in our clinic to ensure that we are exactly on the pain path and so as not to cause damage elsewhere. Did the clinic you went to use in-line ultrasound???

Why did you have such a long period of time between your first three treatments and your last two? Did they bring you back b/c you had not had any improvement? Did you have any improvement after the first couple of treatments??

Please write back and let me know what you can. I would love to be able to not only help you, but ensure that nothing like this ever happens to my patients.

I hope to hear from you soon
Heidi
Translation:
Hallo Trish,

Mein Name ist Heidi und ich verwende ESWT in meiner Klinik für die chronischen Schmerz. Ich gehabt nie alles wie, was Sie geschehen in meiner Klinik durchgemacht und ich sichergehen möchte, daß sie nie. Wir verwenden Inline-Ultraschall hier in unserer Klinik, um sicherzugehen, daß wir genau auf dem Schmerzpfad sind und damit, Beschädigung nicht anderwohin zu verursachen. die Klinik, die Sie gingen, Inline-Ultraschall zu verwenden???

Warum hatten Sie solch einen langen Zeitabschnitt zwischen Ihren ersten drei Behandlungen und Ihren letzten zwei? Holten sie Ihnen zurück b/c, das Sie keine Verbesserung gehabt? Hatten Sie irgendeine Verbesserung nach den ersten Paaren von Behandlungen??

Schreiben Sie bitte zurück und informieren Sie mich, was Sie können. Ich lieben, zu können, Ihnen nicht nur zu helfen, aber sicherstelle, daß nichts so überhaupt meinen Patienten geschieht.

Ich hoffe, von Ihnen Heidi bald zu hören


Re: Sonorex......bad effects

Trish on 11/01/00 at 17:17 (031777)

Post:
No, they did not use ultrasound. The reason there was a delay between the two sets of treatments was that 6 weeks after the first 3 treatments, I had no improvement, so the Doctor did not recommend further treatment. Then, after about another month, there was some noticeable improvement, so the Doctor thought that 2 additional treatments might be of benefit.
Translation:
Nr., verwendeten sie nicht Ultraschall. Der Grund dort war eine Verzögerung zwischen den zwei Sets von Behandlungen war, daß 6 Wochen nach den ersten 3 Behandlungen, ich keine Verbesserung hatte, also der Doktor nicht weitere Behandlung empfahl. Dann nach ungefähr einem anderen Monat, gab es etwas wahrnehmbare Verbesserung, so der gedachte Doktor, daß 2 zusätzliche Behandlungen vom Nutzen sein konnten.


Re: Sonorex......bad effects

David Lowy on 11/02/00 at 11:56 (031825)



Re: Sonorex......bad effects

David Lowy on 11/02/00 at 12:12 (031826)

Post:
Re-posted per Scott R. due to message board error

Heidi,
You infer by your post that using inline ultrasound insures that you are on the correct pain path. Using ultrasound, how do you determine that you are on the exact point of pain? Do you 'see' the pain on the ultrasound, or do you go by patient feedback that you are on the specific point of pain? Who is interpreting the ultrasound at your clinic? Is it a physician? Is it a radiological technician, or a physiotherapist?
Having treated over 1000 patients at our Vancouver clinic in 12 months, and having the Workers' Compensation Board of British Columbia send their patients and fund randomized studies, I, as can the WCB, attest to the fact that ultrasound is not the key to success. Proper patient selection and hitting the exact point of pain is the key....as I'm sure you'll agree.
As you know, the energy levels that the Sonocur uses, are so low, and the focalpoint of the wave is so specific (5 sq mm), that tissue damage does not occur as far away from the treatment point that Trish talks about. Treating pf, as was done in Trish's case, does not mean that there might be other pathology that is not treatable by the Sonocur....ie...if a patient has tendinitis in one area of the shoulder and arthritis in another. Treating the tendinitis is not going to make the arthritis go away.
The results that you posted are impressive. I am pleased to tell you that we have experienced similar results with our patients, even though we don't use ultrasound at Sonorex.
Sincerely,
David Lowy
Vice President, Canada
Sonorex Therapy Centers http://www.sonorex.com
Translation:
Re-bekanntgegeben pro Scott R. wegen des Meldung Brettfehlers

Heidi, schließen Sie durch Ihren Pfosten, daß das Verwenden des Inline-Ultraschalls versichert, daß Sie auf dem korrekten Schmerzpfad sind. Mit Ultraschall wie stellen Sie fest, daß Sie im genauen Punkt der Schmerz sind? ' sehen ' Sie die Schmerz auf dem Ultraschall, oder gehen Sie durch geduldiges Feedback, daß Sie im spezifischen Punkt der Schmerz sind? Wer deutet den Ultraschall an Ihrer Klinik? Ist es ein Arzt? Ist es ein radiologischer Techniker oder ein Physiotherapeut? behandelnd über 1000 Patienten an unserer Vancouverklinik in 12 Monaten und habend das Brett Ausgleich der Arbeiter von britischer Kolumbien, senden Sie ihre Patienten und die randomisierte Kapital studiert, I, wie das WCB kann, zur Tatsache bezeugen Sie, daß Ultraschall nicht die Taste zum Erfolg ist. Korrekte geduldige Auswahl und das Schlagen des genauen Punktes der Schmerz ist das Schlüssel....as, das ich sicher bin, daß Sie zustimmen. Wie Sie wissen, sind die Energiestufen, die das Sonocur benutzt, so niedrig, und das focalpoint der Welle ist (5 Quadrat-Millimeter) so spezifisch, daß Gewebebeschädigung wie weit nicht weg mit vom Behandlungpunkt auftritt, dem Trish sich befaßt. PF zu behandeln, wie im Fall Trishs getan wurde, bedeutet nicht, daß es andere Pathologie geben konnte, die nicht durch das Sonocur....ie... umgänglich ist, wenn ein Patient Tendinitis in einem Bereich der Schulter und der Arthritis in anderen hat. Das Behandeln des Tendinitis wird nicht die Arthritis weggehen lassen. Die Resultate, die Sie bekanntgaben, sind eindrucksvoll. Ich freue mich, Ihnen zu erklären, daß wir ähnliche Resultate mit unseren Patienten erfahren haben, obwohl wir Ultraschall nicht bei Sonorex verwenden. Aufrichtig zentriert Vizepräsident Davids Lowy, Therapie Kanadas Sonorex http://www.sonorex.com


Re: Sonorex......bad effects

Heidi on 11/10/00 at 11:52 (032440)

Message Number 32441
dumb and dumber View Thread
Posted by john h on 11/10/00 at 11:53


yesterday i bought a new pair of Rockport Pro walking shoes. I inserted my two piece birkentsock inserts in them and at the end of the day thought these are the best shoes i have worn and my feet really feel good. when i got home after work i discovered i had only put the insert into the right shoe. the left shoe in which i had removed the insert that came with the shoe had nothing in it at all. the bed was perfectly flat and very hard. what is this all about? a placebo effect?

Re: Sonorex......treatment philosophy

David Lowy on 11/16/00 at 13:23 (032855)

>
Thanks for your question about the use of ultrasound in the
focusing of shock waves administered during ESWT for orthopaedic
indications. As an experienced ESWT technician, I know you are aware of many of the points set out below, but I have written them out for the benefit of others on this board.

As you know, shock wave therapy was first used to treat kidney stones. Since high energy shock waves were used, anesthesia was necessary and the stones were focused with flouroscopy, x-ray, and in some devices with ultrasound. Initial orthopaedic use was for pseudoarthroses (non-unions) which also required high energy shock waves, anesthesia, and imaging to see the ends of the affected bones. Thus, the initial ESWT devices used were modified kidney stone lithotripters with imaging devices. Since these used higher energy and were painful, anesthesia was necessary. Since anesthesia was required, imaging devices were necessary to allow the
operator to focus the shock waves. This model was used by manufacturers to produce newly developed devices specifically for orthopedic applications.

When it became clear that lower energy shock waves were effective in
treating tendinopathies and other conditions of near bone pain, it became possible to treat patients without anesthesia. These newly developed devices also incorporated the use of ultrasound for imaging. Initially, this was used to identify calcium deposits, such as calcific tendinitis of the shoulder, to focus the shock waves on these areas. As the use of shock waves became more frequent and as operators became more experienced with the use of lower energy anesthesia free devices, it became less important to use ultrasound to treat tendinopathies. Sonorex has developed a 'clinical focusing' technique technique which does not use ultrasound or other imaging device. The reasons for this are clinical. In the treatment of tendinopathies, several criteria must be met to achieve maximum results: 1) patients must be properly selected, 2) the exact area of pathology must be treated, and 3) adequate shock wave energy must be given to effect the physiological changes which result in pain relief and long term healing.
Patient selection should be limited to those who have well defined
pain 'trigger points' and in whom other unusual pathology has been ruled out by appropriate imaging studies. If pain is not well localized, the patient will often not have desirable treatment results. Therefore, only those who meet this criteria should be treated. Ultrasound or other imaging devices cannot see ' pain ' nor can they identify these trigger points.
They should initially be identified by palpation to give a
general idea of their location. Shock waves, at the lowest energy setting, should then be applied to this area until the patient indicates that indeed this is the site of their pain. If this area cannot be identified precisely with the patients feedback upon shock wave application, then the patient should not be treated. Using this method, it has become clear that the ability to elicit pain in the exact area of the patient's complaint is a good predictor of treatment response. An experienced technician can precisely focus the shock waves using the patient's feedback and adjusting
the shock head accordingly. The depth is adjusted by changing the amount of fluid in the coupling bellows of the machine. During treatment, after every 200-400 shocks the shock head should be refocused using the patients feedback to make absolutely sure the patient's pain is duplicated and that the entire well localized painful area is thoroughly treated.
Treatment energy levels are increased as per protocol and at the patient's tolerance.

ESWT is a procedure used to relieve pain and promote healing. In
order to accomplish this, the shock wave energy must be delivered to the exact area of pathology. Sonorex believes that the best way to do this is to focus treatment only on those areas of identifiable pain. It is only in this way that one can be sure that the area of pathology which causes the pain can be treated. Examples: A patient may have a heelspur and plantar fasciitis. With ultrasound, the heelspur may be identified and treated, but it is well known that the area of plantar fascia which causes pain may or may not be associated with the heelspur. It is our feeling that treatment of the exact painful area identified with the shock wave application itself
is much better than focusing on the heelspur which may not treat the exact site of pathology. Similiarily, if one has calcific tendinitis of the shoulder, this calcification may or may not be associated with the exact painful area. Therefore, focusing on the area of calcification with ultrasound or other imaging device may again not treat the exact painful area of pathology. Indeed, dependence upon ultrasound imaging in these conditions and focusing upon these anatomical sites may actually decrease the effectiveness of ESWT by missing the painful pathological site. It is for these reasons that we feel 'clinical focusing' is desirable.

You asked about applying shock waves to bone. Once again, it is
important to treat the paient's painful area, even if it is near or at the bone surface, such as a tendon insertion. Epicondylitis of the elbow, for example, is frequently at such an insertion. It is necessary therefore to treat near or on the bone to adequately treat this condition. Lower energy shock waves are not harmful to bone.

In Europe, especially Germany, most users employ ultrasound focusing.
By using ultrasound, the practitioners are able to increase their charge for this procedure. In addition, they are able to keep this technology under the control of those who have specific ultrasound training. Certainly the manufacturers have an interest in keeping ultrasound on their devices since they can obviously charge more for their machines.

We at Sonorex have a philosophy that ultrasound is not necessary
for the treatment tendinopathies, and that clinical focusing actually has significant diagnostic and therapeutic advantages. In addition, we are able to provide this service at a lower cost since it is not necessary to expend capital to purchase ultrasound units. In addition, it is not necessary that our treatment technicians be registered and certified in the use of ultrasound which is required in most provinces such as Ontario under the Radiological Technicians Act. This too allows us to provide this service more cost effectively.
In your experience, what do you 'see' on the ultrasound that you are using while performing ESWT? Who is interpreting the ultrasound during the procedure?

We thank you for you interest in the 'clinical focusing' technique
which we at Sonorex have developed. We wish you well at Bayshore and are pleased that you are involved with this exciting new technology. Should you have further questions, please contact us at 1-877-766-6287.

Please forgive the lengthy response.
Sincerely,
David Lowy
VP, Canada
Sonorex Therapy Center http://www.sonorex.com