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High Energy article copied from ESWT page to read

Posted by Dr. Zuckerman on 12/19/00 at 20:03 (035217)

Abstracts:
TITLE: High energy shock wave treatment of the painful heel spur
TITLE: Hochenergetische Stosswellenbehandlung des schmerzhaften Fersensporns.
AUTHORS: Perlick L; Boxberg W; Giebel G AUTHOR AFFILIATION: Abteilung fur Unfall- und Wiederherstellungschirurgie, Kreiskrankenhaus, Ludenscheid.
ABSTRACT: extracorporal shock wave application (ESWA) has been used in the treatment of stones located in kidneys, bile, pancreas and the glandula parotis. In the last 2 years several studies have shown the benefit of the ESWA on the treatment of soft tissue disorders. The aim of this study was to explore the effect of high energy extracorporal shock waves in patients with painful calcaneus spurs. 83 patients who underwent medicophysical treatment without benefit were treated with 3000 impulses of 0.30 mj/mm2. Follow-ups after 12 weeks and 12 months showed that 51 of 83 patients became pain-free and 20 patients improved from the treatment. The results are showing the benefit of the high energy extracorporal shock wave application in the treatment of chronic plantar fasciitis. NLM PUBMED CIT. ID: 10025241 SOURCE: Unfallchirurg 1998 Dec;101(12):914-8 22

Re: High Energy article copied from ESWT page to read

roberto on 12/20/00 at 05:24 (035240)

Dr. Z., may I suggest these two additional papers:1) 'Analgesic effect of low energy shock waves in tendinosis calcarea, epicondylitis humeri radialis and plantar faciitis' by Maier et al., which appeared in Z Orthop Ihre Grenzgeb, 2000, 138: 34-38, and, 2)'Treatment of painful heels using extracorporeal shock wave' by Wang et al.,published in J Formos Med Assoc, 2000, 99:580-583. In the above mentioned papers low energy (0.09-0.018 mJ/mm2) and, respectively, high energy (14 Kv, I suppose is equal to 0.3 -0.4 mJ/mm2)was adopted. Results were extremely positive in both scheduled trials. We are deeply experienced in Torino (Italy) with low energy shock wave treatment of plantar fasciitis/heel spur (2 -3 subsequent treatments, 7 -10 days interval)adopting Minilith SL1 device. We never need local anesthesia and never complain problems. 4 - 6 months after completion of treatment results are significantly better than few days after treatment.
Thanks for your great care in the field of ESWT !!
Roberto

Re: High Energy article copied from ESWT page to read

David Lowy on 12/22/00 at 01:28 (035282)

Hello Roberto,
How many shocks do you give per session and how many shocks per second?
Do most of your patients have 2 or 3 treatments, and what, if any, type of imaging do you use....ultrasound? fluoroscopy?
How do you localize the site...by patient feedback?
Looking forward to hearing from you.
Regards,
David Lowy
VP, Canada
Sonorex Therapy Centers

PS...Just thinking about how technology has changed our lives. I am here on vacation in Maui, Hawaii reading a post from somebody in Italy!
What's next????? Aloha

Re: High Energy article copied from ESWT page to read

roberto on 12/22/00 at 08:47 (035293)

Hello David,
we give about 1,500 - 2,000 shocks per session, 4 shocks/second. We adopt a Storz Minilith SL1. This device allows to monitor the treatment ultrasonographically as far as possible with the probe coaxial to the source of ESWs.Of course, we take mostly into account patient feed-back !!
Our patients have usually 2 - 3 treatments (mostly 3): you havo to take into account that the cost per treatment in Europe (and especially in Italy)is lower than in USA.
Thanks for your attention, take care of your vacation!
Roberto

Re: High Energy article copied from ESWT page to read

David Lowy on 12/22/00 at 23:10 (035327)

Your protocol sounds very much like ours with the Siemens Sonocur, except that we do not use any type of imaging because we feel that patient feedback is the most important. We are located in Canada. It's interesting to follow the few treatments that are going on now in the US that it is a big deal that requires anesthesia, a doctor, imaging and quite a long recovery period. I'll bet that as the US becomes more familiar with the technology, they will certainly not use anesthesia. Our patients, like yours, are in and out in 15 minutes, depending on the number of painful sites.
Who performs the treatment? A doctor, physiotherapist, chiropractor?
Thank you for the information....it's very interesting.
Regards,
David

Re: High Energy article copied from ESWT page to read

roberto on 12/27/00 at 01:45 (035439)

We agree that the patient feed back is quite important. Just for that reason we do believe it is advisable that a doctor performs the treatment.
Anyay, physiotherapists as well as chiropractors are welcome in the ESWT family (I have to admit that we did not find a great number of physiotherapists interested in the field).
With best regards,
Roberto

Re: using general anesthesia

Scott R on 12/27/00 at 12:18 (035448)

Roberto and David L,
What do you think about american doctors using general anesthesia to put patients 'out' for ESWT? I know it has effects like increased likely-hood of dementia later-on down the road (among many other things). Are they doing it just to make the patient think it's worth $6,000?

Re: using general anesthesia

Dr. Zuckerman on 12/27/00 at 23:49 (035487)

Iwould think that the Canadian and Europeans are getting a real laugh about the use of general and or local anesthesia in the USA. I still can't believe that I used local anesthesis on a routine basis. I know in my case I didn't truely believe that low energy could produce an analgia in the areas that were to be treated. All of my initial experience came from the ossatron experience in Canada and i had this fixed idea that you must use a local because that is what was used for high energy treatments.

Re: using general anesthesia

roberto on 12/28/00 at 02:11 (035490)

I totally agree with dr. Zuckerman's statement. At the very beginning (decenber 1997) of our enthusiastic experience with ESWT we were skeptical about adopting low energies in treating musculo-skeletal ailments. We started our experience by adopting an electrohydraulic device: all of our patients claimed for discmfortable pain (!!), in the face of satisfactory results. Treatments were painful (especially in the case of PF treatments) even by adopting the lowest energy level (about 0.08 - 0.1 mJ/mm2)which could be reached by that kind of generator. Within a few weeks we turned to an electromagnetic device and, much to our surprise, we observed better results with lower energies (we can start from 0.005 mJ/mm2, then increase gradually up to 0.04 - 0.055 mJ/mm2 to treat tendonitis; or up to 0.07 - 0.09 - 0.11 to treat plantar fasciitis). It has to be taken into account that our patients are mostly satisfied, even for not feeling any pain.
With best regards.
Roberto Frairia
Associate Professor of Internal Medicine
Department of Clinical Pathophysiology
University of Torino, School of Medicine
Torino, Italy

Re: using general anesthesia

Scott R on 12/28/00 at 06:30 (035491)

But as I understand it, Dr. Zuckerman is using a high-energy device (Orbasone - electrohydraulic) and seems to have somehow found a way to do it without local anesthesia.

Re: using general anesthesia

Dr. Zuckerman on 12/29/00 at 17:45 (035586)

I am using high energy but using low energy as a numbing procedure first.
I am then switching to the high energy (0.6 joules /mm2 at the focal point of treatment which is the proximal insertional portion of the plantar fascia into the medial tubercle of the calcaneus.

There is an article that I started this conversation with that describes the use of high energy whick in my opinion gave very good results.

The protocol for the treatment as I understand it is the following

1. Use of 0.3 joules. mm2 at the F2 site
2. Use of 3000 shocks ( I use 1500 in two different direction or sites.
3. I believe Dr. Schaden from Austria teaches that the wider the f2 site the better the result. In simple terms - you have a site the beam of shockwave is .5 mm . spread it out to by placing 1500 in one site and then another 1500 next to it.
4. So why not use low energy anything below 0.28 to numb the area that is going to be used for treatment to some degree then slowly switch up to the treatment at 0.6 joules /mm2

5. So no needles. and you have three ways to local the area to treat.
a. Palpation which is then confirmed by flurocopy . I place a lead dot at the area of most pain on deep palpation with the foot fully loaded b. use the x-ray and or mri to help confirm just what is the area of pathology and does the examination match any x-ray/mri pathology

c. Use of pain directed treatment under low energy if necessary or and just the use of low energy to numb the f2 area and then treat at high energy using 3000 shocks in two direction.

I really think that I may be on to something or just learning what the more experience ESWT doctor's know all ready. Anyway this is something that really could place ESWT treatment in the direction that I think it should be which is an in-office procedure without needles with the patient walking into the treatment room and then wallking out of the treatment room

Re: Your new protocol

Dr. Marlene Reid on 1/17/01 at 14:38 (036758)

Dr. Zimmerman,

Your protocol is very interesting. What percentage of your patients are now only requiring one treatment vs. two treatments vs. three treatments. What time frame do you space them out, if not 12 weeks. I noticed one patient Lori K. I think that had a second treatment the next day. Thanks for your info.

Re: Your new protocol

Kay S on 1/17/01 at 20:02 (036779)

I think I can answer this one. I had tx bilaterally, and Dr. Z gave me 1500 shocks to each foot on a Thursday, and 1500 shocks to each foot on the following Saturday. I believe this is the same as what Lori had. So we really just had one complete treatment in divided doses on each foot.
I had my first tx on Dec 14th and will have the second on Feb. 12th. Dr. Z said that I could come back in either six weeks or eight weeks. Another patient from this board had hers spaced about the same, and just had her third after about six months.(from the second one)
I am just now starting to think the tx is working, after five weeks. I had a really bad time around the 10th day and it lasted about a week, but now I think I am better. I still have a lot of pain, but can tell that it is improved because of my ability to concentrate better, among other things.
I hope you will continue to 'listen' to the people on this board. There are some really wonderful, intelligent, caring, knowledgeable people. And we have tried EVERYTHING!
Kay

Re: High Energy article copied from ESWT page to read

roberto on 12/20/00 at 05:24 (035240)

Dr. Z., may I suggest these two additional papers:1) 'Analgesic effect of low energy shock waves in tendinosis calcarea, epicondylitis humeri radialis and plantar faciitis' by Maier et al., which appeared in Z Orthop Ihre Grenzgeb, 2000, 138: 34-38, and, 2)'Treatment of painful heels using extracorporeal shock wave' by Wang et al.,published in J Formos Med Assoc, 2000, 99:580-583. In the above mentioned papers low energy (0.09-0.018 mJ/mm2) and, respectively, high energy (14 Kv, I suppose is equal to 0.3 -0.4 mJ/mm2)was adopted. Results were extremely positive in both scheduled trials. We are deeply experienced in Torino (Italy) with low energy shock wave treatment of plantar fasciitis/heel spur (2 -3 subsequent treatments, 7 -10 days interval)adopting Minilith SL1 device. We never need local anesthesia and never complain problems. 4 - 6 months after completion of treatment results are significantly better than few days after treatment.
Thanks for your great care in the field of ESWT !!
Roberto

Re: High Energy article copied from ESWT page to read

David Lowy on 12/22/00 at 01:28 (035282)

Hello Roberto,
How many shocks do you give per session and how many shocks per second?
Do most of your patients have 2 or 3 treatments, and what, if any, type of imaging do you use....ultrasound? fluoroscopy?
How do you localize the site...by patient feedback?
Looking forward to hearing from you.
Regards,
David Lowy
VP, Canada
Sonorex Therapy Centers

PS...Just thinking about how technology has changed our lives. I am here on vacation in Maui, Hawaii reading a post from somebody in Italy!
What's next????? Aloha

Re: High Energy article copied from ESWT page to read

roberto on 12/22/00 at 08:47 (035293)

Hello David,
we give about 1,500 - 2,000 shocks per session, 4 shocks/second. We adopt a Storz Minilith SL1. This device allows to monitor the treatment ultrasonographically as far as possible with the probe coaxial to the source of ESWs.Of course, we take mostly into account patient feed-back !!
Our patients have usually 2 - 3 treatments (mostly 3): you havo to take into account that the cost per treatment in Europe (and especially in Italy)is lower than in USA.
Thanks for your attention, take care of your vacation!
Roberto

Re: High Energy article copied from ESWT page to read

David Lowy on 12/22/00 at 23:10 (035327)

Your protocol sounds very much like ours with the Siemens Sonocur, except that we do not use any type of imaging because we feel that patient feedback is the most important. We are located in Canada. It's interesting to follow the few treatments that are going on now in the US that it is a big deal that requires anesthesia, a doctor, imaging and quite a long recovery period. I'll bet that as the US becomes more familiar with the technology, they will certainly not use anesthesia. Our patients, like yours, are in and out in 15 minutes, depending on the number of painful sites.
Who performs the treatment? A doctor, physiotherapist, chiropractor?
Thank you for the information....it's very interesting.
Regards,
David

Re: High Energy article copied from ESWT page to read

roberto on 12/27/00 at 01:45 (035439)

We agree that the patient feed back is quite important. Just for that reason we do believe it is advisable that a doctor performs the treatment.
Anyay, physiotherapists as well as chiropractors are welcome in the ESWT family (I have to admit that we did not find a great number of physiotherapists interested in the field).
With best regards,
Roberto

Re: using general anesthesia

Scott R on 12/27/00 at 12:18 (035448)

Roberto and David L,
What do you think about american doctors using general anesthesia to put patients 'out' for ESWT? I know it has effects like increased likely-hood of dementia later-on down the road (among many other things). Are they doing it just to make the patient think it's worth $6,000?

Re: using general anesthesia

Dr. Zuckerman on 12/27/00 at 23:49 (035487)

Iwould think that the Canadian and Europeans are getting a real laugh about the use of general and or local anesthesia in the USA. I still can't believe that I used local anesthesis on a routine basis. I know in my case I didn't truely believe that low energy could produce an analgia in the areas that were to be treated. All of my initial experience came from the ossatron experience in Canada and i had this fixed idea that you must use a local because that is what was used for high energy treatments.

Re: using general anesthesia

roberto on 12/28/00 at 02:11 (035490)

I totally agree with dr. Zuckerman's statement. At the very beginning (decenber 1997) of our enthusiastic experience with ESWT we were skeptical about adopting low energies in treating musculo-skeletal ailments. We started our experience by adopting an electrohydraulic device: all of our patients claimed for discmfortable pain (!!), in the face of satisfactory results. Treatments were painful (especially in the case of PF treatments) even by adopting the lowest energy level (about 0.08 - 0.1 mJ/mm2)which could be reached by that kind of generator. Within a few weeks we turned to an electromagnetic device and, much to our surprise, we observed better results with lower energies (we can start from 0.005 mJ/mm2, then increase gradually up to 0.04 - 0.055 mJ/mm2 to treat tendonitis; or up to 0.07 - 0.09 - 0.11 to treat plantar fasciitis). It has to be taken into account that our patients are mostly satisfied, even for not feeling any pain.
With best regards.
Roberto Frairia
Associate Professor of Internal Medicine
Department of Clinical Pathophysiology
University of Torino, School of Medicine
Torino, Italy

Re: using general anesthesia

Scott R on 12/28/00 at 06:30 (035491)

But as I understand it, Dr. Zuckerman is using a high-energy device (Orbasone - electrohydraulic) and seems to have somehow found a way to do it without local anesthesia.

Re: using general anesthesia

Dr. Zuckerman on 12/29/00 at 17:45 (035586)

I am using high energy but using low energy as a numbing procedure first.
I am then switching to the high energy (0.6 joules /mm2 at the focal point of treatment which is the proximal insertional portion of the plantar fascia into the medial tubercle of the calcaneus.

There is an article that I started this conversation with that describes the use of high energy whick in my opinion gave very good results.

The protocol for the treatment as I understand it is the following

1. Use of 0.3 joules. mm2 at the F2 site
2. Use of 3000 shocks ( I use 1500 in two different direction or sites.
3. I believe Dr. Schaden from Austria teaches that the wider the f2 site the better the result. In simple terms - you have a site the beam of shockwave is .5 mm . spread it out to by placing 1500 in one site and then another 1500 next to it.
4. So why not use low energy anything below 0.28 to numb the area that is going to be used for treatment to some degree then slowly switch up to the treatment at 0.6 joules /mm2

5. So no needles. and you have three ways to local the area to treat.
a. Palpation which is then confirmed by flurocopy . I place a lead dot at the area of most pain on deep palpation with the foot fully loaded b. use the x-ray and or mri to help confirm just what is the area of pathology and does the examination match any x-ray/mri pathology

c. Use of pain directed treatment under low energy if necessary or and just the use of low energy to numb the f2 area and then treat at high energy using 3000 shocks in two direction.

I really think that I may be on to something or just learning what the more experience ESWT doctor's know all ready. Anyway this is something that really could place ESWT treatment in the direction that I think it should be which is an in-office procedure without needles with the patient walking into the treatment room and then wallking out of the treatment room

Re: Your new protocol

Dr. Marlene Reid on 1/17/01 at 14:38 (036758)

Dr. Zimmerman,

Your protocol is very interesting. What percentage of your patients are now only requiring one treatment vs. two treatments vs. three treatments. What time frame do you space them out, if not 12 weeks. I noticed one patient Lori K. I think that had a second treatment the next day. Thanks for your info.

Re: Your new protocol

Kay S on 1/17/01 at 20:02 (036779)

I think I can answer this one. I had tx bilaterally, and Dr. Z gave me 1500 shocks to each foot on a Thursday, and 1500 shocks to each foot on the following Saturday. I believe this is the same as what Lori had. So we really just had one complete treatment in divided doses on each foot.
I had my first tx on Dec 14th and will have the second on Feb. 12th. Dr. Z said that I could come back in either six weeks or eight weeks. Another patient from this board had hers spaced about the same, and just had her third after about six months.(from the second one)
I am just now starting to think the tx is working, after five weeks. I had a really bad time around the 10th day and it lasted about a week, but now I think I am better. I still have a lot of pain, but can tell that it is improved because of my ability to concentrate better, among other things.
I hope you will continue to 'listen' to the people on this board. There are some really wonderful, intelligent, caring, knowledgeable people. And we have tried EVERYTHING!
Kay