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question for the doc.

Posted by ross on 8/17/01 at 19:30 (057037)

Hey doc,
I had my first treatment with the orbasone. I got about 4000 hits with the machine set at 20. How does this compare to what you typically do?
thanks

Re: question for the doc.

Dr. Zuckerman on 8/17/01 at 19:39 (057039)

Hi,

We use 3000 shocks at 15-18 kv. We start at 12 and work up. We have found that no anesthesia is necessary with this method. It is also my opinion that if the first treatment does help you that additional treatments are beneficial. We also know from the literature and from experience that most pain relief and effective healing takes place between week six thru twelve.
good luck and feel free to ask Dr.Z any questions.

Re: question for the doc.

JudyS on 8/17/01 at 19:57 (057040)

although......that sissy John h never got past 12....:)

Re: question for the doc.

ross on 8/17/01 at 21:00 (057048)

It was painful set at 20 but bearable. I didn't take a block but I think most people would have at that level.

Re: question for the doc.

Dr. Zuckerman on 8/17/01 at 22:34 (057056)

Most can't take kv 20.

Re: question for the doc.

john h on 8/19/01 at 10:57 (057162)

judy: sissy john did not screem out in agony and i think dr z gave me all he had. i do not think Frankenstien could have got more voltage than me. I am now what you would call a 'Live Wire'1

Re: question for the doc.

Jasmine on 8/21/01 at 14:13 (057444)

Ross- Where did you have your treatment? I also got a very high voltage treatment...21kV for 2500 pulses, and 22kV for the last 500 pulses. Got my treatments in L.A. Seems like most places treat at a lower voltage. I also had no pain block, but will admit, it hurt like hell! I'm curious to know if you think the higher voltage treatment is more beneficial.

Re: question for the doc.

Ross on 8/21/01 at 18:33 (057476)

I had it done by Mike shapow in LA, probably the same guy as you. I don't know if a higher level is beneficial. The ossatron machine is done in one shot and it's at a higher level so I think higher means less treatments.
Ross

Re: question for the doc.

Dr. Zuckerman on 8/21/01 at 19:24 (057478)

I don't really agree with higher being better with soft tissue
I do believe that multiple treatments are benefical and that if the first
doesn't help then the second or third could help alot.

I have seen this and experienced this. I would be very interested in
the retreat rate for the ossatron.

I do know that the orthowave does two treatment two weeks apart. I don't know if we are ever going to determine if it was the additional treatment of the additional time.

Re: ESWT

john h on 8/22/01 at 11:45 (057548)

Dr Zuckerman: from my personal experience with 3 ESWT treatments it seems i got a little better after each treatment and the effect lasted longer after each treatment. One treatment may work for some and it may take 5 or more for others. Since my first treatment with you (2 years ago-cannot remember) i have become convinced this treatment does work. I would certainly qualify as a chronic hard core case. Probably $10-$15 thousand dollars was spent on surgery and all the associated followups and visits to other doctors. It may not work for all but anyone,without a doubt IMHO, should have this treatment before considering surgery. There is no chance of being made worse as is the case with surgery, there is no down time. you will know the results within 12 weeks, and it is painless. If the insurance companies and bureacrats woul look intelligently at this mode of treatments they would come to the conclusion that is less expensive than many trips to the doctor,meds,crutches, downtime and all the other cost to the patient and society. sometimes you just do not see the forest because of the trees. It is a terrible thing that we have so many people out there in pain and their lives hanging by a thread who cannot have this treatment because it is not approved or they cannot afford it. Your freet treatment each month is a generous thoughtful gesture and a lot of people out here look forward each month to the drawing hoping they will win.

Re: ESWT

Brian V. on 8/26/01 at 20:11 (058053)

>There is no chance of being made worse as is the case with surgery, there >is no down time. you will know the results within 12 weeks, and it is >painless.

Have to disagree here. There IS a chance of having worsening pain. True, there is basically no down time and it is relatively painless. However, I strongly disagree that it categorically can not make you worse. This is not the case for every patient and was not my case. I NEVER had morning stiffness of pain prior to ESWT. It did appear after my series of treatments however, and there was NO change in anything else in my life to explain this.
In medicine, as in life, there is a very old saying that we should live by: 'The only absolute, is that there are no absolutes'. I would caution anyone at making assertions that this procedure is without it's own inherent risks.
I have had a lot of people email me in the past few months since I am one of the few on the Pt Progress board who has reported unfavorable results post ESWT. Some seem to be getting the impression from posts here that this procedure is without risk. That can be dangerous. I am NOT attacking anyone with my post here. I respect all the doctors here for the help that they give to those who suffer everyday with this pain, as I do. Even though statistically the risk of complications post ESWT is astronomically lower than with surgery, it is not absolutely without risk. Use discretion and caution with posts here, is all I am saying. Some read this as Gospel.

Respectfully,
Brian V., RN, PA-S
7 years of PF on the right, 3 years on the left

Re: ESWT

john h on 8/27/01 at 17:08 (058136)

brian: i am also 7 years and well into 8th year with PF. certainly there is some risk. there is risk in walking out the front door. from what i have read i would guess that any risk of being made worse would be less than .5%. i have tts surgery, pf surgery, and 3 ESWT treatments. For me it is a no brainer to go for ESWT over surgery. for me it is a no brainer to have ESWT if your doctor thinks it can help you from your pain of 7 years. i read of one case where a patient suffered a fascia rupture after treatment. that is sort of like having a pf release in the final analysis. i think ESWT is safer than for me to drive my automobile from little rock to dallas (personal opinion). i think some of the medical professionals should weigh in on their personal experience. I have seen data from the German sites and nothing there that would scare me. The warnings on a bottle of aspirin would appear more scary. In the final analysis each person must make this a very personal decision based on the facts available to them. Prologue: after 7 years brian i am the best i have ever been at a pain level of 1 and this comes 6 weeks after my 3rd ESWT treatment.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 18:24 (058147)

John,
If you read my post again, you will see that it is merely a warning to those who post on here asserting that ESWT is without risk. I have read through many of the posts here lately, and have seen several people speak of ESWT as though it is a risk free procedure. This is not the case and is never the case with any treatment in medicine. As I mentioned, several people have emailed me recently, since I am one of the few treatment failures on the progress report page, and they seem to have gotten the impression from posts here that this procedure is without risk. This concerns me as a patient who did have increased pain post-ESWT, as a health care professional who understands the importance of patient education and as a PF sufferer knowing what people go through looking for help with the chronicity of this condition.

You make an important point when you say, 'In the final analysis each person must make this a very personal decision based on the facts available to them'. That is exactly the point of my post. The facts out there are somewhat scarce and the data is still thin, IMHO. One of the few places people can go to research this is right HERE, on this website. And when they read through all these 1000's of posts, some of them are coming away with the impression that this can NOT make them any worse. That is wherein the problem lies. Overall, the success rates appear to be wonderful. But I wonder what happens to those people for whom ESWT does not work? This is probably the most critical group to analyze. Why did ESWT fail for them? This is a population that needs to be more closely studied.

I hope that the intended message is heard by the target audience.
I am glad to see that ESWT was the answer for you. I wish you much luck and continued recovery.

Respectfully,
Brian V, RN, PA-S

The only absolute, is there are no absolutes

Re: ESWT*** new take on an old thread/discussion

john h on 8/27/01 at 19:09 (058151)

brian: i think the Healthtronic's OssaTron FDA trial indicated a success rate of no more that 60% maybe less than that. This is certainly not the final answer but i without hesitation say to anyone, anytime, anywhere try ESWT before surgery. One need look no further than this board to find many cases of failed surgery. Not only failed but made the patients worse for a long time. The first thing i asked my doctor when we got down to a serious discussion of surgery was 'what are the chances it will make me worse'? I could live with a failed surgery that left me no worse than i was going in. ESWT was not an available option for me at that time except in Canada and i knew little about the treatment. I think you are the only one i have seen post who is worse than before treatment. There are of course many who it has not helped. My take was if i have a 50% chance of getting better and a 1% chance of getting worse (which i think is high) then those were odds that were more than acceptable to me. I would like to hear from Dr Zuckerman and the other doctors who have been doing this procedure as to how many are worse. I believe we can both access Scott's ESWT survey and easily see the number made worse or better. This data base should be substantial by now and we will be looking at the people who have been there and done that and posted their results. As for me, i am not ready to cry out 'I am healed'. I have been the best i have been in 7 years for over a month. PF has a way of sneaking back up on you. Are you still worse than before ESWT? Are you sure that you got worse from the ESWT rather than something else? Am i sure i got better from ESWT rather than something else? Things to ponder.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 20:13 (058157)

John,
In response to your post....First, you state 'I think you are the only one i have seen post who is worse than before treatment.' Unfortunately I know of at least one other person who is considerably worse after ESWT. I will not divulge this persons information here. I have informed them of the on-going discussion I am having here and I leave it up to them to post.
Next, you asked, 'Are you still worse than before ESWT? Are you sure that you got worse from the ESWT rather than something else?' Yes, I am still worse than before ESWT. There is NOTHING else to explain why I got worse. I did not alter anything about my lifestyle, occupation, diet, pain regimen, stretching program, shoes, etc. to explain why I got worse. As I also indicated, I NEVER had pain in the morning w/ my PF. That made me an unusual case. From almost week one after ESWT, I had morning pain. There is nothing to explain the appearance of this. This has not passed to this day.
Finally you stated, 'My take was if i have a 50% chance of getting better and a 1% chance of getting worse (which i think is high) then those were odds that were more than acceptable to me.' (Regarding ESWT) This is of course the correct way of thinking, and any intelligent person such as yourself, would accept these odds. My problem continues to be the underreporting and lack of study of those who might have gotten worse, such as myself. Those patients are not adequately discussed and are usually just peripherally mentioned in most study data. I want to know WHY it didn't work for this group of patients? Was there a common denominator that bound them all together? Was it a pre-existing condition such as obesity or concurrent TTS? A 60% success rate, and thus a 40% failure rate, as you reported, is not explained by mere statistical insignificance.

I would also like some of the Physicians to chime in here. They seem to be absent the last two days. Could you post the link to the study data you mentioned from Healthtronics FDA study?

Respectfully,
Brian V.

Re: ESWT*** new take on an old thread/discussion

Dr. Zuckerman on 8/27/01 at 20:15 (058158)

Hi,

I understand and I am hearing what Brian is saying. Did his
stiffness come from the ESWT I don't know. All I have read
and been taught is that the condition won't get worse after ESWT treatment

Now the problem is this. Did it get worse or did it progress
I am not sure about this.

I just saw a patient today that I have followed after she
had ESWT in New York with the orthowave. She was telling ove
the past year that she is worse from the orthowave ESWT

Today after talking and examining her she is better. She still has
some heel pain but she started with the entire pf hurting
Today there is no pain except in her heel. This was a patient
that was treated twice with a very high energy . To be exact
it was 1.75 joules /mm2. I wish that I knew what she was like before the treatment with examination

I wanted to beable to examine her to see if she was worse
In my mind she wasn't worse but in her's she was.

I am not doubting any one who feels they are worse. I have seen some patients that have increased pain after the ESWT treatment

So in summary I don't have any information about being worse. I do have pateints that have had failed ESWT that I have performed surgery on and are pain free.

I also have some patients that are worse after surgery.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 20:22 (058159)

One other thing of general interest. I work with a group of Bariatric surgeons. Bariatric surgery is surgery for the morbidly obese patient, and includes such procedures as Roux-en-Y gastric bypass and gastric banding. They have not done a formal study, but have found through informal survey that approximately 8 out of 10 patients who reported sx's of PF prior to surgery, have had complete resolution of pain post op once they have lost weight and reached their target ideal body weight.
Those are pretty amazing statistics. I am wondering what the Physicians here have found to be the case if you have dealt with the population of patients? This is a potential area of interest for future studies.

Respectfully,
Brian V., RN, PA-S

Re: ESWT*** new take on an old thread/discussion

Barbara TX on 8/27/01 at 20:27 (058160)

I wanted to give a little input as a ESWT 'failure.' ESWT did not work for me. Perhaps it helped a little, but not enough to continue the treatment (I had it twice). I then decided (with a little help from my friends here) to do the MIS surgery - it has helped more than ESWT ever did, but I totally agree that ESWT is to be considered before surgery. Like most patients, ESWT never made me worse. If my right foot continues to worsen I would do ESWT first... cutting is to be taken very, very seriously. B.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 20:31 (058161)

Dr. Z,
Good to see a post from you here.
Truth be known, no one will ever know whether or not I 'got' worse from the ESWT. I know only this. I never had morning pain before ESWT and it appeared about one week after my first treatment, in both feet which were treated. The statistical chances of progression, as it were, of both feet at the same time, just coincidentally coinciding with the first ESWT treatments, is as near to absolute zero as one can get.
It is good to see that you aknowledge that there are a subset of patients who DO have worsening pain after ESWT. The intent of this whole thread was that there are people who are advocating this treatment as a risk free process. To me, the chance of having worsening pain, is in and of itself, a risk. I just don't want to see people led to believe a set of facts that is summarily untrue.

Thanks for the reply.
Respectfully,
Brian V.

Re: ESWT*** new take on an old thread/discussion

Dr.Zuckerma on 8/27/01 at 20:51 (058166)

The only study that I have seen where there have been increased pain for perids
of time after ESWT was with the ossatron study.

I now am told that one of the benefit of low energy is that
patients that get increased pain after ESWT treatment.

There have been postings on here I believe from patients that have
been treated with low ( soncur) medium( orbasone) and high
orthowave and ossatron that do have periods of increased pain
from treatments.

The question is is what is the increased pain from. The procedure
or too much activiy or what.

Is it too much shockwave for that specific patient??

All of the European Studies and reports are always talking about the no risk to ESWT.

Maybe we need to have an open report on the problems that people have had with any ESWT treatments.

If there is any patient that feels that they have been made worse after ESWT either by me or by any ESWT machine. I would like to hear from them . You can e-mail me at footcare@home.com . This is important cause this is something that the manufactors aren't going to tell us.

Re: ESWT*** new take on an old thread/discussion

john h on 8/27/01 at 21:16 (058170)

at one time i downloaded the meat of the completed FDA Studies and their findings on the board Brian. Jeff may still have those studies somewhere on the board and either of us can do a search. If my memory is correct i recall one person was worse but quickly recovered to pre PF conditions. It is an interesting read in any case. I have not looked at the ESWT survey on the board in some times but if you have not it is worth looking at. Among other things the patients are asked pain level and activity level before and after ESWT. I do not know what they will show as of this minute but will take a look see. I understand for you the stats are meaningless because in your case the stats are 100% that you are worse. I know their were some interesting studies i read on the web conducted in Germany where the procedures has been used for many years and the numbers are large enough to have some statistical meaning. by the way i had a kidney stone one time in my life and the lipotriptor was the mode of choice to stop the pain. it can do some real damage to your body. at that time i could care less about stats, survival rates, who did what to whom just get me to the dam lipotriptor as fast as you can and lets discuss survival later.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 21:59 (058174)

John,
I have just finished reading the transcript of the FDA meeting, all 52 pages of it or so.
I also looked at the survey results here on HS.com. I do not see any mention of the use of ESWT as a treatment and whether or not it worked for those who had it. Maybe the data is somewhere and I just don't see it.
Regarding subjective/numerical pain scales, I am not sure what to think of these ratings. This is unfortunately the best method we have available, since this is not like a biopsy where we can see that there was total disappearance of cancer cells post-chemotherapy or some other form of treatment. I just wonder how many people would have gotten better anyway, whether or not they had ESWT. This point is brought up several times during the FDA meetings by some of the panel. I believe that the response from the company was basically, 'we do not know if the treatment relieved their pain, or if they just got better, since the natural course of the disease is that people will improve with time, no matter the interventions provided.
I don't know....the success rate reported of 60% vs. 48% with sham treatment, doesn't seem as glaring of a positive result as I thought it would show, and seems low in comparison to the European studies I recall from years back. I have not taken another look at them though to correlate the data.
Again I would state that I am more interested of course in those who might have gotten worse, since I fall into that category. I need some data on those patients. I just don't see that anywhere I look. I have taken Dr. Z's offer and emailed him privately regarding the worsening of symptoms I experienced post-ESWT.
I hope that there will be some more interest in this subset of patients someday. The measure of a good study is not just the reporting provided on the 'successful' cases. We must look at those who did not respond to ensure that we are providing a complete study to the public and to those who suffer with this chronic condition.
On a side note, as I reported to Dr. Z in my private email to him, I just had an EPF on my right foot five days ago. I am encouraged with the progress I have made. I am concerned about the findings at the time of surgery, and my doctor was surprised at what he saw. I will post a separate topic on this, since I would like the input of the doctors here who have performed EPF post-ESWT on the findings.

Respectfully,
Brian V.

Re: ESWT*** new take on an old thread/discussion

Jen R on 8/28/01 at 18:48 (058292)

I too believe that my initial ESWT treatment made my foot problems worse. Having suffered with PF in both feet for 3 years I decided to try ESWT after much investigation. I would not say my 'pain' increased...'pain' level remained the same. However, I developed a tingling sensation in the bottom of my right foot which was later diagnosed as TTS. A second treatment did not either help nor hinder my situation. I have discussed this issue with Dr. Z and he does not see how the ESWT could cause TTS but I have no doubt that it did. Is it possible that my foot could have moved out of place without knowing and the shock waves penetrated the wrong area? I don't know but I think it would be very easy to move the position of the foot without realizing it. A slight movement could be a big deal, could it not?
Being out of options, I chose to have a very aggressive surgery. It was back in May and I still have a long way to go to overcome the surgery...let alone find out if it was successful. The surgery was something I didn't want to do but felt I had no choice. The surgery was more invasive because the nerve compression could not be fixed through a minimal incision surgery which of course only creates more problems.
In any case, I too believe that although I do not regret my decision to have ESWT and would recommend people to give it a try...I would agree that it is not the risk-free cure-all answer for everyone. For those who have been cured by ESWT, that is wonderful for you and I'm totally jealous, but keep in mind that not everyone has been as fortunate as you.
Despite my situation, I continue to believe that Dr. Z deserves alot of credit for his tireless efforts...not many doctors are willing to go to such distances for his patients. In the event that my surgery does not prove to be successful...I hope the ESWT procedure continues to get refined to the point at which I would consider another try. The only way to continue to make improvements is to try to find out more about the failed cases.
Sincerely,
Jen R.

Re: ESWT*** new take on an old thread/discussion

Dr. Zuckerman on 8/28/01 at 20:27 (058301)

Hi Jen,

I remember the tinging in your foot very well. This is might
made me concluded that the ESWT didn't cause the TTS.

The depth of penetration of ESWT is 50mm at the focal point.
The medial tubercle in on the bottom and the Posterior tibial nerve is
on the side of the foot above the heel bone.

It is possible that the increased pain after the treatment made
you walk differently and put additional stress and pressure on the nerve
due to compensation.

I have also seen early heel spur pain progressive to TTS even without
a positive EMG.

So I don't think it did cause the TTS but there is no way I can
prove this.

One of the problem is that we are walking and our gait is changing
during the heel spur snydrome disease. We want to rest but too much rest is just as bad as too little rest.

Re: ESWT*** new take on an old thread/discussion

Jen R on 8/29/01 at 06:30 (058324)

Hi Dr. Z,

I don't know if I ever told you this...but I did have an EMG prior to my surgery (which was not a pleasant experience) and the findings were all normal. It was explained to me that I could still have TTS even though the EMG is normal...apparently you agree. I don't know what good the EMG can be then...I went thru a very uncomfortable and expensive test...had nothing out of the ordinary...and I still had to have the nerve decompression surgery. I wasn't too happy about that. Anyway, I don't remember walking differently after the ESWT but I guess that is possible. Let me ask you this, though. Once the ESWT pain was gone and I starting walking normal again would the tingling not go away on its own...or could such a short amount of time of walking differently do permanent damage?
Thanks for your post. I appreciate the reply.

Sincerely,
Jen Ross

Re: Orbasone settings ??

BrianG on 8/29/01 at 09:38 (058342)

Hi Jen,

Do you happen to remember what the settings of the Orbasone were, when you had your treatments? I see some people getting low (16kv) and others up near 20kv.

Regards
BCG

Re: ESWT*** new take on an old thread/discussion

Dr. Zuckerman on 8/29/01 at 09:39 (058343)

Hi Jen,

It should go away yes. One of the interesting approaches to your surgery and one that did make sense to me was that an osteotomy of the heel bone was to straighten out your heel. The varus position of your heel is one biomechanical factor that can place pressure on the posterior tibial nerve.
and cause excessive pronation which will place tension on the plantar fasia

This is why one of the reason for the use of orthosis to control the abnormal pronation which stresses the pf.

I have found that your in some cases chronic pf with your foot structure can develop TTS symtoms

Re: Orbasone settings ??

Jen R on 8/29/01 at 10:14 (058345)

Brian,

No I don't remember offhand, but I'll check my records and get back to you.

Re: Orbasone settings ??

Jen R on 8/29/01 at 11:35 (058352)

Brain G

I believe that I received 3000 shocks at 15-18kv. As Dr. Z stated in a previous post, he starts at 12kv and works his way up. My first procedure was done after numbing the foot while my second treatment was without anesthetic.

Re: Orbasone settings ??

john h on 8/29/01 at 18:19 (058385)

my three treatment i think were from 16-18 on each foot. really never felt much of anything. feet were never sore and i had both feet done at the same time and drove back to baltimore and walked through 3 different airports on way home.

i think barbs were at 2.54 and judy's at 1.6. sissy girl voltages. barb talks big but she is into the surgery thing these days.

Re: Orbasone settings ??

Barbara TX on 8/30/01 at 10:40 (058450)

Sissy? I remember hearing Dr. Zuckerman tell me that he was glad I was there because he could finally 'open this thing all the way up' on my heel. I fell asleep during the procedure, and Roxane had to wake me up because I was drooling on the pillow. She gave me some kleenex that she said they kept right next to the Orbasone 'for a patient named John' who tended to weep uncontrollably when zapped. I wondered who that man could be. They told me that he was a military person, with the most dainty, pampered feet they have ever seen; he also slept in a cot. I remember laughing at that, because even I sleep directly on the floor, like a Spartan. B.

Re: question for the doc.

Dr. Zuckerman on 8/17/01 at 19:39 (057039)

Hi,

We use 3000 shocks at 15-18 kv. We start at 12 and work up. We have found that no anesthesia is necessary with this method. It is also my opinion that if the first treatment does help you that additional treatments are beneficial. We also know from the literature and from experience that most pain relief and effective healing takes place between week six thru twelve.
good luck and feel free to ask Dr.Z any questions.

Re: question for the doc.

JudyS on 8/17/01 at 19:57 (057040)

although......that sissy John h never got past 12....:)

Re: question for the doc.

ross on 8/17/01 at 21:00 (057048)

It was painful set at 20 but bearable. I didn't take a block but I think most people would have at that level.

Re: question for the doc.

Dr. Zuckerman on 8/17/01 at 22:34 (057056)

Most can't take kv 20.

Re: question for the doc.

john h on 8/19/01 at 10:57 (057162)

judy: sissy john did not screem out in agony and i think dr z gave me all he had. i do not think Frankenstien could have got more voltage than me. I am now what you would call a 'Live Wire'1

Re: question for the doc.

Jasmine on 8/21/01 at 14:13 (057444)

Ross- Where did you have your treatment? I also got a very high voltage treatment...21kV for 2500 pulses, and 22kV for the last 500 pulses. Got my treatments in L.A. Seems like most places treat at a lower voltage. I also had no pain block, but will admit, it hurt like hell! I'm curious to know if you think the higher voltage treatment is more beneficial.

Re: question for the doc.

Ross on 8/21/01 at 18:33 (057476)

I had it done by Mike shapow in LA, probably the same guy as you. I don't know if a higher level is beneficial. The ossatron machine is done in one shot and it's at a higher level so I think higher means less treatments.
Ross

Re: question for the doc.

Dr. Zuckerman on 8/21/01 at 19:24 (057478)

I don't really agree with higher being better with soft tissue
I do believe that multiple treatments are benefical and that if the first
doesn't help then the second or third could help alot.

I have seen this and experienced this. I would be very interested in
the retreat rate for the ossatron.

I do know that the orthowave does two treatment two weeks apart. I don't know if we are ever going to determine if it was the additional treatment of the additional time.

Re: ESWT

john h on 8/22/01 at 11:45 (057548)

Dr Zuckerman: from my personal experience with 3 ESWT treatments it seems i got a little better after each treatment and the effect lasted longer after each treatment. One treatment may work for some and it may take 5 or more for others. Since my first treatment with you (2 years ago-cannot remember) i have become convinced this treatment does work. I would certainly qualify as a chronic hard core case. Probably $10-$15 thousand dollars was spent on surgery and all the associated followups and visits to other doctors. It may not work for all but anyone,without a doubt IMHO, should have this treatment before considering surgery. There is no chance of being made worse as is the case with surgery, there is no down time. you will know the results within 12 weeks, and it is painless. If the insurance companies and bureacrats woul look intelligently at this mode of treatments they would come to the conclusion that is less expensive than many trips to the doctor,meds,crutches, downtime and all the other cost to the patient and society. sometimes you just do not see the forest because of the trees. It is a terrible thing that we have so many people out there in pain and their lives hanging by a thread who cannot have this treatment because it is not approved or they cannot afford it. Your freet treatment each month is a generous thoughtful gesture and a lot of people out here look forward each month to the drawing hoping they will win.

Re: ESWT

Brian V. on 8/26/01 at 20:11 (058053)

>There is no chance of being made worse as is the case with surgery, there >is no down time. you will know the results within 12 weeks, and it is >painless.

Have to disagree here. There IS a chance of having worsening pain. True, there is basically no down time and it is relatively painless. However, I strongly disagree that it categorically can not make you worse. This is not the case for every patient and was not my case. I NEVER had morning stiffness of pain prior to ESWT. It did appear after my series of treatments however, and there was NO change in anything else in my life to explain this.
In medicine, as in life, there is a very old saying that we should live by: 'The only absolute, is that there are no absolutes'. I would caution anyone at making assertions that this procedure is without it's own inherent risks.
I have had a lot of people email me in the past few months since I am one of the few on the Pt Progress board who has reported unfavorable results post ESWT. Some seem to be getting the impression from posts here that this procedure is without risk. That can be dangerous. I am NOT attacking anyone with my post here. I respect all the doctors here for the help that they give to those who suffer everyday with this pain, as I do. Even though statistically the risk of complications post ESWT is astronomically lower than with surgery, it is not absolutely without risk. Use discretion and caution with posts here, is all I am saying. Some read this as Gospel.

Respectfully,
Brian V., RN, PA-S
7 years of PF on the right, 3 years on the left

Re: ESWT

john h on 8/27/01 at 17:08 (058136)

brian: i am also 7 years and well into 8th year with PF. certainly there is some risk. there is risk in walking out the front door. from what i have read i would guess that any risk of being made worse would be less than .5%. i have tts surgery, pf surgery, and 3 ESWT treatments. For me it is a no brainer to go for ESWT over surgery. for me it is a no brainer to have ESWT if your doctor thinks it can help you from your pain of 7 years. i read of one case where a patient suffered a fascia rupture after treatment. that is sort of like having a pf release in the final analysis. i think ESWT is safer than for me to drive my automobile from little rock to dallas (personal opinion). i think some of the medical professionals should weigh in on their personal experience. I have seen data from the German sites and nothing there that would scare me. The warnings on a bottle of aspirin would appear more scary. In the final analysis each person must make this a very personal decision based on the facts available to them. Prologue: after 7 years brian i am the best i have ever been at a pain level of 1 and this comes 6 weeks after my 3rd ESWT treatment.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 18:24 (058147)

John,
If you read my post again, you will see that it is merely a warning to those who post on here asserting that ESWT is without risk. I have read through many of the posts here lately, and have seen several people speak of ESWT as though it is a risk free procedure. This is not the case and is never the case with any treatment in medicine. As I mentioned, several people have emailed me recently, since I am one of the few treatment failures on the progress report page, and they seem to have gotten the impression from posts here that this procedure is without risk. This concerns me as a patient who did have increased pain post-ESWT, as a health care professional who understands the importance of patient education and as a PF sufferer knowing what people go through looking for help with the chronicity of this condition.

You make an important point when you say, 'In the final analysis each person must make this a very personal decision based on the facts available to them'. That is exactly the point of my post. The facts out there are somewhat scarce and the data is still thin, IMHO. One of the few places people can go to research this is right HERE, on this website. And when they read through all these 1000's of posts, some of them are coming away with the impression that this can NOT make them any worse. That is wherein the problem lies. Overall, the success rates appear to be wonderful. But I wonder what happens to those people for whom ESWT does not work? This is probably the most critical group to analyze. Why did ESWT fail for them? This is a population that needs to be more closely studied.

I hope that the intended message is heard by the target audience.
I am glad to see that ESWT was the answer for you. I wish you much luck and continued recovery.

Respectfully,
Brian V, RN, PA-S

The only absolute, is there are no absolutes

Re: ESWT*** new take on an old thread/discussion

john h on 8/27/01 at 19:09 (058151)

brian: i think the Healthtronic's OssaTron FDA trial indicated a success rate of no more that 60% maybe less than that. This is certainly not the final answer but i without hesitation say to anyone, anytime, anywhere try ESWT before surgery. One need look no further than this board to find many cases of failed surgery. Not only failed but made the patients worse for a long time. The first thing i asked my doctor when we got down to a serious discussion of surgery was 'what are the chances it will make me worse'? I could live with a failed surgery that left me no worse than i was going in. ESWT was not an available option for me at that time except in Canada and i knew little about the treatment. I think you are the only one i have seen post who is worse than before treatment. There are of course many who it has not helped. My take was if i have a 50% chance of getting better and a 1% chance of getting worse (which i think is high) then those were odds that were more than acceptable to me. I would like to hear from Dr Zuckerman and the other doctors who have been doing this procedure as to how many are worse. I believe we can both access Scott's ESWT survey and easily see the number made worse or better. This data base should be substantial by now and we will be looking at the people who have been there and done that and posted their results. As for me, i am not ready to cry out 'I am healed'. I have been the best i have been in 7 years for over a month. PF has a way of sneaking back up on you. Are you still worse than before ESWT? Are you sure that you got worse from the ESWT rather than something else? Am i sure i got better from ESWT rather than something else? Things to ponder.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 20:13 (058157)

John,
In response to your post....First, you state 'I think you are the only one i have seen post who is worse than before treatment.' Unfortunately I know of at least one other person who is considerably worse after ESWT. I will not divulge this persons information here. I have informed them of the on-going discussion I am having here and I leave it up to them to post.
Next, you asked, 'Are you still worse than before ESWT? Are you sure that you got worse from the ESWT rather than something else?' Yes, I am still worse than before ESWT. There is NOTHING else to explain why I got worse. I did not alter anything about my lifestyle, occupation, diet, pain regimen, stretching program, shoes, etc. to explain why I got worse. As I also indicated, I NEVER had pain in the morning w/ my PF. That made me an unusual case. From almost week one after ESWT, I had morning pain. There is nothing to explain the appearance of this. This has not passed to this day.
Finally you stated, 'My take was if i have a 50% chance of getting better and a 1% chance of getting worse (which i think is high) then those were odds that were more than acceptable to me.' (Regarding ESWT) This is of course the correct way of thinking, and any intelligent person such as yourself, would accept these odds. My problem continues to be the underreporting and lack of study of those who might have gotten worse, such as myself. Those patients are not adequately discussed and are usually just peripherally mentioned in most study data. I want to know WHY it didn't work for this group of patients? Was there a common denominator that bound them all together? Was it a pre-existing condition such as obesity or concurrent TTS? A 60% success rate, and thus a 40% failure rate, as you reported, is not explained by mere statistical insignificance.

I would also like some of the Physicians to chime in here. They seem to be absent the last two days. Could you post the link to the study data you mentioned from Healthtronics FDA study?

Respectfully,
Brian V.

Re: ESWT*** new take on an old thread/discussion

Dr. Zuckerman on 8/27/01 at 20:15 (058158)

Hi,

I understand and I am hearing what Brian is saying. Did his
stiffness come from the ESWT I don't know. All I have read
and been taught is that the condition won't get worse after ESWT treatment

Now the problem is this. Did it get worse or did it progress
I am not sure about this.

I just saw a patient today that I have followed after she
had ESWT in New York with the orthowave. She was telling ove
the past year that she is worse from the orthowave ESWT

Today after talking and examining her she is better. She still has
some heel pain but she started with the entire pf hurting
Today there is no pain except in her heel. This was a patient
that was treated twice with a very high energy . To be exact
it was 1.75 joules /mm2. I wish that I knew what she was like before the treatment with examination

I wanted to beable to examine her to see if she was worse
In my mind she wasn't worse but in her's she was.

I am not doubting any one who feels they are worse. I have seen some patients that have increased pain after the ESWT treatment

So in summary I don't have any information about being worse. I do have pateints that have had failed ESWT that I have performed surgery on and are pain free.

I also have some patients that are worse after surgery.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 20:22 (058159)

One other thing of general interest. I work with a group of Bariatric surgeons. Bariatric surgery is surgery for the morbidly obese patient, and includes such procedures as Roux-en-Y gastric bypass and gastric banding. They have not done a formal study, but have found through informal survey that approximately 8 out of 10 patients who reported sx's of PF prior to surgery, have had complete resolution of pain post op once they have lost weight and reached their target ideal body weight.
Those are pretty amazing statistics. I am wondering what the Physicians here have found to be the case if you have dealt with the population of patients? This is a potential area of interest for future studies.

Respectfully,
Brian V., RN, PA-S

Re: ESWT*** new take on an old thread/discussion

Barbara TX on 8/27/01 at 20:27 (058160)

I wanted to give a little input as a ESWT 'failure.' ESWT did not work for me. Perhaps it helped a little, but not enough to continue the treatment (I had it twice). I then decided (with a little help from my friends here) to do the MIS surgery - it has helped more than ESWT ever did, but I totally agree that ESWT is to be considered before surgery. Like most patients, ESWT never made me worse. If my right foot continues to worsen I would do ESWT first... cutting is to be taken very, very seriously. B.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 20:31 (058161)

Dr. Z,
Good to see a post from you here.
Truth be known, no one will ever know whether or not I 'got' worse from the ESWT. I know only this. I never had morning pain before ESWT and it appeared about one week after my first treatment, in both feet which were treated. The statistical chances of progression, as it were, of both feet at the same time, just coincidentally coinciding with the first ESWT treatments, is as near to absolute zero as one can get.
It is good to see that you aknowledge that there are a subset of patients who DO have worsening pain after ESWT. The intent of this whole thread was that there are people who are advocating this treatment as a risk free process. To me, the chance of having worsening pain, is in and of itself, a risk. I just don't want to see people led to believe a set of facts that is summarily untrue.

Thanks for the reply.
Respectfully,
Brian V.

Re: ESWT*** new take on an old thread/discussion

Dr.Zuckerma on 8/27/01 at 20:51 (058166)

The only study that I have seen where there have been increased pain for perids
of time after ESWT was with the ossatron study.

I now am told that one of the benefit of low energy is that
patients that get increased pain after ESWT treatment.

There have been postings on here I believe from patients that have
been treated with low ( soncur) medium( orbasone) and high
orthowave and ossatron that do have periods of increased pain
from treatments.

The question is is what is the increased pain from. The procedure
or too much activiy or what.

Is it too much shockwave for that specific patient??

All of the European Studies and reports are always talking about the no risk to ESWT.

Maybe we need to have an open report on the problems that people have had with any ESWT treatments.

If there is any patient that feels that they have been made worse after ESWT either by me or by any ESWT machine. I would like to hear from them . You can e-mail me at footcare@home.com . This is important cause this is something that the manufactors aren't going to tell us.

Re: ESWT*** new take on an old thread/discussion

john h on 8/27/01 at 21:16 (058170)

at one time i downloaded the meat of the completed FDA Studies and their findings on the board Brian. Jeff may still have those studies somewhere on the board and either of us can do a search. If my memory is correct i recall one person was worse but quickly recovered to pre PF conditions. It is an interesting read in any case. I have not looked at the ESWT survey on the board in some times but if you have not it is worth looking at. Among other things the patients are asked pain level and activity level before and after ESWT. I do not know what they will show as of this minute but will take a look see. I understand for you the stats are meaningless because in your case the stats are 100% that you are worse. I know their were some interesting studies i read on the web conducted in Germany where the procedures has been used for many years and the numbers are large enough to have some statistical meaning. by the way i had a kidney stone one time in my life and the lipotriptor was the mode of choice to stop the pain. it can do some real damage to your body. at that time i could care less about stats, survival rates, who did what to whom just get me to the dam lipotriptor as fast as you can and lets discuss survival later.

Re: ESWT*** new take on an old thread/discussion

Brian V. on 8/27/01 at 21:59 (058174)

John,
I have just finished reading the transcript of the FDA meeting, all 52 pages of it or so.
I also looked at the survey results here on HS.com. I do not see any mention of the use of ESWT as a treatment and whether or not it worked for those who had it. Maybe the data is somewhere and I just don't see it.
Regarding subjective/numerical pain scales, I am not sure what to think of these ratings. This is unfortunately the best method we have available, since this is not like a biopsy where we can see that there was total disappearance of cancer cells post-chemotherapy or some other form of treatment. I just wonder how many people would have gotten better anyway, whether or not they had ESWT. This point is brought up several times during the FDA meetings by some of the panel. I believe that the response from the company was basically, 'we do not know if the treatment relieved their pain, or if they just got better, since the natural course of the disease is that people will improve with time, no matter the interventions provided.
I don't know....the success rate reported of 60% vs. 48% with sham treatment, doesn't seem as glaring of a positive result as I thought it would show, and seems low in comparison to the European studies I recall from years back. I have not taken another look at them though to correlate the data.
Again I would state that I am more interested of course in those who might have gotten worse, since I fall into that category. I need some data on those patients. I just don't see that anywhere I look. I have taken Dr. Z's offer and emailed him privately regarding the worsening of symptoms I experienced post-ESWT.
I hope that there will be some more interest in this subset of patients someday. The measure of a good study is not just the reporting provided on the 'successful' cases. We must look at those who did not respond to ensure that we are providing a complete study to the public and to those who suffer with this chronic condition.
On a side note, as I reported to Dr. Z in my private email to him, I just had an EPF on my right foot five days ago. I am encouraged with the progress I have made. I am concerned about the findings at the time of surgery, and my doctor was surprised at what he saw. I will post a separate topic on this, since I would like the input of the doctors here who have performed EPF post-ESWT on the findings.

Respectfully,
Brian V.

Re: ESWT*** new take on an old thread/discussion

Jen R on 8/28/01 at 18:48 (058292)

I too believe that my initial ESWT treatment made my foot problems worse. Having suffered with PF in both feet for 3 years I decided to try ESWT after much investigation. I would not say my 'pain' increased...'pain' level remained the same. However, I developed a tingling sensation in the bottom of my right foot which was later diagnosed as TTS. A second treatment did not either help nor hinder my situation. I have discussed this issue with Dr. Z and he does not see how the ESWT could cause TTS but I have no doubt that it did. Is it possible that my foot could have moved out of place without knowing and the shock waves penetrated the wrong area? I don't know but I think it would be very easy to move the position of the foot without realizing it. A slight movement could be a big deal, could it not?
Being out of options, I chose to have a very aggressive surgery. It was back in May and I still have a long way to go to overcome the surgery...let alone find out if it was successful. The surgery was something I didn't want to do but felt I had no choice. The surgery was more invasive because the nerve compression could not be fixed through a minimal incision surgery which of course only creates more problems.
In any case, I too believe that although I do not regret my decision to have ESWT and would recommend people to give it a try...I would agree that it is not the risk-free cure-all answer for everyone. For those who have been cured by ESWT, that is wonderful for you and I'm totally jealous, but keep in mind that not everyone has been as fortunate as you.
Despite my situation, I continue to believe that Dr. Z deserves alot of credit for his tireless efforts...not many doctors are willing to go to such distances for his patients. In the event that my surgery does not prove to be successful...I hope the ESWT procedure continues to get refined to the point at which I would consider another try. The only way to continue to make improvements is to try to find out more about the failed cases.
Sincerely,
Jen R.

Re: ESWT*** new take on an old thread/discussion

Dr. Zuckerman on 8/28/01 at 20:27 (058301)

Hi Jen,

I remember the tinging in your foot very well. This is might
made me concluded that the ESWT didn't cause the TTS.

The depth of penetration of ESWT is 50mm at the focal point.
The medial tubercle in on the bottom and the Posterior tibial nerve is
on the side of the foot above the heel bone.

It is possible that the increased pain after the treatment made
you walk differently and put additional stress and pressure on the nerve
due to compensation.

I have also seen early heel spur pain progressive to TTS even without
a positive EMG.

So I don't think it did cause the TTS but there is no way I can
prove this.

One of the problem is that we are walking and our gait is changing
during the heel spur snydrome disease. We want to rest but too much rest is just as bad as too little rest.

Re: ESWT*** new take on an old thread/discussion

Jen R on 8/29/01 at 06:30 (058324)

Hi Dr. Z,

I don't know if I ever told you this...but I did have an EMG prior to my surgery (which was not a pleasant experience) and the findings were all normal. It was explained to me that I could still have TTS even though the EMG is normal...apparently you agree. I don't know what good the EMG can be then...I went thru a very uncomfortable and expensive test...had nothing out of the ordinary...and I still had to have the nerve decompression surgery. I wasn't too happy about that. Anyway, I don't remember walking differently after the ESWT but I guess that is possible. Let me ask you this, though. Once the ESWT pain was gone and I starting walking normal again would the tingling not go away on its own...or could such a short amount of time of walking differently do permanent damage?
Thanks for your post. I appreciate the reply.

Sincerely,
Jen Ross

Re: Orbasone settings ??

BrianG on 8/29/01 at 09:38 (058342)

Hi Jen,

Do you happen to remember what the settings of the Orbasone were, when you had your treatments? I see some people getting low (16kv) and others up near 20kv.

Regards
BCG

Re: ESWT*** new take on an old thread/discussion

Dr. Zuckerman on 8/29/01 at 09:39 (058343)

Hi Jen,

It should go away yes. One of the interesting approaches to your surgery and one that did make sense to me was that an osteotomy of the heel bone was to straighten out your heel. The varus position of your heel is one biomechanical factor that can place pressure on the posterior tibial nerve.
and cause excessive pronation which will place tension on the plantar fasia

This is why one of the reason for the use of orthosis to control the abnormal pronation which stresses the pf.

I have found that your in some cases chronic pf with your foot structure can develop TTS symtoms

Re: Orbasone settings ??

Jen R on 8/29/01 at 10:14 (058345)

Brian,

No I don't remember offhand, but I'll check my records and get back to you.

Re: Orbasone settings ??

Jen R on 8/29/01 at 11:35 (058352)

Brain G

I believe that I received 3000 shocks at 15-18kv. As Dr. Z stated in a previous post, he starts at 12kv and works his way up. My first procedure was done after numbing the foot while my second treatment was without anesthetic.

Re: Orbasone settings ??

john h on 8/29/01 at 18:19 (058385)

my three treatment i think were from 16-18 on each foot. really never felt much of anything. feet were never sore and i had both feet done at the same time and drove back to baltimore and walked through 3 different airports on way home.

i think barbs were at 2.54 and judy's at 1.6. sissy girl voltages. barb talks big but she is into the surgery thing these days.

Re: Orbasone settings ??

Barbara TX on 8/30/01 at 10:40 (058450)

Sissy? I remember hearing Dr. Zuckerman tell me that he was glad I was there because he could finally 'open this thing all the way up' on my heel. I fell asleep during the procedure, and Roxane had to wake me up because I was drooling on the pillow. She gave me some kleenex that she said they kept right next to the Orbasone 'for a patient named John' who tended to weep uncontrollably when zapped. I wondered who that man could be. They told me that he was a military person, with the most dainty, pampered feet they have ever seen; he also slept in a cot. I remember laughing at that, because even I sleep directly on the floor, like a Spartan. B.