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how long should one wait before getting "zapped"?

Posted by elliott on 8/03/02 at 23:15 (091516)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11400896&dopt=Abstract

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Re: how long should one wait before getting "zapped"?

Dr. Zuckerman on 8/04/02 at 08:05 (091528)

I have read this article or one similiar. There are alot of opinions on this subject. Right now the time frame is six months. It is my opinion that each case is different and that the time can't be generalized.

Re: how long should one wait before getting "zapped"?

Ed Davis, DPM on 8/11/02 at 12:35 (092206)

Dr. Z:

I think I can read your mind on this one! The answer to this quest is going to evolve very rapidly over the next few years.
Ed

Re: how long should one wait before getting "zapped"?

elliott on 8/11/02 at 15:17 (092226)

While just about all of the ESWT studies used 6 months as the minimum for eligibility, I would like to suggest that maybe the minimum for a typical insurance-covered case should be more like 2 years. For example, there are loads of runners I know who struggled with PF for about 2 years before finally getting things under control through various conservative means. It's not that I'm advocating suffering for two years, but many seem to have cases that do go away in such a time frame.

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Re: how long should one wait before getting "zapped"?

Dr. Zuckerman on 8/11/02 at 17:12 (092239)

If we were only talking about animals that would make sense . I just don't see how we could make patients wait for any treatment. A study of patients already having plantar fasciitis duration two years could be done
There would be a riot if the insurance companies told the subscriber that they have to wait two years.

Re: OK, let's take the flipside of what you're saying

elliott on 8/11/02 at 21:35 (092255)

Within the first month of suffering PF, patient runs to doc and gets ESWT (why suffer longer than necessary; no real downside risk). Never first tries rest, stretching, NSAIDS, orthotics, splints, etc (why bother?), which everyone agrees cures 90% of patients. Those docs with ESWT machines (including, especially, the first few prescient ones who had the foresight to be at the forefront of ESWT), get rich, which is fine, but the rest of us get poor (not fine) since the high cost of high use of ESWT (remember, 2 million new cases a year) is merged into our insurance premiums.

---

Re: OK, let's take the flipside of what you're saying

Dr. Zuckerman on 8/12/02 at 02:09 (092272)

I don't understand this question. Why would anyone just run and get ESWT without any conservative treatment. There might be an indication for the patient who has had pf for one month, has tried nsaid, stretching ,splints but now is going forward with physical therapy for eight to twelve weeks.
That situation maybe just as effective if not more then the physical therapy and cost effective. Have you ever taken look at what physical therapy costs. Most people don't because its covered by their insurance.

Here is a project and research opportunity . Compare the cost analysis of the above situation . Just think if all the physical therapy was eliminated and ESWT was replaced with it. Now that will reduce YOUR insuracne premiums. We haven't even mentioned the lost of time from work and the lost of productivity that physical therapy created. Look at all the time the patients spend at the physical therapy session

Re: how much do I get paid to do the study? :-)

elliott on 8/12/02 at 08:13 (092279)

Why would anyone run to get ESWT? How many reasons do you want? They don't have faith that the other stuff will work. They know others who went through 4 pairs of useless orthotics. They want to get back to their sports as soon as possible. They have nothing to lose by getting it right away.

Once anything becomes a standard mode of treatment, there's always a push to overuse it.

PT for PF IMHO is way overblown. A pod combined with common sense home treatment is what one needs.

--

Re: how much do I get paid to do the study? :-)

john h on 8/14/02 at 11:03 (092447)

I think the quicker PF is resolved the better chance you will not become chronic so there would seem to be adequate reason to proceed with ESWT early on. I would guess I had spent over $3000 on treatments and devices before I ever got to ESWT. By so doing I think I increased my probablility that I would become a chronic case as I have.

Re: how much do I get paid to do the study? :-)

dave r on 8/14/02 at 11:07 (092448)

How right you are john! Once you hit that chronic stage where you and i are at you may be doomed to alot of pain and suffering for a long time. I too have spent at least that amount on pod's, orthodics, and tape. I wish that i would of had eswt along time ago!

Re: you make a good point

elliott on 8/14/02 at 13:19 (092469)

But then cost is not a side issue to be swept under the rug; it must be dealt with. (BTW, even ESWT proponents say to wait at least 6 months. According to Dr. Z and maybe you too, even that may be dangerous.) Multiply such a cost by the number of new treatments in all areas of modern medicine and then individual health premiums soon become unaffordable.

A lot of the cost of PF treatments is on the individual, so adding up total costs spent up till now may not entirely persuade an insurer. And if ESWT doesn't work, the insurer has to pay for this and all other treatments it covers (that's one reason why getting a handle on success and improvement rates is important, at least to me, although no one else here other than Pauline seems interested enough to inquire).

Also a cost consideration not to rush into ESWT is that 90% supposedly get better through conservative means; I know, not much comfort to those who don't. If criteria to detect more resistant cases up front could be developed, that would help a lot.

No one's stopping anyone from trying ESWT right away. If you feel it has merit, go for it. The question is and always has been who would foot the bill.

--

Re: you make a good point

dave r on 8/14/02 at 13:39 (092471)

i dont know about you but i have read many times that if a person has had pf for more than 6 months they have a big chance of haveing pf for a long time. Treating it early is key. We all know that. And we also know that most people probably closer to 80% will have there pf resolved in a short amount of time. Otherwise there wouldnt be a need for this board. I dont think that anyone is trying to promote their products. I admire all the doctors for their help. I would bet that it is very satisfying for them to be able to help so many people.At the least they are giving some of us some simple advise. its our choice. Seeing 5 or 6 different doctors over a number of years is very frustrating. Its nice to get a different perspective from everyone on this board

Re: I agree

elliott on 8/14/02 at 14:17 (092482)

But are you going to discuss cost or not?

Re: looking at all costs

Ed Davis, DPM on 8/17/02 at 14:27 (092747)

Payors need to consider all costs. Health insurers are focused on the costs of treatment but do not consider the cost of time loss (unless they are a worker's comp carrier) nor are the costs of lost productivity to the employer calculated. Treatments which allow patients to minimize days lost from work, I believe, will need to be looked on very favorably.

I can envision scenarios where ESWT is performed earlier than now indicated while realizing the potential for overutilization. If we start seeing ESWT done as a substitute for the comprehensive ( 3 tiered - biomechanics, inflammation, tissue quality) approach, the success rates for ESWT will plummett and the issue of recurrence will arise.
Ed

Re: looking at all costs

Dr. Zuckerman on 8/17/02 at 14:40 (092751)

What do we do if the tissue quality is poor at the three month or even two month period. Each and every patient will need to be evaluated.as individuals Time frames are important but the idea of having to wait a specific time frame expecially six months seem to me to not make sense as a doctor. As an insurance company maybe but as a doctor no. Patients should have a right to determine when and if they want any type of treatment. There are going to be patients that don't want steriod injections. There are going to be patients that don't won't wear orthosis,
and there are patients that don't want nsaid for medical reasons.

I really would like to see an objecttive way to determine tissue quality.
Do you have any help in this idea. Dr. Ed

Re: looking at all costs

Pauline on 8/17/02 at 14:59 (092756)

Dr. Z,
Interesting pros and cons I think. I don't know of another condition where there is a mandate that treatment can't be offered to a patient for a specific length of them like the 6 month period with ESWT.

Dr. Ed presents good arguements too.

Does anyone know of similar treatment protocol?

Re: looking at all costs

Ed Davis, DPM on 8/19/02 at 21:43 (092943)

Dr. Z:

I see where you are going with this. You are implying that PF does not need to be deemed 'intractable' before deciding on ESWT.

How would you view a patient with very problematic biomechanics that would benefit from ESWT, nevertheless, without adequate biomechanical treatment will suffer recurrences of PF? Is it really fair for third parties to bear the cost of repeated ESWT sessions when that individual is potentially refusing to treat the biomechanical cause of the problem? (I am being the devils advocat here).

One attractive feature of ESWT to patients is that it is a relatively passive modality, that is, it takes little effort on the part of the patient. Making changes in biomechanics can be a high effort, active participation activity -- orthotic use, changes in shoegear, acitvity modification, stretching, conditioning, etc. We may not always be doing people a favor by providing an easy 'out' that early use of ESWT may appear to provide.
Ed

Re: looking at all costs

Dr. Zuckerman on 8/20/02 at 03:25 (092963)

Sorry that isn't what I am saying. I will try again. With ESWT you don't have to deem the foot intractable. Intractable is defined as doing every treatment under the sun before you perform foot surgery.

I have many patients both surgical and ESWT that are post over twenty years surgical and post three year ESWT. None had orthosis.
None had re-occurrence ( they had no orthosis)

The patient with problematic biomechanics is very subjective. The biomechanical cause in my opinion may be a factor but in my opinion isn't the cause just a factor.

Yes I understand biomechanic, yes I use orthosis, But my experience and my reality is that use the use of orthosis routinely post surgery and post ESWT has no effect with re-occurrence. Just how I see.

Do you know of a double blind randon study showing the decrease in re-occurrence post surgical and post ESWT?

It is just amazing how many patients I see in my practice and in the practice of other doctors that had heel spur/pf had orthosis . Stopped wearing orthosis after no pain and haven't worn orthosis and now are pain free year down the road. I am talking five to ten year down the road

Re: how long should one wait before getting "zapped"?

Dr. Zuckerman on 8/04/02 at 08:05 (091528)

I have read this article or one similiar. There are alot of opinions on this subject. Right now the time frame is six months. It is my opinion that each case is different and that the time can't be generalized.

Re: how long should one wait before getting "zapped"?

Ed Davis, DPM on 8/11/02 at 12:35 (092206)

Dr. Z:

I think I can read your mind on this one! The answer to this quest is going to evolve very rapidly over the next few years.
Ed

Re: how long should one wait before getting "zapped"?

elliott on 8/11/02 at 15:17 (092226)

While just about all of the ESWT studies used 6 months as the minimum for eligibility, I would like to suggest that maybe the minimum for a typical insurance-covered case should be more like 2 years. For example, there are loads of runners I know who struggled with PF for about 2 years before finally getting things under control through various conservative means. It's not that I'm advocating suffering for two years, but many seem to have cases that do go away in such a time frame.

--

Re: how long should one wait before getting "zapped"?

Dr. Zuckerman on 8/11/02 at 17:12 (092239)

If we were only talking about animals that would make sense . I just don't see how we could make patients wait for any treatment. A study of patients already having plantar fasciitis duration two years could be done
There would be a riot if the insurance companies told the subscriber that they have to wait two years.

Re: OK, let's take the flipside of what you're saying

elliott on 8/11/02 at 21:35 (092255)

Within the first month of suffering PF, patient runs to doc and gets ESWT (why suffer longer than necessary; no real downside risk). Never first tries rest, stretching, NSAIDS, orthotics, splints, etc (why bother?), which everyone agrees cures 90% of patients. Those docs with ESWT machines (including, especially, the first few prescient ones who had the foresight to be at the forefront of ESWT), get rich, which is fine, but the rest of us get poor (not fine) since the high cost of high use of ESWT (remember, 2 million new cases a year) is merged into our insurance premiums.

---

Re: OK, let's take the flipside of what you're saying

Dr. Zuckerman on 8/12/02 at 02:09 (092272)

I don't understand this question. Why would anyone just run and get ESWT without any conservative treatment. There might be an indication for the patient who has had pf for one month, has tried nsaid, stretching ,splints but now is going forward with physical therapy for eight to twelve weeks.
That situation maybe just as effective if not more then the physical therapy and cost effective. Have you ever taken look at what physical therapy costs. Most people don't because its covered by their insurance.

Here is a project and research opportunity . Compare the cost analysis of the above situation . Just think if all the physical therapy was eliminated and ESWT was replaced with it. Now that will reduce YOUR insuracne premiums. We haven't even mentioned the lost of time from work and the lost of productivity that physical therapy created. Look at all the time the patients spend at the physical therapy session

Re: how much do I get paid to do the study? :-)

elliott on 8/12/02 at 08:13 (092279)

Why would anyone run to get ESWT? How many reasons do you want? They don't have faith that the other stuff will work. They know others who went through 4 pairs of useless orthotics. They want to get back to their sports as soon as possible. They have nothing to lose by getting it right away.

Once anything becomes a standard mode of treatment, there's always a push to overuse it.

PT for PF IMHO is way overblown. A pod combined with common sense home treatment is what one needs.

--

Re: how much do I get paid to do the study? :-)

john h on 8/14/02 at 11:03 (092447)

I think the quicker PF is resolved the better chance you will not become chronic so there would seem to be adequate reason to proceed with ESWT early on. I would guess I had spent over $3000 on treatments and devices before I ever got to ESWT. By so doing I think I increased my probablility that I would become a chronic case as I have.

Re: how much do I get paid to do the study? :-)

dave r on 8/14/02 at 11:07 (092448)

How right you are john! Once you hit that chronic stage where you and i are at you may be doomed to alot of pain and suffering for a long time. I too have spent at least that amount on pod's, orthodics, and tape. I wish that i would of had eswt along time ago!

Re: you make a good point

elliott on 8/14/02 at 13:19 (092469)

But then cost is not a side issue to be swept under the rug; it must be dealt with. (BTW, even ESWT proponents say to wait at least 6 months. According to Dr. Z and maybe you too, even that may be dangerous.) Multiply such a cost by the number of new treatments in all areas of modern medicine and then individual health premiums soon become unaffordable.

A lot of the cost of PF treatments is on the individual, so adding up total costs spent up till now may not entirely persuade an insurer. And if ESWT doesn't work, the insurer has to pay for this and all other treatments it covers (that's one reason why getting a handle on success and improvement rates is important, at least to me, although no one else here other than Pauline seems interested enough to inquire).

Also a cost consideration not to rush into ESWT is that 90% supposedly get better through conservative means; I know, not much comfort to those who don't. If criteria to detect more resistant cases up front could be developed, that would help a lot.

No one's stopping anyone from trying ESWT right away. If you feel it has merit, go for it. The question is and always has been who would foot the bill.

--

Re: you make a good point

dave r on 8/14/02 at 13:39 (092471)

i dont know about you but i have read many times that if a person has had pf for more than 6 months they have a big chance of haveing pf for a long time. Treating it early is key. We all know that. And we also know that most people probably closer to 80% will have there pf resolved in a short amount of time. Otherwise there wouldnt be a need for this board. I dont think that anyone is trying to promote their products. I admire all the doctors for their help. I would bet that it is very satisfying for them to be able to help so many people.At the least they are giving some of us some simple advise. its our choice. Seeing 5 or 6 different doctors over a number of years is very frustrating. Its nice to get a different perspective from everyone on this board

Re: I agree

elliott on 8/14/02 at 14:17 (092482)

But are you going to discuss cost or not?

Re: looking at all costs

Ed Davis, DPM on 8/17/02 at 14:27 (092747)

Payors need to consider all costs. Health insurers are focused on the costs of treatment but do not consider the cost of time loss (unless they are a worker's comp carrier) nor are the costs of lost productivity to the employer calculated. Treatments which allow patients to minimize days lost from work, I believe, will need to be looked on very favorably.

I can envision scenarios where ESWT is performed earlier than now indicated while realizing the potential for overutilization. If we start seeing ESWT done as a substitute for the comprehensive ( 3 tiered - biomechanics, inflammation, tissue quality) approach, the success rates for ESWT will plummett and the issue of recurrence will arise.
Ed

Re: looking at all costs

Dr. Zuckerman on 8/17/02 at 14:40 (092751)

What do we do if the tissue quality is poor at the three month or even two month period. Each and every patient will need to be evaluated.as individuals Time frames are important but the idea of having to wait a specific time frame expecially six months seem to me to not make sense as a doctor. As an insurance company maybe but as a doctor no. Patients should have a right to determine when and if they want any type of treatment. There are going to be patients that don't want steriod injections. There are going to be patients that don't won't wear orthosis,
and there are patients that don't want nsaid for medical reasons.

I really would like to see an objecttive way to determine tissue quality.
Do you have any help in this idea. Dr. Ed

Re: looking at all costs

Pauline on 8/17/02 at 14:59 (092756)

Dr. Z,
Interesting pros and cons I think. I don't know of another condition where there is a mandate that treatment can't be offered to a patient for a specific length of them like the 6 month period with ESWT.

Dr. Ed presents good arguements too.

Does anyone know of similar treatment protocol?

Re: looking at all costs

Ed Davis, DPM on 8/19/02 at 21:43 (092943)

Dr. Z:

I see where you are going with this. You are implying that PF does not need to be deemed 'intractable' before deciding on ESWT.

How would you view a patient with very problematic biomechanics that would benefit from ESWT, nevertheless, without adequate biomechanical treatment will suffer recurrences of PF? Is it really fair for third parties to bear the cost of repeated ESWT sessions when that individual is potentially refusing to treat the biomechanical cause of the problem? (I am being the devils advocat here).

One attractive feature of ESWT to patients is that it is a relatively passive modality, that is, it takes little effort on the part of the patient. Making changes in biomechanics can be a high effort, active participation activity -- orthotic use, changes in shoegear, acitvity modification, stretching, conditioning, etc. We may not always be doing people a favor by providing an easy 'out' that early use of ESWT may appear to provide.
Ed

Re: looking at all costs

Dr. Zuckerman on 8/20/02 at 03:25 (092963)

Sorry that isn't what I am saying. I will try again. With ESWT you don't have to deem the foot intractable. Intractable is defined as doing every treatment under the sun before you perform foot surgery.

I have many patients both surgical and ESWT that are post over twenty years surgical and post three year ESWT. None had orthosis.
None had re-occurrence ( they had no orthosis)

The patient with problematic biomechanics is very subjective. The biomechanical cause in my opinion may be a factor but in my opinion isn't the cause just a factor.

Yes I understand biomechanic, yes I use orthosis, But my experience and my reality is that use the use of orthosis routinely post surgery and post ESWT has no effect with re-occurrence. Just how I see.

Do you know of a double blind randon study showing the decrease in re-occurrence post surgical and post ESWT?

It is just amazing how many patients I see in my practice and in the practice of other doctors that had heel spur/pf had orthosis . Stopped wearing orthosis after no pain and haven't worn orthosis and now are pain free year down the road. I am talking five to ten year down the road