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This article was just published...ESWT

Posted by A Manoli MD on 9/18/02 at 20:03 (095657)

Australian researchers find no benefit in using extracorporeal shock wave
therapy (ESWT) for treatment of plantar fasciitis. According to the study in
the Sept. 18 issue of JAMA, they screened 178 patients and enrolled 166; 160
completed the 15-week protocol. Patients were randomly assigned to receive
either ESWT given weekly for three weeks or identical placebo. At six and 12
weeks, there were significant improvements in overall pain in both the
active group and placebo group. Similar improvements in both groups were
also observed for morning and activity pain, walking ability, Maryland Foot
Score, Problem Elicitation Technique, and SF-36. There were no statistically
significant differences in the degree of improvement between treatment
groups for any measured outcomes. 'We found no benefit of shock-wave therapy
over and above placebo,' said investigator Rachelle Buchbinder of the
Cabrini Medical Center in Malvern, Victoria. 'Many people don't need any
treatment for this condition other than time, as many improve spontaneously
over time,' Buchbinder said, noting that the condition resolves within a
year in more than 80% of patients. JAMA, Reuters Health Sept. 17, 2002
Source: JAMA. 2002;288:1364-1372
The abstract is at:
http://jama.ama-assn.org/issues/v288n11/abs/joc20248.html

i'm just the messenger, not the researcher !!!!!!

Re: This article was just published...ESWT

BrianG on 9/18/02 at 20:50 (095663)

Hi Doc,

Do you agree with the study?

BrianG

PS: There is a thread already going on the ESWT page.

Re: This article was just published...ESWT

Dr. Z on 9/18/02 at 22:09 (095676)

All the study showed is that ESWT treated patiens improved in 80% of the cases It is completey different then the double blind, randonized FDA study

Re: This article was just published...ESWT

BrianG on 9/19/02 at 14:19 (095732)

Hi Dr. Z,

I believe the article said that many people don't need the ESWT treatment, that 'the condition resolves itself within a year, in more than 80% of the patients'

BrianG

Re: To Dr. Manoli This article was just published...ESWT

Pauline on 9/19/02 at 15:39 (095740)

Dr. Manoli,
How do you reconcile the difference between the AMA ESWT report that you posted here and the FDA study presented at your Orthopedic meeting which carries Dr. Zingas's name on it?

Have you had an opportunity to talk to him about the study he did at Henry Ford?

Re: This article was just published...ESWT

Pauline on 9/19/02 at 15:46 (095741)

Am I misreading this or does this abstract say it too was 'A Double Blind Randonized study' after the word 'Design'?

This is from the link provided in the post by Dr. Manoli.

Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis

A Randomized Controlled Trial

Rachelle Buchbinder, MBBS, MSc; Ronnie Ptasznik, MBBS, FRANZCR; Jeanine Gordon, BAppSci; Joylene Buchanan, DipAppSci; Vasuki Prabaharan, BSc, MAppSci; Andrew Forbes, PhD

Context Extracorporeal shock wave therapy (ESWT) is increasingly used for plantar fasciitis, but limited evidence supports its use.

Objective To determine whether ultrasound-guided ESWT reduces pain and improves function in patients with plantar fasciitis.

Design Double-blind, randomized, placebo-controlled trial conducted between April 1999 and June 2001.

Setting Participants were recruited from the community-based referring physicians (primary care physicians, rheumatologists, orthopedic surgeons, and sports physicians) of a radiology group in Melbourne, Australia.

Re: This article was just published...ESWT

Ed Davis, DPM on 9/19/02 at 18:29 (095768)

The study aside, I have to question the author's statement that 'time' is somehow curative. That statement is not derived from the study. Plantar fasciitis can be debilitating so the statement that individuals can somehow carve a year of disability out of their lives to wait for resolution reveals what may be a disturbing bias on the part of the author.

Perhaps Dr. Z can shed some light on the disparity of results between studies. My feeling is that PF treatment usually does not involve 'stand alone' modalities irrespective of how good those modalities are. In other words, you cannot take an individual with faulty biomechanics which have not been addressed and expect ESWT alone to effect a long term cure. Most practitioners in the podiatric community are addressing the treatment triad-- inflammation, biomechanics and tissue quality -- all three. ESWT has provided a modality to directly effect tissue quality so its successful use is in part of a comprehensive approach that addresses all three parts of the triad.
Ed

Re: This article was just published...ESWT

Pauline on 9/19/02 at 19:34 (095774)

Yours, I think is a common sense approach to treating P.F.

Re: This article was just published...ESWT

Dr. Z on 9/19/02 at 21:10 (095782)

Good point., It is well know that plantar fasciitis can resolve itself without any expensive or extentive treatment with time

Re: This article was just published...ESWT

BGCPed on 9/19/02 at 21:55 (095784)

Dr Ed that reference to time heals is a double edged sword indeed. Yes many pf pt get better over time. IMHO the ones that do are the more accute/traumatic cases like injury, pregnancy, working on ladder or using shovel and so on.

I think the more common cases are of a biomechanical/footwear issue. I often tell a pt you dont have a foot problem you have a footwear problem. I also tel them I am putting them on a shoe diet that is much like a food diet in that the more you cheat the worse the outcome.

I think we can all agree that we see too many foot pain pt that just started a walking program and a month later they have symptoms. The first thing I do is ask to see a few pair of shoes they wear most often. This is a common response ' Oh its not the shoes, I have these $70 easy spirit walkers, they cant be the problem' They are in fact the problem they are nothing more than dress shoes with a rubber sole. many Rockport Walkers are junk also.

I will cease now so I dont get labeled a cynic.....thats my story and I am sticking to it

Re: The Treatment Triad

Julie on 9/20/02 at 01:42 (095790)

Ed

I agree about the inefficacy of stand-alone treatments, whatever they are, and am waiting for your Treatment Triad approach to the treatment of PF to be given a prominent, permanent home on heelspurs.com where everyone can read it as soon as they arrive.

The hit-and-miss approach to healing taken by so many is worrying. Almost daily, we see despairing posts from new people who have 'tried everything', when they obviously haven't 'tried everything', or if they have, the 'everything' hasn't been tried in a coherent way. Some never even see a podiatrist: instead they put their trust in what other posters have said. Sometimes this may promote their healing, but sometimes it may delay it.

In an ideal world, all podiatrists would be knowledgeable, experienced, skilled, caring and patient, and all patients with pathological foot conditions could be confident of getting good treatment. We know this isn't the case. But if the Treatment Triad approach (and your flow chart, when it's done) had a permanent place here, people would have a better idea what they were looking for, and what they should be able to expect of a foot doctor.

Re: The Treatment Triad

Sharon W on 9/20/02 at 06:44 (095800)

Julie, Dr. Ed,

I just wanted to say that I agree COMPLETELY with Julie's post, above, and with Dr. Ed's Treatment Triad. 'Trying everything' in a haphazard manner without wise professional direction is not a good strategy for healing.

Julie, that was very well said!

Sharon

Re: what you say makes a lot of sense, but...

elliott on 9/20/02 at 08:04 (095810)

then why did the FDA study and some others show such marked improvement (92% or whatever) addressing only one or even zero legs of the triad?

[[[[[[[

Re: The Treatment Triad

Julie on 9/20/02 at 08:16 (095814)

Thanks, Sharon.

Re: what you say makes a lot of sense, but...

Julie on 9/20/02 at 08:28 (095817)

I don't know, and I don't want to get involved in the argument about the validity of studies and statistics, which I know nothing about: my post to Ed was inspired by his, and really had little to do with this thread. But I'll hazard a guess that ESWT does address the tissue quality leg of the triad (and, possibly, the inflammation leg?)

And, as you said yourself in another post, there are many variables. Perhaps some of the people who got significantly better were already addressing the biomechanical leg with taping or well-made orthoses.

Just guessing.

Re: what you say makes a lot of sense, but...

Dr. Z on 9/21/02 at 08:25 (095893)

Here is my understanding of Dr. Ed's approach and mine. Dr. Ed does a fine job of organizing the approach . You have to treat just not one factor in the acute stages of plantar fasciitis. For example just stretching, just change shoes, just do physical Therapy. You need to addres all factors and determine which factor is the most important and what other factors are contributing to the problem. My own opinion is that the best way to cure pf is to treat the cause at the very early stages ie two weeks. The longer you wait the great the chance it will become chronic.
Does everyone in my opinion need orthosis No . Does everyone need steriod injectins. No. Does everyone have to modify or stop some current activity YES YES YES

Re: This article was just published...ESWT

Ed Davis, DPM on 9/21/02 at 10:06 (095898)

Excellent observations BG! By the way, are you finding that shoe recommendations are getting a bit more tricky in recent years? I have patients coming in with comments like... ' you told my friend to get a New Balance running shoe but I got these and my feet are killing me...' That person is wearing the bottom line New Balance junker plus that was on sale for $29.95 at the local big sporting goods chain -will mention no names).
I then have to explain that only certain NB models are good since the company decided they need to compete with Nike and Reebok on low end junk they can sell too the big chain stores. Similar problems with Rockport, Munro and others whom we wish we could always recommend with confidence.
Ed

Re: need to look more closely at variables

Ed Davis, DPM on 9/21/02 at 10:13 (095899)

Elliott:

My dilemna is that I just don't have the time to go beyond the abstracts of those articles and sit down to carefully study the design of the 'experiments.' It would be hard to believe that some would be able to make patients enough of guinea pigs to ensure they do nothing for their PF but get ESWT, that is, adequately control the other variables. Most informed patients would at least make some attempt at other treatment be it stretching, acitvity/shoegear/lifestyle modifications.
Ed

Re: need to look more closely at variables

elliott on 9/22/02 at 21:40 (095983)

But Dr. Ed, according to Dr. Z in a recent post on the ESWT board,

'The AMA study allowed patients to contiune [sic] with orthosis, pain meds and orthosis [two pair? :-)]. There was complete discontinuation of any type of treatment post FDA dornier study'.

Dr. Z clearly views the FDA study as one of the better medical studies conducted by homo sapiens, and acccording to his info that study did not allow concurrent treatments of any sort, and yet ended up with fabulous results. Sure, people can cheat, but if they did on that study they certainly did on others.

[[[[

Re: need to look more closely at variables

Dr. Z on 9/23/02 at 20:03 (096044)

That what the studies reports.

Re: This article was just published...ESWT

BrianG on 9/18/02 at 20:50 (095663)

Hi Doc,

Do you agree with the study?

BrianG

PS: There is a thread already going on the ESWT page.

Re: This article was just published...ESWT

Dr. Z on 9/18/02 at 22:09 (095676)

All the study showed is that ESWT treated patiens improved in 80% of the cases It is completey different then the double blind, randonized FDA study

Re: This article was just published...ESWT

BrianG on 9/19/02 at 14:19 (095732)

Hi Dr. Z,

I believe the article said that many people don't need the ESWT treatment, that 'the condition resolves itself within a year, in more than 80% of the patients'

BrianG

Re: To Dr. Manoli This article was just published...ESWT

Pauline on 9/19/02 at 15:39 (095740)

Dr. Manoli,
How do you reconcile the difference between the AMA ESWT report that you posted here and the FDA study presented at your Orthopedic meeting which carries Dr. Zingas's name on it?

Have you had an opportunity to talk to him about the study he did at Henry Ford?

Re: This article was just published...ESWT

Pauline on 9/19/02 at 15:46 (095741)

Am I misreading this or does this abstract say it too was 'A Double Blind Randonized study' after the word 'Design'?

This is from the link provided in the post by Dr. Manoli.

Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis

A Randomized Controlled Trial

Rachelle Buchbinder, MBBS, MSc; Ronnie Ptasznik, MBBS, FRANZCR; Jeanine Gordon, BAppSci; Joylene Buchanan, DipAppSci; Vasuki Prabaharan, BSc, MAppSci; Andrew Forbes, PhD

Context Extracorporeal shock wave therapy (ESWT) is increasingly used for plantar fasciitis, but limited evidence supports its use.

Objective To determine whether ultrasound-guided ESWT reduces pain and improves function in patients with plantar fasciitis.

Design Double-blind, randomized, placebo-controlled trial conducted between April 1999 and June 2001.

Setting Participants were recruited from the community-based referring physicians (primary care physicians, rheumatologists, orthopedic surgeons, and sports physicians) of a radiology group in Melbourne, Australia.

Re: This article was just published...ESWT

Ed Davis, DPM on 9/19/02 at 18:29 (095768)

The study aside, I have to question the author's statement that 'time' is somehow curative. That statement is not derived from the study. Plantar fasciitis can be debilitating so the statement that individuals can somehow carve a year of disability out of their lives to wait for resolution reveals what may be a disturbing bias on the part of the author.

Perhaps Dr. Z can shed some light on the disparity of results between studies. My feeling is that PF treatment usually does not involve 'stand alone' modalities irrespective of how good those modalities are. In other words, you cannot take an individual with faulty biomechanics which have not been addressed and expect ESWT alone to effect a long term cure. Most practitioners in the podiatric community are addressing the treatment triad-- inflammation, biomechanics and tissue quality -- all three. ESWT has provided a modality to directly effect tissue quality so its successful use is in part of a comprehensive approach that addresses all three parts of the triad.
Ed

Re: This article was just published...ESWT

Pauline on 9/19/02 at 19:34 (095774)

Yours, I think is a common sense approach to treating P.F.

Re: This article was just published...ESWT

Dr. Z on 9/19/02 at 21:10 (095782)

Good point., It is well know that plantar fasciitis can resolve itself without any expensive or extentive treatment with time

Re: This article was just published...ESWT

BGCPed on 9/19/02 at 21:55 (095784)

Dr Ed that reference to time heals is a double edged sword indeed. Yes many pf pt get better over time. IMHO the ones that do are the more accute/traumatic cases like injury, pregnancy, working on ladder or using shovel and so on.

I think the more common cases are of a biomechanical/footwear issue. I often tell a pt you dont have a foot problem you have a footwear problem. I also tel them I am putting them on a shoe diet that is much like a food diet in that the more you cheat the worse the outcome.

I think we can all agree that we see too many foot pain pt that just started a walking program and a month later they have symptoms. The first thing I do is ask to see a few pair of shoes they wear most often. This is a common response ' Oh its not the shoes, I have these $70 easy spirit walkers, they cant be the problem' They are in fact the problem they are nothing more than dress shoes with a rubber sole. many Rockport Walkers are junk also.

I will cease now so I dont get labeled a cynic.....thats my story and I am sticking to it

Re: The Treatment Triad

Julie on 9/20/02 at 01:42 (095790)

Ed

I agree about the inefficacy of stand-alone treatments, whatever they are, and am waiting for your Treatment Triad approach to the treatment of PF to be given a prominent, permanent home on heelspurs.com where everyone can read it as soon as they arrive.

The hit-and-miss approach to healing taken by so many is worrying. Almost daily, we see despairing posts from new people who have 'tried everything', when they obviously haven't 'tried everything', or if they have, the 'everything' hasn't been tried in a coherent way. Some never even see a podiatrist: instead they put their trust in what other posters have said. Sometimes this may promote their healing, but sometimes it may delay it.

In an ideal world, all podiatrists would be knowledgeable, experienced, skilled, caring and patient, and all patients with pathological foot conditions could be confident of getting good treatment. We know this isn't the case. But if the Treatment Triad approach (and your flow chart, when it's done) had a permanent place here, people would have a better idea what they were looking for, and what they should be able to expect of a foot doctor.

Re: The Treatment Triad

Sharon W on 9/20/02 at 06:44 (095800)

Julie, Dr. Ed,

I just wanted to say that I agree COMPLETELY with Julie's post, above, and with Dr. Ed's Treatment Triad. 'Trying everything' in a haphazard manner without wise professional direction is not a good strategy for healing.

Julie, that was very well said!

Sharon

Re: what you say makes a lot of sense, but...

elliott on 9/20/02 at 08:04 (095810)

then why did the FDA study and some others show such marked improvement (92% or whatever) addressing only one or even zero legs of the triad?

[[[[[[[

Re: The Treatment Triad

Julie on 9/20/02 at 08:16 (095814)

Thanks, Sharon.

Re: what you say makes a lot of sense, but...

Julie on 9/20/02 at 08:28 (095817)

I don't know, and I don't want to get involved in the argument about the validity of studies and statistics, which I know nothing about: my post to Ed was inspired by his, and really had little to do with this thread. But I'll hazard a guess that ESWT does address the tissue quality leg of the triad (and, possibly, the inflammation leg?)

And, as you said yourself in another post, there are many variables. Perhaps some of the people who got significantly better were already addressing the biomechanical leg with taping or well-made orthoses.

Just guessing.

Re: what you say makes a lot of sense, but...

Dr. Z on 9/21/02 at 08:25 (095893)

Here is my understanding of Dr. Ed's approach and mine. Dr. Ed does a fine job of organizing the approach . You have to treat just not one factor in the acute stages of plantar fasciitis. For example just stretching, just change shoes, just do physical Therapy. You need to addres all factors and determine which factor is the most important and what other factors are contributing to the problem. My own opinion is that the best way to cure pf is to treat the cause at the very early stages ie two weeks. The longer you wait the great the chance it will become chronic.
Does everyone in my opinion need orthosis No . Does everyone need steriod injectins. No. Does everyone have to modify or stop some current activity YES YES YES

Re: This article was just published...ESWT

Ed Davis, DPM on 9/21/02 at 10:06 (095898)

Excellent observations BG! By the way, are you finding that shoe recommendations are getting a bit more tricky in recent years? I have patients coming in with comments like... ' you told my friend to get a New Balance running shoe but I got these and my feet are killing me...' That person is wearing the bottom line New Balance junker plus that was on sale for $29.95 at the local big sporting goods chain -will mention no names).
I then have to explain that only certain NB models are good since the company decided they need to compete with Nike and Reebok on low end junk they can sell too the big chain stores. Similar problems with Rockport, Munro and others whom we wish we could always recommend with confidence.
Ed

Re: need to look more closely at variables

Ed Davis, DPM on 9/21/02 at 10:13 (095899)

Elliott:

My dilemna is that I just don't have the time to go beyond the abstracts of those articles and sit down to carefully study the design of the 'experiments.' It would be hard to believe that some would be able to make patients enough of guinea pigs to ensure they do nothing for their PF but get ESWT, that is, adequately control the other variables. Most informed patients would at least make some attempt at other treatment be it stretching, acitvity/shoegear/lifestyle modifications.
Ed

Re: need to look more closely at variables

elliott on 9/22/02 at 21:40 (095983)

But Dr. Ed, according to Dr. Z in a recent post on the ESWT board,

'The AMA study allowed patients to contiune [sic] with orthosis, pain meds and orthosis [two pair? :-)]. There was complete discontinuation of any type of treatment post FDA dornier study'.

Dr. Z clearly views the FDA study as one of the better medical studies conducted by homo sapiens, and acccording to his info that study did not allow concurrent treatments of any sort, and yet ended up with fabulous results. Sure, people can cheat, but if they did on that study they certainly did on others.

[[[[

Re: need to look more closely at variables

Dr. Z on 9/23/02 at 20:03 (096044)

That what the studies reports.