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What is ESWT role in treating P.F?

Posted by Pauline on 5/13/03 at 12:43 (118540)

I'm starting to believe that the dominate role ESWT plays in treating P.F. patients is simply to keep them off the surgeons table for a longer period of time while providing income for the doctors. After Mohez's post about all the ESWT treatments he had, it sure doesn't appear to be the magic bullet that any of us hoped for or that the FDA reports displayed.

Frankly I was expecting more positive results, but seem to be reading fewer and fewer on this board.

What happened to all the one treatment cures and improvements that were in those reports?

Re: What is ESWT role in treating P.F?

SteveG on 5/13/03 at 14:02 (118551)

Interesting question, Pauline. Since I don't think the studies are fraudulent or deceptive, my guess is that the cases on this board are truly difficult and often have pain and injury that extends beyond the insertion point. That coupled with the fact that, as is often pointed out, the cases that get better often don't hang around the boards - they are out walking the dog, at the mall, etc. Having lurked here for over a year I notice that certain people (e.g., Monte) don't post nearly as much as they used to - my guess is because he is not in as much pain as he was prior to the treatment.

In fact, if you spend a lot of time hanging out on this board, you most likely have a pretty severe case. My wife had a bout with PF about a year ago and her symptoms were classic - pain at the insertion point, first step pain. She did some stretching and bought some over the counter inserts and within a month she was cured. If her pain had continued for 6 months I am sure that one ESWT treatment would have done the trick. Her case is not even in the same league with mine. I used to joke that I was about to throw in the towel and become a morphine addict. There have been periods when I could not stand for more than a minute or two - and getting ready for work in the morning was nothing short of an ordeal. It is no surprise to me that cases like mine, John h's, Monte's, Rachael T's, required more than one treatment - their experiences and symptoms are qualitatively different then my wife's and the majority of PF sufferers.

This statement seems false or misguided -

I'm starting to believe that the dominate role ESWT plays in treating P.F. patients is simply to keep them off the surgeons table for a longer period of time while providing income for the doctors.

This implies, I think, that ESWT is just a short term palliative treatment that enables pods to make quick money without all the hassle of getting on a gown and cutting someone's foot -- and eventually they are going to have to operate on Monte and me anyhow. If I used to contemplate surgery, I don't now, and this is because I am about 50% better than I was prior to the treatment. Now I can do the dishes, sweep the floors, and make the bed without grinding my teeth and looking frantic. Those of us who have suffered a lot can appreciate what a boon this is to me. I received my second treatment about a week ago and I am hoping for even more improvement.

This has been a bit long winded, but to sum up I think that this board is a) composed of difficult cases and b) it cannot be taken as a representative sample because many of the successful treatments move on with their lives.

Re: What is ESWT role in treating P.F?

Dr. Z on 5/13/03 at 14:04 (118552)

What I am finding is that the cure rate is exactly what the FDA studies showed after a one year follow. I just saw another group of patients post six months ESWT with the dornier Epos that have no pain. I can understand your feelings when only viewing this board but this board isn't the typical plantar fascia population that has pf or undergoes ESWT. For example BrianG who I have twice performed ESWT had foot surgery on his foot. That isn't the typical patient that has ESWT done. ESWT on many patient from this board is the only hope for this patient

Re: What is ESWT role in treating P.F?

dave r on 5/13/03 at 14:13 (118555)

I would bet that if a person is active in there treatment against pf turning chronic that the majority of them would be cured.If a person has pf longer than 6 months then they are probably doomed for a long battle with pf. I would also bet that if they are still able to stretch properly then eswt would be a great tool for them to try! i will say this;my general practioner talked me out of getting pf surgery for 5 years! He had seen many patients with pf and surgery. Many of his patients were in really bad shape. I spoke with two of them that had surgery and they are in worse shape. For me eswt didnt help. But i had it done 6 years into my recovery and by that time my achilles and calf muscle have shrunk done to nothing. I can no longer bend my foot past 45 degress. I finally went under the knife for my pf and now i can say that my pf pain is gone. I still have achilles pain but again i have had this all along. To make a long story short i need to have my achilles lengthened somehow. I am pursueing that now. If i would of had eswt or traditional surgery sooner i strongly believe that i would be in much better shape. But i was deathly afraid of being worse off since i read so many horror stories.......

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/13/03 at 15:15 (118567)

Pauline:

Keep in mind that surgery probably is successful more than half of the time and that few surgical success cases post on this board.

If ESWT is successful 85% of the time, I would expect the 15% who have not been cured to keep looking for a cure and some will make their way to this board. Many more post will come from the 15% than the 85%. One of my earliest ESWT successes was a patient with a 9 year history of intractable PF. She was informed by 4 doctors that surgery was the only thing left. I sent her to the Sonorex treatment center in Vancouver for Sonocur treatments in July 2002. I did not see her again until the end of November 2002. She informed me that she had 4 rounds of ESWT (each round has 3 applications). Each 'round' costs $750 Canadian or about $530 US so 4 times $530 is $2200 --- much less than the cost of surgery, not to mention time loss issues. That patient had a total cure by the end of November and was ecstatic. I asked her to write a reference letter and asked her to post on this website. She did neither. The take home lesson here is that posters here do not repesent a normal cross section of the population of PF cases being treated.
Ed

Re: What is ESWT role in treating P.F?

elliott on 5/13/03 at 15:32 (118570)

Pauline, I have another theory, not quite as pessimistic as yours, namely that for the most part (other than the occasional miracle story), ESWT, or perhaps the Dornier in particular, simply speeds up the healing process for those who eventually were going to get healed anyway. While of course I don't have proof of this, I don't think it would be inconsistent with the FDA study either.

[]

Re: What is ESWT role in treating P.F?

elliott on 5/13/03 at 15:42 (118573)

Dr. Z, if you like, throw out the cases who didn't have surgery or extreme accompanying complications. You're telling me your 'success' rate has been around 94%? I can recall far too many regulars on these boards who came to you early on for treatment and did not have success. At the success rates quoted, we'd rarely see a failure.

Are there any other exclusionary criteria besides surgery likely to result in far lower success rates you'd specifically like to list, e.g., length/severity of the problem, accompanying injuries, bone structure, etc.?

Also, are you keeping track of the success rates among the post-op or accompanying-complications (by type) crowd? If the success rates for these crowds are rather low, perhaps the patient and even the insurer should be aware of that beforehand.

[]

Re: What is ESWT role in treating P.F?

BrianG on 5/13/03 at 17:39 (118595)

Personally, I'd like to see the FDA follow up their original trials with some new ones. This time I'd like them to only treat chronic cases, at least 5 years old, and also include cases that had failed surgeries. We know the OssaTron and Dornier are safe for patients who have had PF for 6-12 months, and who have tried a couple things to cure the PF. I just have to wonder if the FDA would be recommending 1, or 2 treatments, or would it be much higher, like 6 to 8 ?????

I don't think anyone would look forward to all the additional treatments, but wouldn't it be better for the patient, to know just what to expect? I'm beginning to think that 1 or 2 treatments will not do the trick, but no one really knows for sure. By performing these additional trials, patients like myself may continue to find ways to get additional treatments, rather than just stopping after 2, if I'm not cured.

Just a thought
BrianG

Re: What is ESWT role in treating P.F?

Dr. Z on 5/13/03 at 17:59 (118599)

I will be putting together a paper in the future. I will try to put together an exact criteria that was used by the FDA.

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/13/03 at 18:18 (118603)

Brian:
Limiting the number of treatment to two is problematic. I have had a number of patients with severe cases, as the one mentioned above, who have needed more treatment and achieved success. There is , basically,. a backlog of cases in need of treatment and, as such, a number of patients needing treatment that is more intensive than the 'average' case.
Ed

Re: What is ESWT role in treating P.F?

Bev on 5/13/03 at 18:27 (118607)

Steve,
You are hoping to be able to be able to get back to doing things again after your second ESWT , I am hoping to be able to go back to work after my first ESWT whenever I do have it. Workmans comp. would like for me to go back to work too :D However I am not able to even do household chores now -- let-a-lone go out in the public to work. I am hoping after ESWT I will be able to get to a lower pain level to do something -- is there hope out there for us :-/ Pauline makes it sound so very hopeless:((

Re: What is ESWT role in treating P.F?

Bev on 5/13/03 at 18:40 (118611)

Dr. Z,
So you are telling us that there are many ESWT success stories out there - we just are not aware of them in our little world here :-/ They get PF, get treated, and go on their happy ways, right? Do you think there are more 'cures' with surgery or ESWT ? What has the highest success rate? If I did not have to wait to jump through all of these hoops (jump was the wrong word) with workmans comp, I would have gone and had ESWT ages ago and got this done and over with , but I have to wait for them to make up their minds as to what to do :(

Re: What is ESWT role in treating P.F?

Pauline on 5/13/03 at 18:56 (118613)

Elliott,
Your theory is very interesting and something that I think Rompe may have touched on briefly in one of his studies. I think it certainly has merit.

If ESWT is going to give a patient their best shot for a cure I think the waiting period needs to be shortened to less than 6 months. It probably should be jumped on ASAP.

Re: What is ESWT role in treating P.F?

Pauline on 5/13/03 at 18:57 (118614)

Brian,
I like your idea.

Re: What is ESWT role in treating P.F?

Dr. Z on 5/13/03 at 20:21 (118620)

I agree that time shouldn't be the end all for when to perform ESWT IF there is inflamation and increase thickness then ESWT should be considered.

Re: What is ESWT role in treating P.F?

elliott on 5/14/03 at 00:13 (118648)

Pauline and Dr. Z, regarding shortening the time before getting ESWT, you can't have it both ways: one of the shortcomings frequently pointed out (by the docs on this board as well) regarding the JAMA study (which found no difference between the treatment and control groups) is that it allowed shorter duration of symptoms before ESWT. If getting to it early is key, then why was no difference between the groups found? If because of other weaknesses in the study, then this was not one of them.

Furthermore, the jury is still out on when is the earliest ideal time to administer ESWT. Check out this excerpt from the JAMA study quoting other authors:

'Helbig et al43 have suggested that patients with chronic symptoms are more likely to have a positive effect from ESWT, since in their study longer duration of symptoms correlated with greater success of therapy. They postulated that this difference in response is related to fragmentation of the relatively avascular, sclerotic, biomechanically abnormal reparative tissue, which encourages more effective healing in those with chronic symptoms, whereas there is not the degree of interstitial tissue change in acute disease that is conducive to the effects of shock waves. On the other hand, a recent study by Maier et al44 found that the presence of calcaneal bone marrow edema on magnetic resonance imaging was highly predictive of satisfactory outcome, suggesting that greater inflammation and vascularity may be more responsive to the effects of ESWT. The latter view is supported by further analyses from the trial by Ogden et al,36 which showed that a shorter duration of symptoms was significantly associated with success of therapy (P = .005).'

It is also fair to point out that, especially given the current ambiguity, early use of ESWT at its current price (at least when that bill is footed by everyone paying premiums) for an ailment for which around 95% get better without it may well be an unwise allotment of health care dollars; some other strategy may be far more cost effective.

[]

Re: A question for Dr. Davis

JenL on 5/14/03 at 10:11 (118675)

Dr. Ed Davis,

You mentioned in above posts that severe cases need treatments in more intensive way. I think we all agree. The case you gave made me think of this: which of the low-energy or high-energy treatment should be preferred in difficult cases. Why did you send that patient of 9 yrs history to Sonocur treatment of low energy in Canada where she received 12 treatments in 4 sessions? Was it only because of the cost? I know for $2200 she would probably be able to get one of high energy ESWT here in the states, but not two. But if we put the cost issue aside, do you think generally a higher of number of low energy ESWT is more effective in treating difficult PF than a lower of number of high energy ESWT? Or was it because that patient's condition was not typical to be treated with ESWT in accordance with FDA' rules?

Thanks for your insight.

Jen

Re: A question for Dr. Davis

Ed Davis, DPM on 5/14/03 at 15:23 (118745)

Jen:
There is insufficient evidence to assert that high energy ESWT is better than low energy ESWT or vice versa. I am sufficiently comfortable with both to use and recommend either protocol.

The particular patient I mentioned would have probably needed at least two or three high energy applications and the only machine we had available in July 2002 in my area was Ossatron. Ossatron works but it is an expensive machine to own and operate and that patient had no coverage for ESWT. I
referred her to Sonorex largely for financial reasons.
Ed

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/14/03 at 15:26 (118746)

Brian:
I am all for continued studies but have to clench my teeth when turning the FDA loose with the studies as the degree of politicization of results does not always turn out in the best interest of the public, in my opinion.
Ed

Re: What is ESWT role in treating P.F?

BrianG on 5/14/03 at 22:19 (118787)

Well, I don't see any other professional groups stepping up to the plate. I only mentioned the FDA, as they have already done the trials, and would most likely be the quickest to get a new study off the ground.

B

Re: What is ESWT role in treating P.F?

john h on 5/15/03 at 09:50 (118827)

Sometimes, after all else has failed and you are in pain you just go for it and forget all the studies and statistics. In particular if it is a procedure that is unlikely to produce any serious side effects. I read so many stats and studies on ESWT that I could find what ever I wanted to find in the results. ESWT helped me it did not cure me. I am glad I did it and have not ruled out another treatment. As a PF patient I recommed it. I think there was about 4 months between my first and second treatments (both feet).

Re: What is ESWT role in treating P.F?

Scott D. on 5/15/03 at 11:10 (118845)

Brian,

I think that as time goes on you will see more and more papers published in scientific journals, with results from sites in the US. In order to write these papers, the authors need a sufficient number of treated patients as well as the follow-up time. The EPOS has only been out in the US for about a year now, so the papers will soon be seen. I know one of our docs is finishing one up now. You have to remember that patients for an FDA approval study are really cherry-picked to include those who have a good chance of meeting the objectives of the company seeking approval. The 'cure' rates in those studies will almost always be higher than when we are treating the general population. That said, our 6 month success rate is at about 80%! I also know that the 12 month rate will be improved from that number. Is ESWT a miracle that will guarantee a cure for 100% of the patients treated? Of course not! Does it significantly help the vast majority of those treated? Absolutely!

Re: What is ESWT role in treating P.F?

Dr. Z on 5/15/03 at 20:33 (118923)

When I say shorten the time for ESWT treatment I don't mean six weeks as was the criteria with some patients. It should be after a period of conversative treatment Six months of pain is really a very long time.

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/15/03 at 21:46 (118924)

Brian:
Take a look at the ISMST -- International Society for Musculoskeletal Shockwave Therapy -- they present papers every year. I think that the impetus is to study ESWT for tendinopathies in the body other than the plantar fascia. Considering the scores of papers out there plus years of successful experieince with ESWT for PF, that information is old hat. There are few treatments in which every study done has reached a virtually the same conclusion (except for the discredited Buchbinder study). The evidence for ESWT is stronger than for orthotics and for surgery. Studying something again and again sounds good but it is someone's money that is being spent to do so. The collective experiences of the numerous providers offering ESWT offers significantly greater numbers of patients than all of the studies combined and is largely positive -- I know of no provider who has done any appreciable numbers of ESWT who has had a negative experience.
Ed

Re: What is ESWT role in treating P.F?

elliott on 5/16/03 at 08:58 (118954)

Dr Z, is it just coincidence that you always seem to take the point of view that conveniently will generate more profits for you? My pod in Baltimore, who made my orthotics, firmly believes that 95% (or did he say 99%) of the people who walk into his office with PF will be cured by conservative means, and that only the most severe and recalcitrant cases should be relegated to ESWT. This even though he himself is trained to use and does use the Dornier Epos:

http://www.baltimoreheelpaincenter.com/

I sure hope the difference between him and you is not simply that he does not own the machine (I think the hospital does) and you do; I want to have more faith in doctors' motives than that.

I can't tell you how many people I know personally who had PF for quite some time but got rid of it or managed it through conservative means--a personal friend of mine (orthotics), the neighbor across the street (night splint), at least 4 runners I can think of right now (various combos). Some of these had very severe cases. My own wife has had it for well over 6 months, but she's making slow progress with rest, a change of shoes, heel insert and a night splint (under the care of above-mentioned pod, who interestingly even told my wife it was too early to try orthotics even though she came to him with the intent of being fitted for them). All these people would have gone to you using your criteria, and of course would have been included in your ultimate success figures.

No one likes pain, but that doesn't mean insurance should foot the bill right away. As I said, the jury is still out on how early ESWT is warranted, but even many of its proponents think the 6 months wise. There is a long batch of research on PF, and so far the consensus is that 6 months is about right as a minimum. That's about what one might need, if not much more, to try the gamut of conservative means, which includes rest, rest, rest, and more rest for that slow-healing PF. I might add that not having the minimum also encourages people not to try things they find nuisances, such as night splints, and even orthotics.

Every time I bring this issue up here, like clockwork there is a person who always posts the same predictable, irrelevant line that you can find stats for anything and since ESWT is safe you have nothing to lose by trying it (other than $2000). That is not the issue. The issue is who pays for it. You want it right away? Gezuntehait, it's fine with me, really, but until there is very clear evidence why it must be done right away or the price comes way down, don't make me and others pay for it in our premiums or other out-of-pocket insurance expenses; pay for it yourself.

[]

Re: What is ESWT role in treating P.F?

Dr. Z on 5/16/03 at 10:52 (118970)

I did a survey on Wednesday at a lecture asking how many people get better with conservative non-surgical treatment for PF. We asked each to raise his hand as we shouted out 50% 60% 70% etc each doctor had one had a different opinion.

ESWT is an elective optional procedure that PATIENTS have a choice to use. Insurance can determine if they want to pay for this elective procedure. Insurance have no obligation to pay for ESWT. It is an elective procedure. but go tell patients that are in real pain.
By the way there are over 70 patients that use the machine . You sound like you think I over use the machine.

The majority of my ESWT patients are referred by doctor, patients that are in severe chronic pain and have taken the mulitple doctor conservative routine.
IF you wanted and needed ESWT you would have a choice to either receive the treatment, have foot surgery, try to live out the pain in hopes that it gets better. seek out other doctor, treatments or pay for it. You have options. IF you were on an insurance comittee you would be entitled to your opinion and the patient would be entitled to pay for the treatment and not have their insurance criteria.

By the way 99.9 o% of my patients who undergo ESWT had had the problem for much longer then the typical six months.

Re: What is ESWT role in treating P.F?

Dr. Z on 5/16/03 at 10:54 (118971)

PS: I think I trained your podiatrist on the Dornier. I did a training for podiatrist in VA and Maryland last year.

Re: What is ESWT role in treating P.F?

elliott on 5/16/03 at 12:46 (118991)

Very scientific survey, I must say.

I do appreciate your acknowledging that ESWT is elective and insurance companies can decide as to coverage, in contrast to oft-repeated previous comments suggesting that everything in the world would be right if only those bad insurance companies would cover it.

I never said you overuse the machine, rather that you are in favor of early use without clear basis. I don't doubt at all that as one of the first to get such a device, you are seeing patients with serious prolonged cases. Can't argue with 99.9% longer than 6 months; hope it stays that way until evidence clearly suggests otherwise.

[]

Re: What is ESWT role in treating P.F?

Dr. Z on 5/16/03 at 15:20 (119025)

Try telling a patient in severe pain that it is elective and that insurance considers this elective optional procedure. By the way there are patients that have had ten or more conservative treatment with ONLY four months of heel pain that in my opinion and the patients request have undergone ESWT with total 100% relief. Not many but it exists

Re: At what point should we call it quits?

BrianG on 5/16/03 at 19:36 (119045)

I wasn't thinking about the Buchbinder study, but more like how many doctors are actually thinking (and informing their patients) that it may take numerous ESWT treatments to get positive results for chronic patients. If anyone in this country is thinking along those lines, they have been pretty quiet about it. The FDA did their one treatment, and most people think this is the 'gold standard'. A few doctors offer a second treatment if needed. Once that second treatment is completed, from what I can see, the patient is not encouraged to get any more treatments. Is this the message we want to be passng on to everyone that has not recvovered after 2 treatments?

I think a perfect example is Mohez, who on his own, went out and continued to get additional treatments, until he was cured. In all the reading I've done, I don't think I've read about anyone who has been advised to continue additional treatments. Unless a group steps up, who has the backing and authority, to suggest numerous treatments, 1 or 2 treatments will continue to be the 'gold standard'.

Is this fair, or is everyone afraid of the high cost of healing, especially trying to convince the insurance companies that 1 or 2 treatments may not be enough? How much is too much, or not enough ?????????

BrianG

Re: At what point should we call it quits?

Ed Davis, DPM on 5/16/03 at 21:13 (119055)

Brian:
One reason this is even an issue is that our 'system' has so badly inflated the cost of this modality.
Ed

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/17/03 at 01:00 (119072)

Elliott:
Tissue quality is probably the main reason why PF becomes recalcitrant. If we eventually determine a reliable means to measure tissue quality, perhaps thickness of the plantar fascia, then a more productive criterion may exist than the 'time' issue. I think that we need a formula that takes body weight, age, occupation and possibly avocation into consideration since thickness of the fascia is relative to those factors.
Ed

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/17/03 at 01:04 (119073)

Dr. Z:

We get into a similar discussion with surgery. I think that we are more likely to recommend surgery to a patient with recalcitrant PF who has made little or no progress with conservative treatment after 4 months as opposed
to an individual who is 8 months out but making slow but steady progress.
Ed

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/17/03 at 01:13 (119074)

Elliott:
If asked to give success rates for ESWT, those rates would not reflect ESWT alone but would reflect the entire gamut of treatment performed in conjunction with ESWT, and, as such, would lead to fairly high percentages.
One dilemna can be different inclusion criteria. I generally treat PF conservatively but aggressively and view ESWT as a component of the treatment plan as opposed to an isolated treatment. As such, I would expect success rates from those such as myself, Drs. Z and W to be higher than those in studies.
Ed

Re: What is ESWT role in treating P.F?

Dr. Z on 5/17/03 at 08:27 (119082)

People in the math world tend to think only in terms of one plus one is two. We are treating human being with conditions that are painful, cause depression, lose jobs, lose time with family. I agree with your statement

Re: At what point should we call it quits?

Pauline on 5/17/03 at 11:44 (119094)

Dr. Ed,
How can you blame something called our 'system' for the high cost of ESWT?
Doctors are free to charge any amount for the services they render. I don't see where the doctors doing ESWT hands are tied, that they have no recourse, but to charge the thousands of dollars for this treatment that you seem to imply.

This is just crazy. It's like getting the public to believe tax cuts are bad for them, or that Fast Food restaurants should be sued for obesity in the U.S.

Doctors are banking on insurance coverage for ESWT down the road, so they will continue to charge high prices, because they expect that their bill will eventually be paid by insurance companies. If they dropped their price before the insurance ball is rolling they would end up with much less income per treatment from insurance companies which would be a stupid move on their part and they know it. Therefore they have no incentive to drop their costs.

They have it made right now. There is some insurance coverage and some people are willing to fork out the money to have the treatment. If no one came, these doctors would lower their price rather than let their machines collect dust.

All this baloney about 'our system' causing the problem is just that baloney. Dr. Z's group just about has a monopoly on ESWT in the Eastern U.S, so what incentive would they have to lower their price? The answer is none. You can't tell me they are not turning a profit.

The high cost of ESWT rides on the shoulders of the doctors that are now using the machines, especially those that own their own. Dr. Z's group of 50 could drop their cost to $50 tomorrow and no 'system' would be to blame or attack them for doing so.

Healthronics has begun discounting their share of the take for the Ossatron, and are working with surgical centers to lower their costs to the patient. The doctors using these machines could also drop their fee if they desired which in some cases they may be doing, however, the Ossatron patients are still at a big disadvantage because they must use the services of a surgical center. Those costs cannot be eliminated.

This disadvantage doesn't affect those being treated with the Dornier or Sonocur machines. These machines are privately owned and the doctors are setting their OWN fees based on what they expect insurance coverage to pay now and in the future, as well as, wanting to keep their costs in line with those doctors using the Ossatron set up.

Doctors using Dornier or Sonocur machines would never get their expected amount of return (profit) if they dropped their prices before total insurance coverage exists. Thus patients will continue to see high ESWT costs, but it's not 'the system's' fault it's the doctors who are counting on a specific return down the road on their initial investment after purchasing these machines.

It's much easier to blame insurance companies for the high costs and keep the income you have from ESWT coming in, for the time being, expecially since you already have people beating a path to your door and expect more insurance coverage down the road.

Why shoot your self in the foot, when all you have to do is sit back and wait. Time is on your side and you simply brain wash people into believing the 'old insurance companies' are at fault until they start providing coverage. The insurance companies have been the bad guys for so long it's easy to pull off.

If you don't belive me let's have the doctors using Dornier and Sonocur machines drop their ESWT treatment costs to $50 per foot and see if 'the System' attacks them in any way, shape or form. My guess is this boogie man that they have created in peoples' minds won't even care, but I guarantee it will bother them tremendously to see their dreams of profit from ESWT go down now and in the future.

Re: At what point should we call it quits?

Dr. Z on 5/17/03 at 12:22 (119097)

Pauline,

You have no idea what it cost to run an ESWT company, or do you know what competition our group is encounting. There are at least at six plus Dornier machine within 100 miles of my office. I am not blaming the insurance for anything. The manufactor set the price by seting the cost of the machine and the cost of doing business its that plain and simple.
I told you from the first time I entered this site so long as there is a class three approval two years of testing millions of dollors double study there is going to be a cost of $350,000 for each machine. The cost doesn't involve the maintance, vehicle, insurance I could go on but this might be over your head.

Re: At what point should we call it quits?

Bev on 5/17/03 at 13:01 (119105)

Pauline,

Are you saying that you do not think that ESWT is worth trying for us whom have tried everything else for 18 months ? I am so very weary of all of this disability , anguish , agony ,distress ,pain ,etc , I am ready to try anything there is out there . My life has been on hold long enough , nothing else has worked , I am now hoping to get the ESWT if it gets approved .

Re: Note to Bev

SteveG on 5/17/03 at 14:04 (119111)

Bev - I know how easy it is to get discouraged, but by all means you need to get ESWT. Pauline has never had the treatment and is fairly sceptical. But I am sure that she would agree that it is worth doing if you have a chronic case. The majority of people who try ESWT get improvement from the treatment. If you cannot get it approved, I would consider a trip to canada. The folks at Bayshore claim a very high success rate, and with the exchange rate, you can get it at a mere fraction of what it costs here is the US. Where do you live?

Re: At what point should we call it quits?

Pauline on 5/17/03 at 14:21 (119113)

Gee Dr. Z, I didn't see a smiley face at the end of your post. You have nooooooo idea of what I know or don't know about running a company be it ESWT or Rockwell International.

You indicate there are at least 6 other Dornier machines within a hundred miles, my question for you is what would you do if you sold insurance and there were 100 other agents in those same hundred miles? This is fact not fiction.

Who would you blame then 'the system' or 'your competition' she says with a smile:*

Re: To Bev. At what point should we call it quits?

Pauline on 5/17/03 at 14:55 (119115)

Bev,
I'm certainly not God, although Dr. Z thinks I am:*, but I'd encourage anyone who can afford ESWT or has insurance coverage to try this treatment before considering any form of surgery.

For all practical purposes it's relatively safe. There have been a few reports of injury most of which were transient in nature. For me, it's success is still in question regardless of all the VAS numbers, reports and studies posted on this site. I'd like to see more hard core cases studied as Brian indicated in one of his post. I think we all want to know the money spent will provide the good results we want to see, that the JAMA report is proved wrong, and all insurance companies give it their blessing by paying for the treatment.

I know of very few things in life that are 100% sure except for death and having to pay taxes, but I do know once cut the Plantar Fascia cannot be
returned to it former state and there is no guarantee that comes along with this surgery that you will be pain free following it. In fact Dr. Z has posted that patients are almost assured of lateral column support problems following it.

By reading the surgery board, which by now I'm sure you have, you realize
the truth in what I am saying about surgery. There have been tooooo many people reporting they are still in pain or worse off after their surgery than prior to it. This makes me want to call for an investigation into
any procedure that cuts the P.F.

There is no magic bullet when it comes to curing P.F. The best that we can all do is to read everything we can, ask questions, do our best to find a 'good' doctor, try all the conservative treatments, and try if possible ESWT prior to any surgery.

This is what I would do, but everyone must make their own decision based on their situation, financially and mentally and then be prepared to accept the results of their decision be they good or bad.

This is called 'LIFE' and it's not always predictable.

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/17/03 at 15:20 (119117)

Dr. Z:
Part of the reason is also lack of a better criterion. Perhaps plantar fascial thickness adjusted for weight and occupation will be a better criterion in the future.
Ed

Re: At what point should we call it quits?

Ed Davis, DPM on 5/17/03 at 15:49 (119120)

Pauline:
What were you drinking before you made this post? ;) You have generally been rational and well informed.

If it was up to the doctors we would want to provide services to everyone who needs it. We spend enormous amounts of time trying to get insurance companies to authorize treatments like ESWT for patients. That takes up valuable staff and doctors time and money.

Doctors are NOT free to charge 'any amount' for services they render. Doctors pay rent, have staffs to pay, insurance and overhead like any other business. If doctors don't stay in business, they cannot render the services.

Dr. Z's group has a 'monopoly' on ESWT in the Eastern US? Are you serious?

By the way, if you write me a check for $350,000 so I can buy my own Dornier unit, I will agree to give you a screaming deal on ESWT treatment.

While you are defending the insurance companies, please explain why they will not hesitate to pay several thousand dollars for plantar fascial release surgery plus a few more thousand to treat complications of the surgery but not pay for ESWT.

You stated that 'Doctors using....machines would never get their expected amount of return if they dropped their prices before total insurance coverage exists.' I and virtually every provider I know has lower prices for cash paying patients so you, again, are just plain wrong on this item too.

You stated that Dornier machines are privately owned so doctors can set their own fees. Wrong again. Most Dornier machines are owned and maintained by third parties. The Dornier machine I use is owned by United Shockwave of Chicago. I do not know of a single privately owned Dornier machine in the northwest US.

We are 'brainwashing' people. Please explain how we are doing so.

Perhaps you have forgotten the last two years of posts on this board but there is a lot more to the 'system' and its effects on costs than the insurance companies that are so dear to you. FDA politics has raised cost of a number of medial services including drugs into the stratosphere. It is obvious by your comments that you have never studied economics but a basic tenet of economics is called 'supply and demand.' If the supply is limited costs go up. There are over a dozen different ESWT machines available in Europe (more supply, less cost). Many of those models will probably never make it to market in the US since the FDA has raised the bar on approval to absurd levels (class 3 for ESWT -- do a search on this on this as I prefer not to have to repeat all of those discussions).
Ed

Re: At what point should we call it quits?

Ed Davis, DPM on 5/17/03 at 15:55 (119121)

Bev:

ESWT is the best treatment that has come along in years. Nothing is 100% effective but ESWT has virtually no side effects. If one looks at the benefit to cost ratio, I have not seen such an effective treatment to come along in decades. I don't mind giving people some latitude for irrationalism but when it serves to discourage or dishearten those in need as Pauline is doing, such behavior is not acceptable.
Ed

Re: At what point should we call it quits?

Ed Davis, DPM on 5/17/03 at 15:56 (119122)

Pauline:
Your comments indicate that you probably never passed Economics 101, let alone know anything about running a company.
Ed

Re: To Bev. At what point should we call it quits?

Ed Davis, DPM on 5/17/03 at 16:03 (119123)

Pauline:
Who do you propose pay for all the studies needed to convince you and your friends in the insurance industry? Are you planning to find researchers who will donate their time?

You cannot have it both ways. If you want whoever to spend several more tens of millions of dollars on research, then those costs will be reflected in higher costs for treatment. There are numerous highly effective ESWT machines commonly and economically used in Europe that cannot be sold in the US. HMT, the manufacturer of Ossatron is barely selling that product in Europe but sells the Reflectron for much lower cost. Don't expect to see the Reflectron in the US anytime soon particularly if we have individuals with your mindset involved in the approval process.
Ed

Re: To Dr. Ed. At what point should we call it quits?

Pauline on 5/17/03 at 16:52 (119125)

Dr. Ed,
Please re-read my recent reply to Bev. and post the part where I discourage her and other people from having ESWT. When you find my words in that post please quote them here so everyone can see them.

Funny I don't read them in my message to her. Could it be your eyes are still burning with fire from that last post to me???? God love ya:*

Re: To Dr. Ed. At what point should we call it quits?

Ed Davis, DPM on 5/17/03 at 16:56 (119126)

Pauline:
Your recent reply to Bev was, for the most part, encouraging.
Ed

Re: At what point should we call it quits?

Pauline on 5/17/03 at 17:00 (119127)

Dr. Ed and Dr.Z
If this discussion going to get down and dirty----lets move it to the social board.

You guys can go first.

Re: At what point should we call it quits?

Ed Davis, DPM on 5/17/03 at 17:39 (119130)

Pauline:

Do you think it is humorous to bring misinformation to this board? Patients come here who are in pain, seeking help. This is not the place to get your jollies.

Ed

Re: At what point should we call it quits?

Dr. Z on 5/17/03 at 19:00 (119137)

I will try but I really don't have the energy for this same argument again and again again.

Re: At what point should we call it quits?

Dr. Z on 5/17/03 at 19:03 (119139)

I do know you know nothing about running an ESWT company from what you say in your posts ( smile smile).

Re: At what point should we call it quits?

Dr. Z on 5/17/03 at 19:10 (119140)

Ed,

Don't get upset every once in a blue moon Pauline turns crazy and starts acting like this . This too shall past. You should of seen in the old Big O days. Boy was she on a roll.

Re: What is ESWT role in treating P.F?

elliott on 5/18/03 at 10:21 (119174)

No, Dr. Z, actually, people in the math world tend to think in terms of one plus one is 0 (mod 2). So basically, what you're saying is, people in the math world are so narrow-minded and calcualting they're virtually useless, while all doctors, or at least those who own ESWT machines, are loving and caring and only trying to cure pain in the world, nothing else.

Let me tell you a big difference between a math article and a medical study: The contents of a math article, perhaps suitably peer-reviewed to ensure accuracy, are beyond reproach. Simply put, the results are true. Doctors, OTOH, constantly come out with studies making all kinds of lavish claims, only to have them rejected--not just in scope, but often in totality--shortly thereafter by another study. It's more like the norm. For that reason, a healthy dose of math skepticism is a good thing to have. A shame you don't have any of it. You seem to accept any flimsy evidence in support of ever-expanded ESWT use for everything always without the slightest hesitation or reservation, without ever considering opposing evidence, and use anecdotes to support your case. Not every other doc associated with and believing in ESWT behaves that way. To me, that attitude diminishes your credibility, especially given you have a very big monetary interest, perhaps even your career livelihood, wrapped up in ESWT.

[]

Re: Note to Bev

Bev on 5/18/03 at 12:20 (119194)

Steve,
I am in Michigan. I am just in the process of my stupid workmans comp to tell me if they are dropping me or what so I will know what to do before I can make any decisions as to what to do next. Such a L_O_N_G drawn out process, and I am sssssoooo tired of all of this crap they put us through :(( My life has been on hold for so long and I just hate x-(

Re: At what point should we call it quits?

Paula A on 5/18/03 at 16:04 (119198)

Pauline,

You may know how to run a company and you may know how to sell insurance but it is obvlious you need to know more about the healthcare system. There are thousands of insurance companies out there and each has there customary fee for services provided. If the facility, anesthesia,
physician and yes the eswt company are providers under the plan then they must accept the insurances customary fee as payment in full. If a physician charges $2000.00 for services and the customary fee is $125.00
then that's what he gets. And for the most part these customary fee are often based on CMS customary fee. You mentioned the physician charge should be lowered why? These fees for the most part are set. You don't hear of any liability company lowering there premiums quit the contrary.
In Pa. you pay out the wazoo in liability and we are loosing good physicians because of this. It's a large loop and unfortunately the only factor left out of this mess of a loop is the patient.

Re: What is ESWT role in treating P.F?

Humphry B on 5/18/03 at 19:14 (119210)

I hope that you are never in the position where a new therapy may resolve some painful affliction that you have and some bean counter like yourself says the cost is too high so you just are made to sit there and suffer. Tell me Elliot, would you have someone put to death because they are too sick to cure and your numbers say it is uneconomical to keep them alive?

Re: What is ESWT role in treating P.F?

Dr. Z on 5/18/03 at 20:25 (119220)

Elliott,

You should be ashamed of yourself. The FDA studies aren't flimsy evidence. The real difference between math and medicine is that I treat humans. My experience is what I accept. Thank g-d you aren't my peer. My peers and my patients have alot of faith in my credibility.
What purpose you I have no idea. You comments are without fact they are just there to be negative. I have no time for you and your stupidity.

Re: What is ESWT role in treating P.F?

elliott on 5/19/03 at 08:05 (119244)

Dr. Z, if you don't distinguish between good and bad science in the applicability of ESWT and always conveniently lean in favor of an approach that just happens to enrich you, how are you any different than some other docs who come on these boards hawking their wares, all the while claiming they are treating humans? I've watched you post for several years now, and, while I really wanted you to be one of my heroes, I'm sorry to say I can't see much difference between you and them. Dr. Ed is not that way. He's more open, be it to high-energy vs. low, to giving conservative methods their due, and so on.

Again, around 90% of PF sufferers will get better without ESWT. That means the number of people ESWT is helping who would not have got better without it is small. That is a good reason to tread carefully before insurance covers it right away, maybe even to have a six-month minimum. Is that so unreasonable or cold a thought?

I will give you a perfect example of how you could take a different, more reasonable approach, something I've asked you numerous times in the past to consider but you've brushed aside. As a doctor, you should have library privileges at your alma mater or other research libraries, or be able to join an on-line medical journals service, or even pay a few hundred a year out of pocket to keep abreast of current ESWT research. Given your history in getting ESWT started in the U.S., I'd say keeping apace with such research is almost a necessity. Then, when an article like

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

comes out, you will read it and decide, based on the quality of the study, how persuasive its conclusions are compared to another published study advocating earlier use. If the one advocating earlier use is more persuasive, fine, you can tell us why.

[]

Re: At what point should we call it quits?

john h on 5/19/03 at 08:14 (119245)

No! do not come to the Social Board as I am a monitor along with Wendy. Stay here where you are un-monitored.

Re: What is ESWT role in treating P.F?

elliott on 5/19/03 at 08:50 (119259)

Thanks for your kind thoughts, Humphry B. Actually, I already *am* in a position where a new therapy may resolve some painful affliction that I have and some bean counter like myself says the cost is too high so I am just made to sit there and suffer. I have had severe right-sided bulging-disc-induced sciatica for almost 4 years now, which I mysteriously developed right after that horrendous surgery leaving my right foot a mess. I've been in chronic pain ever since, and the back problem may be affecting some of my other problems too. There is a 10-minute outpatient facility procedure invented I believe in the late 80s, called an epiduroscopy, which is a scope-guided epidural shot to the back that sends anti-inflammatory and anti-nerve-pain drugs down various nerve roots in an effort to provide pain relief. The risks are minimal and it is a great alternative to rushing into a full-feldged disc surgery. Admittedly, data on how well it works, how much is temporary or diagnostic, etc., are still unclear. All I know is I got a permanent 50% reduction in pain from that one shot, and that is the only thing that has worked so far. Living even with the remaining pain is still extremely difficult; the longer you deal with something, the harder it is to handle. Well, I'd really like another such shot, and can make the case it likely would do additional good, as the doc would like to inject down some other nerve roots not reached the last time around (they can't inject everywhere the first time since your body would overload on the drugs). Problem is, for technical reasons, this time around my insurance company (BCBS) won't cover the procedure (which would cost me around $3000), claiming it's experimental. Uncanny how it is similar to PF in that they'll cover a full-fledged disc surgery (which often makes one worse and can lead to additional surgeries including fusion, and even disability) but won't cover this more-or-less risk-free procedure at their cheaper negotiated rate. In case numbers of patients are important, note that there are even more people with back pain than with PF.

I don't have the money to pay for the procedure myself right now. Similar to many PF sufferers seeking ESWT, I'm trying to do what I can, hoping I will be able to switch to another insurance covering it come next January. So yes, I know exactly what this is all about. Since these boards are primarily for PF sufferers, it's a popular view and an easy one to take to promote the most broad insurance coverage and as early as possible for ESWT. Well, what about *my* procedure? What about other procedures for people suffering for many different things? Some of the same people rueing that ESWT is not covered on their insurance are also complaining that their out-of-pocket insurance expenses (prems, deducs, co-pays) are already too burdensome. Well, add in ESWT, epiduroscopy, and a slew of other procedures and watch what happens to the premiums.

No, I don't have all the answers, but I do consider myself to be more level-headed than many here when it comes to health costs. That doesn't mean I'm cold and unfeeling. At times my own pain is so bad I often feel I'm dying, so am not unsympathetic to those in severe pain. But I still say, for an ailment for which a very large percentage get better on their own, a six-month waiting period for insurance coverage for a device whose merits in the first 6 months are still uncertain is not outrageous.

[]

Re: What is ESWT role in treating P.F?

Dr. Z on 5/19/03 at 09:21 (119262)

You are just plain amazing. You have no idea how many books, articles, interviews I have done over the past five years, trying to learn as much about ESWT as I can. So how many people do you think that 10% represents ??

Re: At what point should we call it quits?

wendyn on 5/19/03 at 09:50 (119273)

Thanks so much John. 8-(PIPE)

I've been away for 2 weeks, then sick in bed with a brutal cold for the last few days. :-&

Since you mentioned my name in your post - it triggered an email.

Nice thread.

The more things change - the more the stay the same 8-(PIPE)

I'm going back to bed.

(:(PIPE)

Re: What is ESWT role in treating P.F?

john h on 5/19/03 at 10:50 (119281)

Elliott: Have you looked or researched VAX-D treatment for the bulging disc. It is a non invasive procedure that is FDA approved with many facilities now open. It is especially effective according to literature for bulging disc. A clinc just opened up next to my office (run by an orthopedic surgeon) who I know well. He said he has a bulging disc and will start treatment on the first of June. Typical treatment requires 20 treatments of about 45 minutes each. Go to http://www.VAX-D.com

Re: What is ESWT role in treating P.F?

elliott on 5/19/03 at 13:38 (119290)

Thanks for the suggestion, john h. Never heard of VAX before you posted about it (even so, the site is rather sparse on details), but I doubt I'd try it, for several reasons:

1. There's no provider (as yet) in my state, and that's far to travel for so many visits.

2. When they don't give the cost, it's usually prohibitive.

3. It seems mainly to be a way to stretch the body in beneficial ways.

Regarding #3, which is my main reason, many who have back pain are extremely inflexible (and often overweight) to start with, and they are the ones likely to gain the most from increased flexibility. When I got the problem, I was already lightweight and flexible (which is not to say there couldn't be improvement). Every PT I go to is amazed at how flexible I am. I've already tried traction, both horizontal and vertical, to no avail. I've been taking yoga for a few years now. I have the best standing forward bend in my yoga class, being able to palm my hands flat on the ground. Now, as typical of disc problems, forward-type bends do bring on increased pain, but only at positions far past where a practitioner would push another person's limb without fear of hurting. OTOH, I noticed that backbends, even such as pictured below,

http://www.yogajournal.com/poses/473_1.cfm

(and, after having worked on it, can now do just about as well as shown), cause me no pain at all and somehow feel 'right'. I discussed this a couple of weeks ago in a private consult with the biggest yoga guru in my region who also has been a PT for 30 years handling such problems. Aside from him making me feel good by telling me I do a great cobra (a backbend pose), he told me there's a whole theory behind backbends for discs--Mackenzie method--and, rather than just hold poses for 30 seconds or so, showed me how to practice backbend positions daily for a long time through such use as a cylindrical bolster and props, and claims doing this regularly may help me a lot. I'm awaiting the bolster I just ordered. What I'm saying is, any benefit from stretching and the like, I really think I have covered.

[]

Re: What is ESWT role in treating P.F?

elliott on 5/19/03 at 13:47 (119291)

Dr. Z, the things you list you have done are more along the lines of a marketing blitz than ESWT research. I'm talking about getting access to current research articles and the like (attending an ESWT research conference in Germany would certainly count). Aren't you willing to do that?

[]

Re: Vax-D

Ed Davis, DPM on 5/19/03 at 15:37 (119299)

John:
I have followed the Vax-D for some time. The theory behind it makes a lot of sense but am curious to know more about outcomes. I would imagine that the orthopedic surgeon did hos homework before ordering the device.
Ed

Re: What is ESWT role in treating P.F?

Dr. Z on 5/19/03 at 16:24 (119305)

I you knew the books I read you would know that they are from many of the international conference over the past few years. Elliott the only explanation I can think of for your attitude and lack of respect is your in pain. Enough is enough with this off the cuff stuff

Re: Vax-D

Dr. Z on 5/19/03 at 16:45 (119309)

Vax has been around for some time. I have seen patients that it has helped.

Re: Vax-D

john h on 5/19/03 at 19:05 (119325)

Ed they claim a 75-85% success rate. Success being defined as a pain level of less than 1 out of 5. Like ESWT it is sure worth looking at as it is non invasive. I have seen a number of letters from Neurosurgeons, Orthopedic surgeons, and family Doctors who have actually had the treatment. If you have time look over that web site. The theory makes a lot of sense. The Doctor I know who works there part time was considered one of the premier hip replacement surgeons in a four state area. He did a fusion on my neck well over 20 years ago. We had a long chat about the procedure and he was very much a skeptic when he first read about it but as I said will be having the procedure himself when he gets back from Vienna.

Re: Value of experience and cumulative experience

Ed Davis, DPM on 5/19/03 at 19:06 (119326)

Elliott and Dr. Z:

I need to try to divert this converstation a bit. It is interesting to see that the Europeans are virtually looking at concerns over ESWT efficacy in PF to be a non-issue; they are now focusing on other areas of the body.

The studies we are discussing have the highest value in the early stages of a new treatment but what we now have is a relatively large body of experience in the treatment of PF with ESWT. I would still be interested in studies for the purpose of comparing high to low energy and perhaps the advantages of the different targeting techniques. While issues of controls and documentation are admissable concerns, the numbers of patients treated by European clinicians with ESWT dwarfs the study numbers. One must look at the collective experience very seriously. Quite frankly, as a clinician, it means more to me than the studies. It is the main means of judging the efficacy of surgical procedures. Furthermore, considering the limited downside of ESWT, I know of few procedures in modern medicine that have such a favorable benefit to risk ratio.
Ed

Re: Vax-D

Ed Davis, DPM on 5/19/03 at 19:07 (119327)

John:
If you don't mind my asking, what is the cost of the procedure (I am assuming it is not covered by insurance)?
Ed

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/19/03 at 19:21 (119329)

Elliott:

'VAX' stands for vertebral axial decompression. If the vertebrae are distracted, the bulging disc gets 'sucked in.' The discs are composed of an outer ring, the annulus fibrosis and a soft, gelatinous inner core, the nucleus pulposis. The vacuum created by distraction pulls fluid into the nucleus pulposis, basically plumping it up. A well hydrated nucleus pulposis has increased hydraulic lift to better separate the vertebrae.

VAX performs intermittent, rhythmic distraction of the vertebrae to help effect the above process.

I, and some others, have 'tested' this theory from a mechanical point of view. Basically, one takes a roman chair and moves it up to a cable pull in a gym -- about 4 to 5 feet apart. The person is hanging on the roman chair, ready to do the 'reverse sit up' but is holding on to the cable, with the cable emanating from the ground position. Distraction is created by a combination of gravity and the pull of the cable. Wish I had a fluoroscope to measure the amount of intervertebral distraction -- would be a interesting study.

Disclaimer: Don't try this at home.
Ed

Re: What is ESWT role in treating P.F?

john h on 5/19/03 at 21:33 (119337)

Ed: In studies with the VAX-D they performed a myleogram on patients and inserted a needled into the disc and measured the pressure in water pressure HG. Normal pressure in the disc being somewhere between 150-200 HG. Then under a pull with the VAX-D table the pressures was measured and found to be a negative 150 HG. Bulging disc were found in many cases to pull back in and form a decentric form which is the normal form of a disc. Also sucked in were various nutrients. Many patients have remained pain free since treatment. The normal course of treatment is 20 treatments of about 45 minutes. I think the maximum traction is on the order of 150 lbs. The patient has some control if the pull becomes uncomfortable. The treatment is recommeded for bulging disc, degenerative disc disease and for people with failed surgery back syndrome. The harness is most effective on the lower lumbar disc. Typical cost for 20 treatments which is the typical protocol is about $2300. Treatments are every day of the week except Saturday and Sunday so the course runs 4 weeks. Traction has been around for a long time but not the controlled traction of the VAC-D. The science makes sense to me and sure beats surgery as I have been there and done that. This will not replace surgery but is sure worth a try prior to surgery. Low back pain is very much like PF. People just do not understand how it effects your daily life.

Re: Vax-D

john h on 5/19/03 at 21:43 (119338)

Ed: As I mentioned above it is $2300 and not covered by Medicare. The physical therapy that goes with it is covered. During treatment you are prescribed a course of particular antibiotic which the Doctor told me was found to be be effective in the disc space. From all I have read there has never been one case of someone being made worse. He also said they prescribed an anti-inlamatory during the course of treatment. I am a skeptic at heart but the science seems to be there. To many people reporting excellent results after years of pain to be kissed off. Considering 20 treatments of about 1 hour each with an expensive computer controlled traction table and the Doctors and Nurses time the $2300 would seem to be worth a shot in lieu of surgery.

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/20/03 at 15:43 (119399)

John:

Interesting information. I can understand the right of third parties to question treatments but WHY do insurers have a much higher standard for accepting non-surgical treatments than surgery.

Surgery is a lot more fun than zapping patients heels with an ESWT unit; it pays a lot more and there are a lot less insurance company hassles. I can do a plantar fascial release in less than 5 minutes ( about 10 minutes if I do it blindfolded) ;)
Anyone who is going to do the right thing, though, will need to favor ESWT over surgery.
Ed

Re: What is ESWT role in treating P.F?

Dr. Z on 5/20/03 at 15:48 (119401)

Hi

I can do a pf release in under five minutes. Just joking. Ed. It is so true about the right thing. ESWT is the right thing to do before any surgical intervention. One major complication is just too many and ESWT avoid the complications that won't go away with pf surgery

Re: What is ESWT role in treating P.F?

Ed Davis, DPM on 5/20/03 at 16:48 (119409)

Dr. Z:
But how fast can you do it if blindfolded?
Ed

Re: Value of experience and cumulative experience

elliott on 5/21/03 at 08:36 (119480)

Dr. Ed, I agree there is enough evidence as to the general efficacy of ESWT for PF, but as with any other new treatment, research articles are an ideal source of information to be able to maximize on that efficacy, since it can do things like carefully target sub-populations or sub-uses, or compare devices, things not as likely in a general setting. There is still a lot to be learned in this regard.

Dr. Z, lectures touting the merits of the Dornier Epos don't count as research. I have no doubt you are very skilled at using the Dornier and are helping heal people with it, but you just don't strike me as the research type, as your posted comments have been so automatically pro-Dornier it's almost comical, and you've generally seemed uninterested in reading research articles, even when they address issues on which you opine (e.g. early use of ESWT), and even when they are posted here for your convenience. The fact that I managed to obtain the 1-year Dornier Epos study before you and had to correct your own steadfastly maintained (to the point of appearing in print) but mistaken assertion that your beloved FDA study had a 2-year minimum rather than a 2-year average is mind-boggling. Your unkind comments heaped on me that whole period for daring to challenge you on this point until you were proved wrong I will attribute to the pain you must be in. Please cut the hyperbole.

[]

Re: Value of experience and cumulative experience

john h on 5/21/03 at 08:56 (119485)

Dr Z and Dr Ed work where the rubber meets the pavement. Medicine is still an art. After all the research is done someone has to see if it works in the real world and these guys are there on a daily basis to see first hand what ESWT really does and does not do. Are they biased? Probably, as all of us carry our past with us in judging anything. To get a new aircraft in the air it takes a lot of research but in the end some pilot has to strap himself into it and see if that research works.

Re: What is ESWT role in treating P.F?

john h on 5/21/03 at 08:58 (119486)

From what you guys tell me when you cut the fascia it is by feel for the most part. Ray Charles might be an excellent guy to cut the fascia as he sure has the feel in those hands.

Re: Value of experience and cumulative experience

Dr. Z on 5/21/03 at 09:13 (119489)

I read alot of research articles on ESWT. You are right I am a clinician. I like people and I like treating people. There can and will be studies from my use of the dornier epos in the future. Why wouldn't I be pro-Dornier so far its the best machine in the USA market and that is from personal experience in addition to FDA studies.

Re: What is ESWT role in treating P.F?

Dr. Z on 5/21/03 at 09:18 (119490)

Helen Keller use to be my first assistant. It really is all feel and the sound of the fibers being cut

Re: What is ESWT role in treating P.F?

Paula A on 5/21/03 at 14:26 (119527)

Elliot
I find it hard to believe that BSBS won't cover a lumbar epidural steroid injection unless the HNP was related to work or auto accident.
Where you referred to a physician (preferrably an anesthesiologist) that was board certified in pain managment? Each pain managment clinic differ slightly in their approach but bacically you receive a series of one to three epidural steroid injection either fluoro guided or not.The fact that you got that much relief from the first injection is very encouraging.More than likely you will receive a greater response with a second injection.
Bringing the medicine level up to a more threraputic effect. An ESI wont't
cure your Disc disease but it can help decrease the pain to a tolerable level to improve you quality of life. Don't give up! Challange your insurance co.. See if the pain managment physician would provide documentation to your ins.co. to reverse their decision. It's worth a try

Re: What is ESWT role in treating P.F?

elliott on 5/21/03 at 14:44 (119529)

Paula, thanks for responding. According to my back doc's office, BCBS (at least mine, in MD) really won't cover it. The first procedure was covered because it was called a frac frag or something like that, whereas the second one would be coded as #62264, percutaneous lysis of adhesions, and not covered. The doc's office has said they constantly sit in on BCBS meetings and can't get them to change their mind. I asked BCBS about it when I called about something else, and they said that's just a code nota diagnosis, and the doc could submit a request and maybe it will be approved, but the doc's office says it has been through this repeatedly and even recently and they always reject it. Yes, my doc is pain-mgmt certified.

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Re: What is ESWT role in treating P.F?

john h on 5/21/03 at 15:13 (119538)

I had 3 epidurals, 3 series of facet injections, 1 series of Radio Frequency Lesioning, and a Discogram and Medicare approved and paid. Hard to imagine an insurance company not approving epidurals.

Re: What is ESWT role in treating P.F?

elliott on 5/21/03 at 15:23 (119540)

Regular epidurals are cheap (and no doubt covered), but scope-guided ones aren't. I've been led to believe that a regular epidural is hit or miss, usually the latter, and not without some risks as well. Given the relief I got with the scope-guided epidural and the limitations on how many epidurals (3?) one can get, I think it pays to hold out for the scope.

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Re: Value of experience and cumulative experience

Ed Davis, DPM on 5/21/03 at 15:28 (119542)

Elliott:

I certainly agree to the value of further studies but I will take issue with third parties that insist on calling ESWT 'experimental' or requiring further research. There is a lot of refining of protocols and our knowledge base that can be forwarded with research. Considering the existing knowledge base coupled with the reward/risk ratio, there is absolutely no valid reason for third parties to refuse reimbursement for ESWT at this time.
Ed

Re: What is ESWT role in treating P.F?

john h on 5/21/03 at 17:13 (119549)

My epidurals were all under flouroscope. The Pain Mangement physician who did them scheduled them on a particular day of the week so there were about 20 of us in the hospital lined up. Like Elliott I think the flouroscope guided epidural is a lot less risky. In the case of Radio Frequency Lesioning, Discogram, and Facet Injections it is an absolute must.

Re: What is ESWT role in treating P.F?

Paula A on 5/21/03 at 18:59 (119558)

Elliot,

Are you saying you had an epidural injection with the use of an endoscope or and epidural guided by a fluoroscope. An endoscope consist of
half inch incision verses a needle injection to the epidural space . The epidural is a potential space lining the spinal column. This is where the steroids are delivered then in 48 to 72 hours the anti inflamatory properties take effect. I'm confused as to exactly what you had done the first time. The second procedure you mention is a surgical procedure not a treatment. Have you already had back surgery that now you have scar tissue?
Is your Doc.a neurosurgeon? If you have a chance check into ESI's . It's an option worth looking into. Good luck wish you well.

Re: What is ESWT role in treating P.F?

elliott on 5/22/03 at 08:14 (119602)

Paula, the distinction between an endoscope and a fluoroscope, if there is one, has never been made clear to me, but I think it was a fluoroscope. The procedure I had is called an epiduroscopy. I can try and dig up the paperwork if it's important. There is something like a half-inch incision or even smaller to get the scope in. The 48-72 hours description sounds familiar. I went to work a day or two later. Based on his findings and my initial improvement, the back doc initially decided I didn't need a second procedure right away. It's now a year later.

I did not have back surgery other than the scope procedure and am tring to avoid it at all costs, especially in light of difficulties with my foot surgeries. Back doc is not a neuro but a pain mgmt back doc/chiro (listed under Phys Med & Rehab) trained in this procedure who combines a program of the shot with PT/chiro through other docs he refers you to. In retrospect, I can say the other things didn't seem to have any effect. Several people I know personally who went through the same thing with the same set of docs and who got totally better all say they're not sure which of the treatments was the one that really helped--one thought it was the chiro alignments, another traction, but not the epidural. The back doc is very anti-full-fledged back surgery, claiming it's a racket making far too many worse, and he says that in Europe as a rule they just don't operate like they do here unless there are extreme symptoms.

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Re: PS

elliott on 5/22/03 at 08:16 (119603)

Paula, what is ESI? I hope not another crime drama. :-)

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Re: What is ESWT role in treating P.F?

john h on 5/22/03 at 10:06 (119635)

Pala I had a laminectomy some 20 years ago and an MRI clearly shows the scar tissue. The pain management Doctors and all the Doctors at the prestigeous Texas Back Institute all use flouroscopy to guide the needles as I could see the scope. I cannot imagine a shot into a precise area of the spinal column without flouroscopy. Is this done?

Re: What is ESWT role in treating P.F?

Paula A on 5/26/03 at 19:39 (119975)

Elliot,

ESI(epidural steroid injection)in conjunction with physical therapy and oral medication often can produce enough relief to make life tollerable
again . As I said before the above treatment is not a cure. Usually it not one treatment that is the cure but a combination. I glad to here that your Doc is not surgery happy. Patients with a history of post lami pain syndrone are more difficult to help although not impossible. Unfortunately
Elliot you will be dealing with your back forever so find a modality that works for you to produce enough relief. It will be a long tern relationship
between you and your pain clinic. Always keep inquiring into other forms of treatments for back pain to ward off the need for back surgery. Wish you well.