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For Dr. Z

Posted by Ed Davis, DPM on 6/04/03 at 14:23 (120937)

Some quirk is preventing me from listing a reply to your message below so I have to start start a separate post.

I have not heard of the company you mentioned. Did you do a search on the web. Sonorex is the primary supplier of Sonocur Basic machines in the US but I do not know if they have an exclusive -- perhaps David Lowy will reply.

Ed

Re: For Dr. Z

David L on 6/05/03 at 11:38 (121036)

Yes Ed....Sonorex does indeed have the exclusive for the US for the Siemens Sonocur Basic with the exception of a few of Siemens' largest accounts. We now have about 90 locations throughout the US and are adding more constantly. The listing of current locations is at http://www.sonorex.com . I'd be happy to answer any questions I can regarding the Sonocur Basic as it relates to tennis elbow and ESWT in general in the US and my personal opinions. I posted the latest reimbursement news yesterday further down the board on the tennis elbow thread. There is much more to come, and very soon.

Re: To David L.

Pauline on 6/05/03 at 15:12 (121049)

Do you feel an ESWT treatment that uses a Sonocur Basic is compromising e in any way for patients because there is no ultrasound component on your machine? Also is the quality of training provided to doctors similar to that of other manufacturers?

Re: To David L.

David L on 6/05/03 at 16:25 (121054)

Good question. It was us in Canada who really started to promote the use of 'clinical focusing', whereby the patient directs the operator to the most tender spot. This is of utmost importance, and we feel, the key to success. We have performed over 5000 treatments in Canada and anybody that you speak to that has had the treatment (me included!) will strongly attest to how precise the shock can be. This is the protocol that Siemens used in the FDA trials. Clinical focusing is becoming more and more widespread and we anticipate that it will soon be the most common way of treating patients, both from a superior clinical and cost-effective standpoint. Rompe et al discussed this recently in the Am J Sports Med Vol 31 No 2 pp 268-275

As far as training, all operators are trained according to our strict guidlines developed between our Canadian experience and the European experience. As I mentioned, this is the protocol that was followed in the FDA clinical trial.

Re: To David L.

Dr. Z on 6/05/03 at 17:57 (121058)

Hi
What is the difference between manuel palpation of the pf by the doctor and patient feed back. I would think that the areas would be very similiar.
Once the ESWT procedure starts and the analgesic property of the shockwave takes place wouldn't ultrasound be very important to ensure that you are still in the same area that was orginally the painful noted from patient feedback

Re: To David L.

Pauline on 6/05/03 at 20:00 (121071)

Five thousand treatment adds up to a lot of experience and certainly has to add up to precision. Did you have your ESWT for P.F. or was it used in another area?

Re: To David L.

Dr. Z on 6/05/03 at 20:53 (121079)

Pauline,

I believe David L is talking about three-five treatment per patient as opposed to 5000 pateints. That is still alot of patients.
I just read the most recent healthronics newsletter they have well over 5000 treatment. If you add Dornier you can add another few thousand patients .
Look for many peer review articles in American Journals within the next year or so.

Re: To David L.

Sunny Jacob on 6/05/03 at 21:06 (121081)

To David L.,
As Dr. Z. states, once the analgesic property of ESWT takes place, use of ultrasound imaging during treatment is very important.
This brings me to the point about Sonorex's marketing in Canada. They used Sonocur basic (without ultrasound to reduce the cost of the equipment) and then proceeded to obtain FDA approval in USA. ‘Clinical focusing' may sound scientific but says loudly that there is no ultrasound imaging during the treatment.
Dr. Georg Dahmen, an orthopedic surgeon at the university of Hamburg, Germany, and one of the pioneers in ESWT and ESWT research, was responsible for training the original Sonorex therapists. He highly recommends the use of in-line ultrasound, i.e. Sonocur Plus, and uses it in his own clinic. Likewise, I am certain that Dr. Rompe will not minimize the importance of ultrasound imaging during ESWT application. Of course, there will be positive outcome without ultrasound imaging. However, based on our own experience since 1998, I am convinced that treatment success and outcome with inline ultrasound imaging is higher.
I also question the claim that the ‘clinical focusing' is a Canadian development. During the 90s when the German health care system was reimbursing ESWT on a grand scale, some did purchase ESWT equipment without ultrasound because it was cheaper and the reimbursement from the health insurance was the same if one had ultrasound with the equipment or not.

Re: To David L.

David L on 6/05/03 at 22:17 (121086)

In answers to your questions:

Dr. Z.....As the analgesic effect occurs, you increase the level of energy and keep it at the point that the patient is 'comfortably uncomfortable', for lack of a better term. We generally ask the patient's pain level on a scale of 1-10 during treatment and you usually want to keep it around a 6-7. As for palpation vs. patient feedback....I agree with you....there is no difference. Only the patient can give you the feedback as to the most precise area. Question Dr. Z....when you inject at plantar fascia, do you use ultrasound guidance to insert the needle or do you go by patient feedback. I'd really be interested to know.

Pauline.....I first had it on my plantar fasciitis, then lateral epicondylitis and just recently on my shoulder bursitis. I'm an avid golfer and I pay for it with aches and pains!

Sunny....I guess we'll just have to agree to disagree on the use of ultrasound with ESWT. I know you are adamant about using it, although in speaking with your colleague Dr. Gordon at the recent AANA meeting in Phoenix he certainly agreed with me that it wasn't necessary. You probably see it as a competitive advantage to say that things are far more accurate with ultrasound. I have no problem with that. In your experience with your one Sonocur, I'm certain it has worked well for you. In our experience with 90 Sonocurs so far, it has worked extremely well for us.
I'm really sorry if you believe that the reason that we didn't use an ultrasound component was to lower our costs, as opposed to doing what was best clinically. The FDA clinical trial speaks for itself. As Dr. Z notes, you will see considerable literature coming out in the near future using this protocol. We didn't become one of the first and subsequently largest lithotripsy companies in the United States by not doing what was best clinically.

Re: To David L.

Pauline on 6/06/03 at 08:44 (121104)

I'm glad I asked what conditions you had treated with ESWT. I believe I have a simple bursitis of the left shoulder and didn't know ESWT could be used for that condition. My doctor has orderd an MRI to rule out other things. If it turns out to be bursitis I'd probably be a candidate for ESWT to clear this up.

Would it have any application in the petella area of the knee?

Re: To David L.

john h on 6/06/03 at 09:59 (121120)

David I can speak to the analgesic effect with ESWT. I had two Big O treatments on both feet with no blocks. After about 12 shocks waves I really could not feel any pain worth mentioning. On occasion the machine would put out a stonger pulse which I would notice but I do not think I would be able to tell the Doctor if he was on the right spot or not. Dr. Z did move the head around and I think had the power set at around 16-18KV. The first 12 or so shocks were moderately painful but nothing like a steriod shot. Unless the Epos is significantly stronger than the Big O I cannot help but wonder if after about 12 shocks your foot is not numb.

Re: To David L.

john h on 6/06/03 at 10:07 (121121)

Sunny: When using the ultasound are you looking for something in particular to focus on or are you looking at a specific area to focus on? As I looked at the ultra sound image when I received treatment with the Epos I did not see anything you could say was inflamation or abnormal. I could tell the doctor rather close where my pain was coming from as it is very much at a dime size point where the fascia attaches to the heel on the inside of the foot. Just forward of the heel bone. From all I read this is the classic point for PF to occur. As my foot was blocked I certainly could provide no feedback. Dr. A did move the focus to a couple of other areas.

Re: For Dr. Z

john h on 6/06/03 at 10:14 (121122)

David: I went to your web page and only found locations in Canada. Are th U.S. locations supposed to be there?

Re: For Dr. Z

john h on 6/06/03 at 10:30 (121125)

David L: I did find the locations for the Sonnerex on your web page and I called one of the Doctors near me as to treatment protocol and price. There price was normally $700 each for three treatments but they are offering three treatments at $250 each which makes this a very affordable plan. Treatments are spaced one week apart. The person I talked to had no statistics on outcomes but said they have had more success with treating Plantar Fasciaitis than with tennis elbow. If you can treat this disease with some success at that price then you will be successful. They indicated they are trying to get the insurance companies to accept their claims by lowering the price which makes some sense to me. You of course have to visit the Doctor to see if you are a candidate for the treatment. It takes two weeks to get an appointment so they must be doing some business. Obviously the Doctor's visit is covered by most insurance. I also asked if you could receive treatment the same day if you were a candidate as someone coming in from out of town would not want to make an extra trip. The answer yes.

Re: For Dr. Z

john h on 6/06/03 at 10:40 (121127)

David L: I called the other center in the same city that offer the three treatment Sonnocur for PF and there price is $625 per treatment so obviously the other center would get my business. I guess marketing this treatment is like any business you do what you can to get on top. The $750 for three treatments is hard to pass up and obviously word of mouth works in the world of PF. Having never tried low energy treatment I may take a flyer on this as it is near and affordable.

Re: To John For Dr. Z

Pauline on 6/06/03 at 11:52 (121141)

John,
You may have just discovered something and that is there it another side to ESWT treatment, one that is affordable. One that hasn't been discussed here before and at these prices certainly worth taking a look at.

Let us know if you go for it.

Re: For Dr. Z

Pauline on 6/06/03 at 12:01 (121144)

What's also interesting is individual clinics or doctors are setting various prices (their own) for the same treatment. They have competition. This may not be possible if all those doctors belonged to the same group. They have no incentive to compete against each other if they already know the doctor down the street is charging the same price because he belongs to the group?

Re: To David L.

Ed Davis, DPM on 6/06/03 at 12:56 (121150)

David L., Sunny:

The verdict is still not in on the best way to aim. Experience appears to be showing that ALL of the currently used methods work and I suspect that it will take at least 5 to 10 years until we can come up with a more definitive answer. We have several effective very effective methods currently and eventually we will find the 'best.' For now, we should not let this issue divert us from the goal of getting as meany patients who would benefit from ESWT access to treatment.

Ed

Re: For Dr. Z

Ed Davis, DPM on 6/06/03 at 13:00 (121151)

John:

Affordability of ESWT is something the Europeans and Canadians worked out via their move to low energy. I use Sonocur in my office so I can offer a reasonable fee to all who need the treatment.

Ed

Re: For Dr. Z

Pauline on 6/06/03 at 13:57 (121157)

Dr. Ed,
Is your Sonocur machine the same or different than the one David L. is talking about?

Re: To David L.

David L on 6/06/03 at 14:44 (121173)

Pauline....if you are a resident of Canada, you may wish to view the different indications that are treated here at http://www.sonorex.com/world/files/physicians/treatment_protocols.html

If you are a US resident, your doctor would determine whether you are a candidate for something other than lateral epicondylitis.

Re: For Dr. Z

David L on 6/06/03 at 14:47 (121175)

John....as one of the few patients who would have had both low and high energy, I'll be very very interested to hear your comments on the different treatment.

Re: To David L.

Pauline on 6/06/03 at 15:16 (121179)

David,
I live in the States, but as with P.F. treatment can I also be treated for my shoulder at one of the sites in Canada?

Re: For Dr. Z

Ed Davis, DPM on 6/06/03 at 15:20 (121182)

Pauline:

The same.

Ed

Re: For Dr. Z

Pauline on 6/06/03 at 15:35 (121187)

Where would your prices fit on the scale that John is quoting, and compare to the big guys Ossatron and Dornier's charges?

Re: To David L.

Dr. Z on 6/06/03 at 16:36 (121196)

Hi

When I inject a local steriod injection I use local palpation to locate the area that is painful. I have ultrasound but only use if for confirmation of pathology. I see where you are going with this and I appreciate the fact that physical palpation with patient feedback is a very important aspect for both ESWT application and local steriod injections.
My comments about the future literture refers to ESWT in general whether it be with or without ultrasound. I truely believe that ultrasound is very important with ESWT applications both pre ESWT evaluation and when is is used to moniter ESWT positioning.

Re: For Dr. Z

Dr. Z on 6/06/03 at 16:44 (121199)

In a previous posting by Dr. Ed he pointed out and I agree that most if no all doctors use an ESWT machine from an equipment company.. The doctors can reduce their fees if they want too. The equipment company never instruct any of the treating doctors on what their fee should be. So one way for a doctor to get more business would be to reduce his fee

Re: For Dr. Z

Dr. Z on 6/06/03 at 16:47 (121200)

Ed,
Would you say that the reason for the affordability is due to lack of FDA regulations and not whether it is high or low energy.

Re: For Dr. Z

Ed Davis, DPM on 6/06/03 at 18:34 (121210)

Pauline:

My basic goal was to find the most cost effective way to get my patients treated. My fee is $390 per treatment or $1170 for a series of 3 Sonocur treatments if prepaid. We do take into consideration patients' ability to pay and use a sliding scale as appropriate.

Ed

Re: For Dr. Z

Ed Davis, DPM on 6/06/03 at 18:39 (121211)

Dr. Z:

Yes. FDA regulations, the expense of chasing insurance companies around for payment and liability issues have raised the cost of not only ESWT but various treatments to the point that patients are being priced out of the market. We really need to take a serious look at what our 'system' is doing to costs. I realize that I am being redundant on this issue but I think that the ESWT situation is illustrative of the problem.

Ed

Re: For Dr. Z

Pauline on 6/06/03 at 22:04 (121220)

I thought this is what I said a while back and was told that the manufacturer and equipment company has set the fee structure by the cost of their equipment.

Doctors can drop their fees, but there's no incentives and currently competition is low.

Why should doctors drop their fee when they have no idea how much their best insurance payer will eventually give them toward treatment? It would seem in their best interest to keep costs at the higher end of the fee schedule right now in order not sell their services and treatment short.

Re: For Dr. Z

Dr. Z on 6/06/03 at 22:53 (121227)

There are two fees . One for the cost of the equipment/techician. Since most doctors don't own the equipment and thus have no true overhead they could lower their fee for performing the procedure. The cost of the equipment will and does dictate the cost of the techical fee which is the what is charged by the companies that own the equipment. So yes you are right doctors can drop their fees but equipment companies really can't due to the hugh overhead. expenses. Many doctors do lower their fees with hopes of getting more patients when they first start out.
Speaking of fees there are always going to be high , middle and low fees in every type of elective procedure performed. Some will go for the low fee, some will go for the best doctor they feel that will help them. So there is going to be different fees for different types of markets. Just last week I saw an Ad for lasik surgery at $500 per eye. I paid $3000 for both eyes.when I had my eyes corrected
I would never go to the doctor who is trying to either get patients with low balling the fee or his tring to do volume. There is the old saying you get what you pay for so if you can afford to pay for it you should if the fee is reasonable. By the way our fee is $2500 for one foot and $3500 for two . This includes all aftercare and any additional treatment that are determined to be needed

If is my opinion that is a very fair fee for ESWT for an high energy FDA approved machine in the USA. This isn't the highest fee in the USA and it isn't the lowest. So if you are looking for someone with alot of experience, an FDA approved ESWT machine for pf and willing to spend alot of time before,during and after the ESWT procedure Excellence Shockwave Therapy Group may be your choice for ESWT.

Re: For Dr. Z

Elizabeth C. on 6/08/03 at 21:44 (121336)

John,
I received what you are talking about(Three@$700.00/treatment). I asked the tech. how many patients they have treated and what was the sucess rate? She told me they have treated (Soncur-low frequency)100 patients and she has seen a 85% success rate. What concerns me is I never had an ultrasound as part of this treatment. She (the tech)could tell by my reaction the areas to work on. I would also tell her, especially when it was really painful. My Pod. did not tell me it was going to be painful. At my forst visit, I was in the waiting room, and I heard a woman screaming and crying. I was getting nervous, when the tech came out she asked if I was her new patient. I laughed and said 'I'm not sure!' She told me that the woman before me had a low threshold for pain. I just held my breath and held(clenched)on to the table. Now after reading that the high frequency is better, I feel discouraged, but I also heard there is a chance of nerve damage from a nerve block. Also, when I had my three cortisone shots in each foot, the pod just sprayed the inside of my ankle and injected the shot there. He didn't look for a sore spot, I wonder if that why I eventually tore part of my facia. Can someone respond to this?

Elizabeth

Re: For Dr. Z

john h on 6/09/03 at 08:19 (121359)

I think the general consensus on high energy vs low energy is that there is no consensus. From all I read I do not think anyone can say with scientific certainity that one is better than the other. I have only had high energy. So many variables here I doubt there will ever be an answer to this. Such questions as did the energy hit the right spot be it high or low? Did the patient really have PF? Was the patient on the road to recovery anyway? How did the patient act after the treatment(s)--did he rest,run,walk,etc? All these factors will make it most difficult to come up with a final answer as to what type of treatment is better?