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Got concerns, write

Posted by Pauline on 10/10/03 at 15:28 (133482)

A way to get your individual concerns answered by Dr. Buchbinder.

Thank you for your email and we understand your concerns.

We are happy to engage in informed discussion and debate concerning our study in an appropriate scientific forum. We have already done so in Letters to the Editor in JAMA and will do so again for any letter to the editor that are published in the future.

(eg. see Buchbinder R, Forbes, Ptasznik. Shock wave therapy for treatment of plantar fasciitis (Letter) JAMA 2003;289:172-3.)
Best wishes
Rachelle Buchbinder
Director, Associate Professor
Department of Clinical Epidemiology, Cabrini Hospital
Department of Epidemiology and Preventive Medicine
Monash University

Suite 41
Cabrini Medical Centre
183 Wattletree Road
Malvern Vic
Aus 3144

Tel: (613) 9508 1652
Fax: (613) 9508 1653
email: (email removed)
website: http://www.med.monash.edu.au/epidemiology/

Re: Got concerns, write

Ed Davis, DPM on 10/10/03 at 15:40 (133485)

Good find! We need to make you the official detective of heelspurs.com :)

Did you write to Dr. Buchbinder yet?

Re: Got concerns, write

Pauline on 10/10/03 at 15:47 (133487)


Re: Got concerns, write

Ed Davis, DPM on 10/10/03 at 15:48 (133490)

What was Dr. Buchbinder's response (of course I am guessing about the question you asked)?

Re: Got concerns, write

Pauline on 10/10/03 at 16:00 (133497)


Re: Got concerns, write

Donald Iain Scott on 10/10/03 at 17:17 (133521)

Polite!!! does not cut it. You have written out what is on the web sit of Monash University. What we need are specifics answers from Buchbinder.
By the way no one has made any attempt to reply to my previous post. So to all the detractors of ESWT. PUT UP or SHUT UP


Re: Got concerns, write

Pauline on 10/10/03 at 17:24 (133526)

Wants and needs are two different things. Sometimes you don't get all your wants.

I took the time to write a personal letter and received a response. I'm not required by anyone to make any of my personal correspondance public.

My post was merely information so other needing questions answered may do the same. No more no less.

Re: Got concerns, write

Ed Davis, DPM on 10/10/03 at 17:27 (133528)


The impact of the Buchbinder study was very strong as Buchbinder is what most of those who oppose ESWT are using. There were major problems with the study and an answer is needed from Dr. Buchbinder as to why her study deviated from the manner in which such a study should have been conducted.
The net effect of her study was a tool that was used to deny patients in pain, needed, effective treatment so you can understand Donald's frustration.

Re: Got concerns, write

Ed Davis, DPM on 10/10/03 at 17:31 (133531)

Your response here comes across as teasing people in need who want to know why a flawed study got big political billing and is used to deny their treatment. That may not be your intent but it is the end effect.

Re: Got concerns, write

Pauline on 10/10/03 at 19:21 (133554)

Dr. Ed,
All they need do is write. I provided the address. Anyone that has issues should get them addressed individually. I provided that means. .

I had an issue, I delt with it and received my answer. Others here now have an address to do the same.

I thought it might be helpful , but if it's not then the post should be deleted.

Re: Got concerns, write

Pauline on 10/11/03 at 07:27 (133590)

I'm in a quandary as to why you as a doctor who provides ESWT along with other colleagues,and the Podiatric Medical Societies haven't formally asked Dr. Buchbinder for the answers you seek on this site.

Perhaps this has been done and I missed the posted response that was received.

I doubt a formal inquiry made by members of an entire medical society would go unnoticed publicly or not receive a response. I would think a
poignant letter from such a large group would resonate throughout all the halls of medicine and those of insurance companies. It certainly would have a better chance to achieve the answers to the questions you pose on this board.

Posting your question here is one thing, but by going to the well you may find water. Will it be drinkable as Dr. Rompe pointed out is another question.

Re: Got concerns, write

Dr. Z on 10/11/03 at 08:15 (133594)


ESWT is such a young procedure in the USA. There are maybe five hundred plus doctors in the USA doing ESWT . It is growing each and every week but it is still a very small number.
I don't know of any LARGE medical society that would write a letter for a procedure that most don't perform or even know what it is all about.
Medical Societies don't tend to get involved with these types of issues.
I have been impressed with our APMA and how they have worked with ESWT Doctors, insurance issues, and even written ESWT policy for podiatrists to use.
I think Dr. Rompf stated it very well that the writers such as Dr. Buchbinder and group had no clinical experience with ESWT/plantar fasciitis and were writing strictly from what pateints they were given etc.
The parameters of any study should include clinicians that treat the disease and the study should only include patients that are typically treated with ESWT.
I look at the Buchbinder study as a study that confirms what patients not to include in ESWT treatment.
I have found that the Buchbinder study in MOST cases had no effect what so ever on insurance coverage except for Aetna US Healthcare
In a court of law Aetna would get its A__ hung out to dry if they used this study as the for its foundation for non-coverage ESWT
What concerns Dr. Z about the entire issue of this study was how only this study hit the major newspapers and news media. Did Dr. Rompf sucessful papers get such PR?
These is no question in my mind that just maybe there were insurance interests behind the entire pr Blitz. Come on it is only ESWT and every newspaper, TV etc has coverage for this.

If was a great learning experience for Dr. Z. Our ESWT group became stronger and better. We received so much positive pr as a result of this . I actually signed our first major insurance contract because I brought to the attention of the medical director of a specific company . I evaluated the article for him and he completely understood
It is possible to turn lemons into lemonaide and this Buchbinder article in the long term is going to be positive for ESWT. IT will be only one piece of the puzzle for anyway to read,understand and learn.

Re: Got concerns, write

Pauline on 10/11/03 at 09:46 (133601)

Dr. Z,
If the Buchbinder study had no affect on insurance coverage accept for Atena U.S. Healthcare, why does Dr. Ed keep posting it has such a powerful impact on insurance coverage.

I still think that a lobbying group from the American Podiatric Societies
should at the very least address the issue in the formal medical arena
indicated by Dr. Buchbinder.

She apparently has no problem discussing the issue at a formal medical forum. Why not talk to or in front of her instead of behind the scenes here? It seems to me it would make more sense.

The best way to eliminate that which haunts this issue here, a created boogie man of sorts, would seem best handled by confronting the issue in the correct arena.

Re: Got concerns, write

Dr. Z on 10/11/03 at 10:29 (133606)

I am talking about in my region of the country . Each part of the country could be different.
Maybe I missed something. What formal medical forum can I discuss her article in.
I agree 100% that you go to the source to handle any problem that may or may not be real.

Re: Got concerns, write

Pauline on 10/11/03 at 11:15 (133614)

I'd give her a call to find out when and where or get published.
We are happy to engage in informed discussion and debate concerning our study in an appropriate scientific forum. We have already done so in Letters to the Editor in JAMA and will do so again for any letter to the editor that are published in the future.

Re: interpretation

Ed Davis, DPM on 10/11/03 at 11:31 (133615)


Dr. Z makes a good point in that if the study is properly interpreted the conclusions are somewhat different: the study shows which patients should not get ESWT.

Sometimes you assume that we are a more unified or monolithic group than is the case. We rarely publish things as a group or take on projects as you suggest.

Re: Got concerns, write

Ed Davis, DPM on 10/11/03 at 11:37 (133617)


The study SHOULD not have had a significant effect. Nevertheless, the national tech committee for Blue Cross/ Blue Shield used that study for an adverse recommendation on ESWT as did the WA State Dept. of Labor and Industries. One, though, must wonder about the objectivity of such organizations as it appears that they were looking for any piece of evidence to fit their agenda.

The other thing that was unusual was that that paper, flaws and all, was accepted for publication in a 'prestigous' journal such as JAMA. Why would a journal of that caliber accept a paper which, under 'normal' circumstances would not pass muster? Was it a 'slip' by JAMA editors or...????

Re: Got concerns, write

Dr. Z on 10/11/03 at 12:12 (133625)

My first impression was how could the AMA journal accept such a flawed study?
Here is my take. Why shouldn't they accept this study. The AMA editorial board probaby doesn't know anything about plantar fasciitis.
The AMA board probaby doesn't know anyting about proper ESWT selection. The AMA journal probaby only looked at this from a standard protocol for proper double bind studies which it then considered it to meet the BARE miminium standards

As time passes and more and more papers are written confirming ESWT effectiveness, this AMA paper will be placed in its proper prospect.
Here are a few strange observation. AMA journal for an orthopedic/podiatric procedure. ?????? Why not the JBS? Dr.Rompf published
previous article in this journal you would think the logical approach would be to go to a journal that is read by orthopedic and or podiatric physicians.
Why did they pick the AMA journal? I have learned over and over what comes around goes around and when the truth comes to the surface the Blue Shields will have to answer to the subscribers.
I was reading in the newspaper today when a poor two year old was left numb from the neck down and a New York Giant Fan left the game drunk and injured her. The family is sueing everyone but the football.
So I can see down the road patients sueing Washington State Blue Shield after undergoing plantar fascia release. Claim was fraudant reject of pre-certification for ESWT. Patient claims that her perment 100 billion injury
of RSD was directly related to her lack of acess to ESWT services. Blue Shield Tech committe deposition will be taken next week . This isn't funny it can be done and don't think it won't . Remember only in America !!

I remember when ESWT fist start in the USA. Insurance company didn't even know what ESWT was. No code etc. What really stuck in my mind was how patients after fighing,arguing and even sueing were paid by the Blue Shields.
I have a fold of all of the check made out to the patient in the 1oo cents on the dollar repayment to the patient. I have alot of these.
So it can be done by it must come from the subcribers with the help of teh doctor, human resourses. etc.
If the doctor leads the fight with patient on board there is no way anyone will win. It just how it works.
If it will Dr. Z I will just fill out a small claims form for $20 and serve the insurance company CEO. This is the best way to get the attention quickly and not one year after the fact. You must serve the CEO's .
Maybe I should start a company and get patient paid for ESWT. I am really good at it because I NEVER NEVER give up.
So if there is any form that you wnat on this board it is a small claims form to sue . I have the link for New Jersey. If anyone wants them just ask
I am sure that every state has a web site for small claim which is a division of superior court.
Hey anyone want to start a company. ED?

Re: Got concerns, write

Ed Davis, DPM on 10/11/03 at 12:26 (133628)

Dr. Z:
All valid points. The company suggestion sounds like an interesting idea. Like any 'business' it will have overhead -- how does the company get reimbursed -- by the docs? patients? ESWT machine owners?

Re: Got concerns, write

Donald Iain Scott on 10/11/03 at 18:27 (133653)

To all
It look like I have stirred the Kangaroo stew.
Ed, I am a current member if ISMST
Buchbinder live in Melbourne about 1,000km South of me.
I have tried to phone Buchbinder, but cannot get past the secretary
epodiatry 13th october 2003 has two articles on ESWT
I still maintain that once a patient leaves our care what they do to there body is their responsibility. Any injury how slight (may,could, somehow might) affect the plantar fascia, so asking a patient 12 months down the track if their pain levels have reduced or increased are/is irrelevant.

Donald Iain Scott

Re: Got concerns, write

Dr. Z on 10/11/03 at 19:04 (133660)

Where can I read the two articles in epodiatry? Never heard of Kangaroo stew do you like it cooked with high or low energy. Ha Ha. Seriously has the Buchbinder study had any deleterous effects with your patients. They don't read the AMA journal or see the USA newspapers.

Re: Got concerns, write

Ed Davis, DPM on 10/11/03 at 19:21 (133661)

Buchbinder may answer inquiries selectively. I don't think it is up to use to chase her down -- what was done was done. There are some much better studies in the pipeline.

Re: Got concerns, write

Donald Iain Scott on 10/11/03 at 23:14 (133682)

Dr Z,

http://www.epodiatry.com is a US publication group they appear to be able to access podiatry artilce from around the world.

Kangaroo stew is cooked at low energy for several hours. Very high in protein but the meat can be very chewy.

The only effect the Buchbinder study has done is to make me concerned that a university could allow this type of study to take place, the long term effect is, will this or any other institution get further funding if they waste taxpayer money.
In Australia people interseted in ESWT have gone to their G.P. They then go the the Radiologist for X-Ray and Ultrasound. With only 10 ESWT nation wide feed back to patients from the G.P's is still limited.
Australia has a population of less than 20M and at present the medicare system is in meltdown, private insurance companies pay back a pitance of the $500.00AUD that I charge for 3* 2000 treatment


Re: Got concerns, write

Donald Iain Scott on 10/11/03 at 23:20 (133684)

To true Ed, Melbourne has now had 12 months to re-evaluate and her whole study, maybe now it can be put in FILE 13

There is a group in Asia experimenting on Achilles Tendon and another in Europe working on Plantar Facia thickness


Re: Got concerns, write

Ed Davis, DPM on 10/11/03 at 23:42 (133686)

There is a lot of taxpayer money wasted on worthless studies. Most of it gets stuck in some obscure journal. The difference with Buchbinder is that, somehow it got thrust into the limelight. Dr. Z has a plausible explanation for it above, although, I cannot help but wonder. By the way, my local Medicare carrier, I beleive, has set the reimbursement rate at about $375 US so with the exchange rate, we've got you beat.

In the US, providers cannot balance bill above the Medicare allowable fee. I don't know how that compares in Australia.

Re: Got concerns, write

Donald Iain Scott on 10/12/03 at 00:06 (133689)

In Australia MEDICARE is the Federal Government. They do not cover Podiatry or anything related to podiatry. It was introduced in 1983 by the Labor government.
Our exchange rate is about $1.00 AUD to .65 centes USD so $500AUD is about $325USD


Re: Got concerns, write

Ed Davis, DPM on 10/12/03 at 00:51 (133693)


Medicare in the US is only for those 65 yo and older. It does cover podiatry.

Such coverage can be both good and bad. Coverage means control over services. For example, no one can afford to provide ESWT for $375 so, as a consequence, I am not familiar with any Medicare patients who have had ESWT im my region since that coverage went into effect on July 1, 2003.

Re: Got concerns, write

Pauline on 10/12/03 at 09:47 (133714)

I think it's very easy for people to call her study 'flawed' in this arena, but very few have taken her on face to face.

Dr.Z has data on his patients dating back to 1999 maybe earlier, you've got data, Dr. Z's partners all have stats., as well as, all the other Pods. that are providing ESWT. Dr. Weil is well published and respected and also has collected data. Why don't those that think this study is flawed put their collective data together, present it to her and her colleagues and ask questions? Pods are leading the way in using ESWT in the U.S. it's only logical they take her study on.

It's very easy to keep saying her study is flawed, but without an attempt on the part of those that keep crying 'flawed' to provide their contrary evidence in a scientific forum I think weakens your case.

Why not attempt to dethrone the study within the walls of science instead of simply repeating the same words over and over here?

By now you all have the data to support what you are claiming. Why not do something positive with it?

I think you can continually yell JAMA has been discredited by accepting this study, but I think you'll do little damage to it's reputation unless you can prove otherwise.

Re: Got concerns, write

Dr. Z on 10/12/03 at 10:03 (133716)

There is nothing to dethrone. This is a ESWT study for plantar fasciitis with certain levels of energy and certain patient inclusions ie six week duration.
This paper is just a very small piece of the ESWT puzzle. There will be many papers in the future regarding eswt and each paper will have variations due to the criteria and patient population.
Time will be the only thing that will place this paper in it proper historical order. Is it flawed? that will depends on what this paper set out to prove. I would have to go back and see if Dr. Buchbinder stated a goal in her paper.

Re: Got concerns, write

Pauline on 10/12/03 at 10:31 (133721)

I agree it's simply a study among many others that have been presented and those that are still to come. To base the decline of JAMA on it seems to me to be a little over the top as the Brits. would say.

As Dr. Rompe pointed out no study is perfect, but that doesn't mean under the perimeters that were set for the study it's flawed, in any way, and she's seems more than willing to personally discuss this paper in any scientific forum with any one or group.

I don't think a conflect of interest involving insurance companies has been proven or been associated with this study.

Re: Got concerns, write

Dr. Z on 10/12/03 at 10:50 (133725)

Dr. Rompf comments were very eye opening to Dr. Z. Initially there was alot of emotion even with Dr. Z but now with time I understand that the AMA journal was just publishing an article. Still very strange why this wasn't published in other journal such as APMA JBS ( orthopedic )

It is my opinion that there is a conflict of interest when the insurance companies use this article in their review. Here is why I say this. The standard Blue Shield Policy for any ESWT coverage is six months. This article had patients with pf as early as six weeks.
Now the problem of proving conflict of interest or what impact this article had with the Blue Shield Tech Committee when discrediting ESWT is very hard to evaluate. I have no idea role whether positive or negative this article was used in this tech committe evaluation. Maybe it was used to confirm their original medical policy of must be six month duration who knows
And to be honest who really cares. Here is how I see ESWT . It MUST stand on it own two feet . If insurance is the only thing that keeps it alive then let it die. It must survive on its ability to provide a safe, effective procedure that improves the quality of life in a heel pain patient.
I do ESWT because I have observed and I believe its ability to cure patients without foot surgery. I believe and I have observed how safe and effective it can be.
I have also observed and seen how dangerous foot surgery can be and have it can ruin a patients foot and life. !!
So let the paper be published and lets see where this technology goes from here.

Re: Got concerns, write

Pauline on 10/12/03 at 11:28 (133731)

It might have been had it been submitted. Do we know if it was?
How many multiple journal published studies have their been in the past? Maybe among researhers it's not common practice nor felt necessary.

I don't think we can think of medical journals like newspapers, everyone gets the story.

Re: Got concerns, write

Pauline on 10/12/03 at 11:55 (133732)

Dr. Z.
I found this for publication requirements for NEJM which may be similar for all medical journal publications.

It looks like they may be restricted because it is original materal.


Manuscripts containing original material are accepted for consideration if neither the article nor any part of its essential substance, tables, or figures has been or will be published or submitted elsewhere before appearing in the Journal. This restriction does not apply to abstracts or press reports published in connection with scientific meetings. Copies of any closely related manuscripts must be submitted along with the manuscript that is to be considered by the Journal. The Journal discourages the submission of more than one article dealing with related aspects of the same study.

Re: Got concerns, write

Dr. Z on 10/12/03 at 12:26 (133733)

You can only submit to one journal. I don't know if you are rejected by one journal you have to tell the next that you were but you can't submit to more then one journal at a time