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What questions should I ask? Anyone....

Posted by Connie H on 10/27/04 at 09:49 (162251)

I need to choose a new podiatrist, one who does ESWT, in a city 2 hours from where I live. I have a list of names, but I know nothing whatsoever about these people. What I'm hoping you all can help me with, is what questions should I ask them when I call up and talk to their office? These are the questions I've thought of, but I know you might have other questions that I'm not think of.

1) How long have you been doing ESWT?
2) What is your success rate?
3) How many ESWT treatments do you do in a typical week?
4) What is the cost? What does that include?

Any suggestions?
Connie

Re: What questions should I ask? Anyone....

Tina H on 10/28/04 at 20:44 (162376)

Connie- You should find out if it is high or low engergy and which machine it is that they use, if it will require gen anes. or just local numbing.

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/29/04 at 06:57 (162389)

Connie,
Please read message 71869 by Alan Gottliebsen from Australia. There is no need for either GA or LA when ESWT is being used for Plantar Fasciitis or any other tendon repair.
LA is only used in rotator cuff calcific (Shoulder spurs)
GA is only for the Non Union fractures of the long bones.
Lets set a few things straight, in the Blue Book,

ESWT Ultrasound Imaging of the Muscularskeletal System

Introduction
3rd paragraph
'It is important to point out that the latter indications pain treatment may be performed with 'soft' ESWT using low to medium energy levels, calcium deposit disintegration is observed at medium to high energy levels,'

As long as you obtain between 1000-1500mJ/mm2 over 6,000 pulses, within 3 months you should have a positive outcome.

The Dornier EPOS Ultra has intensity levels from 1-9. If you have the full 6,000 pulses at Level 9 that would equal 3,000m/mm2. If it was directed at bone spur (ie Shoulder) it would induce disintegration, or at a non union fracture site it would induce osteogenesis (development of new bone growth).

For all the patients I have treated with P.F, I have not used L.A. ankle block.
My patients give the direct feedback and with the Ultrasound targeting the exact site the intensity is only increased when the patient is comfortable to do so.

Donald Iain Scott
Podiatrist
Australia

Re: What questions should I ask? Anyone....

vince on 10/29/04 at 07:09 (162390)

If low energy ESWT is so effective, studies show different, why isn't it FDA approved? I think it's being pushed because the patient can be charged 3 times. The podiatrist who treated me had used low energy for about a year and gave up using it because of the extremely high failure rate. He said over 75%. He swtiched to using the Dornier EPOS and I was the 27th. successful patient out of the first 30. As far as discomfort using low energy he told me that practically all his patients had significant pain and could barely stand level 3.

Re: What questions should I ask? Anyone....

Dr. Z on 10/29/04 at 07:34 (162392)

Donald,

If I recall the dornier epos in the USA has different energy levels that yours in Austrialia. There are very few if no patients that can tolerate level six which is 0.29mj/mm2, without alot of pain and the inability to complete the treatment

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/29/04 at 07:37 (162393)

Vince,
What studies are you referring to?
What machine was used?
What levels?
As the pulses are administered there should be some numbing effect at the site before increasing the intensity.
In Australia FDA does NOT RULE here
Low energy means a gradual increase in intensity from Level 1 through to Level 9.

An Example of how it works in some cases it may vary from patient to patient

Remember there are 3 session 1 week apart

Week one 2,000 pulses Level 1 to Level 5
Week two 2,000 pulses Level 3 to Level 7
Week three 2,000 pulses Level 5 to Level 9

The rate 60/min 1/sec up to 240/min 4/sec is the speed the pulses are administered. Starting at 1/sec to target the site, increase the intensity until desired level in reached then increase pulse rate

Donald Iain Scott
Podiatrist
Australia

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/29/04 at 07:39 (162394)

Thats BS
Dornier sets the levels worldwide

Donald Iain Scott

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/29/04 at 07:44 (162395)

If that was the case why did your Jounrals approve the Buchbinder Paper for publication and your insurance companies give it credence.
I personally refute the Buchbinder study.

Donald Iain Scott

Re: What questions should I ask? Anyone....

Dr. Z on 10/29/04 at 08:22 (162399)

Donald,

I though we compared our machines before.
I also have spoken with Dr. Bach from Germany. His dornier has 13 levels. What is your level seven?

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/29/04 at 08:36 (162401)

Level 7 is .27mJ/mm2
Level 9 is .5mJ/mm2

What machine does Dr Bach from Germany have what year and what model?

The time here is 23:37 (11.37pm)I am going to bed. Good night everyone.

Re: What questions should I ask? Anyone....

Dr. Z on 10/29/04 at 11:48 (162416)

Hi
My level seven is 0.36/mm2
Dr. Bach has a dornier. Not sure of the year and or model. I believe it is around seven year old. Level 1-7 is exactly like mine after that if changes.

Re: What questions should I ask? Anyone....

vince on 10/29/04 at 18:11 (162437)

According to Dornier levels 8& 9 should not be used and at one point they were considering disabling those levels.
In addition I seriously doubt that anybody would tolerate any level above 4 without a local block for long enough to have any benefical effect. And that includes the 2nd, 3rd or 100th treatment. Level 7 is probably in excess of 35kpa.

Muliple treatment only mean multiple $'s for the podies.

Re: What questions should I ask? Anyone....

Dr. Z on 10/29/04 at 21:06 (162443)

Vince the FDA High energy approval treatment protocol for the dornier Epos ulras is 0.36mj/mm2 which is level seven. Level eigth is about 0.5mj/mm2 which is much too high for any ESWT treatment except bone fracture non-unions

Re: What questions should I ask? Anyone....

Ed Davis, DPM on 10/29/04 at 22:52 (162460)

vince:
Looking at individual situations is interesting but you have to consider the big picture. That is, why is most of Canada, Europe and non-US ESWT practice migrating to low energy? Because it works. It does not work for everyone, but then, nothing does.
Ed

Re: What questions should I ask? Anyone....

Ed Davis, DPM on 10/29/04 at 23:46 (162466)

Donald:
The act of acceptance of such a flawed study by a prominent journal can lead to damage to that journal's reputation for having quality and objectivity standards. Usually the New England Journal of Medicine is highly regarded but why the Buchbinder paper got accepted and published is a good question. One possiblity could center around the overall lack of knowledge and expereince by US physicians on the editorial board of that journal concerning ESWT -- giving them the benefit of the doubt. One can certainly only speculate on more sinister motives...
Ed

Re: What questions should I ask? Anyone....

Lori S. on 10/30/04 at 01:32 (162472)

At level 7 with my heels numb I could feel it somewhat. I couldnt imagine not being numb.

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/30/04 at 07:21 (162480)

Ed,
That means that all studies prior to 2003 are invalid, unless all machine being used in the studies have the SAME mj/mm2 rating at the SAME intensity.

I have just contacted Dornier in Germany to put this matter to rest once and for all.
Dr Z. said that one machine goes to Level 13. If you use parabolic scale to measure the intensity what would the mJ/mm2 be?

Researchers are now using META analysis in their studies and the results are not pure,and could be detrimental to the out come of the research.

Don

Re: What questions should I ask? Anyone....

Tina H on 10/30/04 at 08:07 (162484)

I agree with Lori, With all due respect to Dr. Scott, who knows more about this than I, Even with numbing shots, being treated with high energy shock waves in the US is not a walk in the park! In fact my doctor said she accidently hit her hand with shock waves one time and it made her cry it hurt so badly. (She related this story after I asked if I could try it without the shots) Tina

Re: What questions should I ask? Anyone....

Ed Davis, DPM on 10/30/04 at 10:07 (162491)

Donald:
There seems to be some question, based on the nature of your discussion with Dr. Z, if the machines Dornier is marketing are identical in terms of energy level coorelation with output. Nevertheless, I don't think that the outcome of that question being affirmative or not will have a bearing on the final conclusion of efficacy.
Ed

Re: What questions should I ask? Anyone....

Ed Davis, DPM on 10/30/04 at 10:22 (162496)

Don;
In other words, we may be unnecessarily confusing readers here over a technical matter that has little relevance to the outcomes.
Ed

Re: What questions should I ask? Anyone....

Pauline on 10/30/04 at 10:59 (162502)

All aspects involving a patients treatment I consider relevant and cost and payment are part of that treatment. How the doctors and providers are collecting their fees are also relevant because patients pay whether its out of pocket or through insurance payments.

We should care about the 'behind the scene' arm twisting that is going on.
They are dueling with our money.

Re: What questions should I ask? Anyone....

Dr. Z on 10/30/04 at 12:01 (162508)

Donald,

This is why it is important to talk in terms of mj/mm2 and the total amount of energy given for the entire treatment.
The FDA approved Dornier epos ultra study was level 7 ( 0.36mj/mm2) Total amount of energy delivered 1300 mj/mm2

Re: What questions should I ask? Anyone....

Ed Davis, DPM on 10/30/04 at 14:49 (162539)

Pauline:
Yes but the discussion here is about a question of energy levels being equivalent on various machines, not the issues that you have brought up.
Ed

Re: What questions should I ask? Anyone....

Dr. Z on 10/30/04 at 17:26 (162567)

It sure does hurt. Even low energy hurts in the range of 0.22mjs/mm2

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/30/04 at 23:07 (162580)

Ed,
You are very much spot on. As long as the patient is getting the best possible treatment result.

Don

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/30/04 at 23:31 (162581)

Pauline,
In Australia our Medicare system does NOT cover ESWT. If you have private cover at the TOP ancillary level you might get back 60% of the treatment fee. I am the only Podiatrist in Australia currently using the Dornier EPOS Ultra, based in a Radiology Practice in Sydney, New South Wales. All other Dornier machines are in Radiology Centre, Melbourne, Adelaide, Perth, Canberra and Brisbane.
There are at least 2 Dolcast machines in use, but they are classified as RSWT (Radial).

What a practitioner charges is based on what type of expenses they incur throughout the financial year,

Cost of machine
Rental of machine
Cost of consumables
Rent on rooms
Wages for staff
TAXES
Vehicles costs
Insurances
Advertisement
Postage
Stationary

This list goes on

To give you an idea and this is rough, for a podiatry consultation it cost ME $20.00AUD before I see the patient and they sits in the chair

For a dentist it is around $32.00AUD

If you own a small business you can relate to the above list.

Being a health professional (Podiatrist) in Australia on insurance alone is about $1,000 AUD per month on average $12,000.00AUD PA

A patient should enquire as the to success of treatment, the practitioner should be honest in their answers.
If the patient knows someone who has had good results from, they should be confident of getting the same results. BUT as we know no two people are the same and the outcome maybe entirely different.

Don

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/30/04 at 23:44 (162582)

Dr. Z,
When I was trained it was drummed into me that the patient must get between 1000 -1500 mJ/mm2 to obtain best results

For Achilles tendonitis the same but only up to level 5

That after treatment at 12 weeks best results are achieved.

If our machine are giving different outputs our mathametics will be all skewed

Is this correct

Don

Re: What questions should I ask? Anyone....

Donald Iain Scott on 10/30/04 at 23:51 (162583)

Vince,
All the patient I have treated over the past 2 years have reached level 9 at some stage of the treatment WITHOUT L.A. and at least 1,000 pulses.
I work on a three treatment course.
My wife was the 27th person treated in Australia in 1998 and she was able to toletate over 5,000 pulses at level 9. Her treatment is on record at South Coast XRay in Wollongong. (NOT TREATED BY ME)She is clear of PF since 1998

Don

Re: What questions should I ask? Anyone....

Dr. Z on 10/30/04 at 23:55 (162584)

Scott

What energy is level 5
and what is the total amount of energy you gave for insertinonal tendinosis?
Thanks

Re: What questions should I ask? Anyone....

john on 10/31/04 at 00:17 (162589)

Dr Scott,

Based on your levels and protocol, it seems that you are providing high energy ESWT treatments. When the patient comes in for the third treatment, is their foot numb? Are you able to start at level 9?

Re: What questions should I ask? Anyone....

Donald Iain Scott on 11/04/04 at 02:08 (162915)

John,
The foot is not numb. Third Tx. By 500 pulses the level is increased to Level 9 and NO L.A.
I am about to give an update from Dornier Look at Machine V.s Machine.

Don

Re: What questions should I ask? Anyone....

john on 11/04/04 at 07:27 (162919)

Donald,

Would you say that you are giving a high energy treatment? It looks like you are delivering the same amount of energy that is given in the US protocol.