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High-energy "I"

Posted by Jan R. on 11/30/04 at 11:18 (164954)

Let´s talk data:

Chronic Plantar Fasciitis: Acute Changes in the Heel after Extracorporeal High-Energy Shock Wave Therapy - Observations at MR Imaging.

Zhu F, Johnson JE, Hirose CB, Bae KT.

Radiology. 2004 Nov 24; [Epub ahead of print]

PURPOSE: To prospectively evaluate with magnetic resonance (MR) imaging the acute changes in the heel associated with extracorporeal shock wave therapy (ESWT).

MATERIALS AND METHODS: MR imaging was performed within 24 hours before and after ESWT on 18 feet of 12 patients (eight women and four men; age range, 33-63 years; average, 49.9 years) with chronic plantar fasciitis. ESWT was applied to the most painful point on the plantar surface of the heel, with a total of 1500 shocks at 18 kV. The images were reviewed to assess the post-ESWT changes in soft-tissue and bone marrow edema, the thickness of the proximal plantar fascia, and the presence of a heel spur.

RESULTS: Soft-tissue edema, which was present in 16 of 18 heels before ESWT, had increased in severity in 12 heels after ESWT. Calcaneus bone marrow edema at the insertion site was observed in eight heels before ESWT. After ESWT, the extant of bone marrow edema had increased in one heel and had newly developed in another heel. The heel spur seen in nine feet was not affected by ESWT. In 17 heels, the proximal plantar fascia was abnormally thick, with thickness not significantly changed with use of ESWT.

Here are my comments to the Editor:

Sir,

I read with interest the article by Dr. Zhu and colleagues on 'Chronic Plantar Fasciitis: Acute Changes in the Heel after Extracorporeal High-Energy Shock Wave Therapy - Observations at MR Imaging'.[1]

The authors claimed that in plantar fasciitis imaging modalities such as MRI were clarify some of the controversies regarding the effectiveness and mechanism of action of ESWT.

I would like to receive answers to the following objections:

(1) The finding that an increase in soft-tissue edema is the most common acute response associated with ESWT is not surprising as it is the typical unspecific manifestation of a posttraumatic reaction.
It remains unclear how this finding should enhance assessment of the effectiveness of ESWT and how it should allow to optimize the treatment?

(2) Their additional observations that the heel spurs seen were not affected by ESWT and that the proximal plantar fascia was abnormally thick in these patients, with thickness not significantly changed with use of ESWT are not at all new.
I wonder what results the authors expected when including only 12 patients in this trial?

(3) They wrote that patients were treated in a hospital outpatient surgical suite by using general anesthetic with either a face mask or a laryngeal mask airway. ESWT (total of 1500 shock waves at a power setting of 18 kV) was applied on the heel at the point of maximal intensity of heel pain.
If patients were under general anesthesia how was the point of maximal intensity of heel pain verified during the ESWT procedure?

(4) They found, although claiming to use a high-energy treatment protocol, that bone marrow edema had increased in one case and had newly developed in another case. They hypothetized that this relatively little effect on the bone marrow could be explained by the magnitude of the shock waves used in ESWT.
Following Ogden et al.[2,3]18 kV (defined by him as high-energy treatment) are equivalent to an energy flux density of 0.22 mJ/mm². In a recent article, Rompe et al.[4] treated patients at an energy flux density of 0.18 mJ/mm², defining this as low-energy. I therefore question the labelling of the treatment concept as high-energy. The negligible bone marrow reaction described in the current study supports this, particularly when compared to changes after real high-energy treatment.[5-7]
Why didn´t the authors discuss those references? Because J.E.J. had a financial interest through a partnership that owns and operates an extracorporeal shock wave device, OssaTron, and because one of the characteristics of the Healthtronics advertisement campaign is 'High-energy'?

Summing up it may be said that the results of this trial do not provide any new knowledge. The authors, in an extremely small number of patients, described an unspecific phenomenon common to a posttraumatic reaction.
It is my firm opinion that they should have waited with their publication until they had correlated pre- and post-ESWT MRI findings with clinical data, particularly long-term clinical data.


References

1.Zhu F et al. Chronic plantar fasciitis: acute changes in the heel after extracorporeal high-energy shock wave therapy - observations at MR imaging.
Radiology 2004; Epub ahead of print.

2.Ogden JA et al. Shock wave therapy for chronic proximal plantar fasciitis.
Clin Orthop 2001;387:47-59.

3.Ogden JA et al. Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis. J Bone Joint Surg 2004; 86-A:2216-2228.

4.Rompe JD et al. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med 2003; 31:268-275.

5.Maier M et al. New bone formation by extracorporeal shock waves Dependence of induction on energy flux density. Orthopade 2004; Epub ahead of print

6.Maier M et al. Detection of bone fragments in pulmonary vessels following extracorporeal shock wave application to the distal femur in an in-vivo animal model. Z Orthop Ihre Grenzgeb 2003; 141:223-226.

7.Maier M et al. Substance P and prostaglandin E2 release after shock wave application to the rabbit femur. Clin Orthop 2003;406:237-245.

Re: High-energy "I"

Dr. Z on 11/30/04 at 19:48 (164999)

Dr. Rompe,

There is one question that I can try to answer to shed some light

If patients were under general anesthesia how was the point of maximal intensity of heel pain verified during the ESWT procedure?

A good podiatric/orthopedic physician should be able to palpate the area of maximal intensity of heel pain ( pain epicenter) by physical palpation and then mark this area before any type of anesthesia.
I am very surprised and confused with the labeling of 0.22mj/mm2 as high energy by Healthronics. It has been explained by Sunny from Pain Free ESWT and From the podiatrist Scott from Australia that they use energy flux density levels above 0.28mj/mm2 during the 2nd or 3rd session of ESWT treatments. This would have one conclude that you can apply levels of 0.6 mj/mm2 or more during the 2nd or 3rd treatment session or that maybe energy flux density levels are different for different machines. Would you care to comment on this. Is 0.6mj/mm2 different on the dornier then on lets say the Sonocur or the Ossatron. I never could understand why Healthronics talks only in terms of KV and not mj/mm2. You have to twist their arm to get what is my understand that the international units are mj/mm2. Your comments in this area are appreciated. Anyone else who has engineering background i bes most welcome and invited to help me fine an logical explantation