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an alternative view of ESWT

Posted by elliott on 3/16/05 at 10:37 (171301)

For the most part, the dominant view we see on this board is that expressed by ESWT providers--not casual providers, but those concentrating on it and earning a good bulk or even all of their income from it. They have left enough of an impression on all the boards here that the prevailing thinking and advice offered by posters is that every PF pain sufferer who has tried some conservative measures and not had success within 6 months should strongly consider ESWT (price no object). Since it gets virtually no airtime around here, I think it's worth at least mentioning that there is an alternative but still respectable view (I don't mean my own), namely that ESWT does not really work or if so only marginally. Please read carefully Blue Cross Blue Shield's updated (Dec 04) Tec Assessment on ESWT for plantar fasciitis, whose conclusion is to reject coverage of ESWT:

http://www.bcbs.com/tec/tecinpress/02.html

Yes, BCBS might be viewed as slanted against new treatments it'll have to pay for (as if ESWT providers are not automatically slanted for it). But that does not mean its reasoning and conclusions are invalid. It should also be remembered that covering ESWT does not automatically mean a loss for BCBS; what it certainly would mean is hefty premium and/or out-of-pocket increases for those with BCBS coverage, especially if PF really is an epidemic as many claim.

In previous versions of this report, BCBS basically lumped together the results of all studies it considered to be of sufficient quality, e.g., including Buchbinder's low-energy Dornier study on patients with shorter-term symptoms, using the rationale that no clear evidence has been offered as to ideal protocol of machine settings and patients. But this time around, they also offer separate combined statistics for just the high-energy studies, generally perceived as being of higher quality. What they conclude is that there is a small bias in favor of ESWT for first-step-in-the-morning pain, but that this does not translate into improved function, and that overall, ESWT has not been shown to improve health outcomes.

The report discusses the Roles & Maudsley scoring. For the two high-energy trials, the number needed to treat (i.e., to declare a single success actually attributable to the machine based on the test measure) was a dismal 6.

--

While on this topic, there is a feeling out there that the Dornier Epos is sort of the gold standard in ESWT machines. Not enough has been talked about the *complete* Dornier FDA results. Here is a list of ALL the tests in the Dornier FDA study, and the outcomes as compared to the control group at 3 months (at which time the control group was unblinded):

PRIMARY:

1) VAS improvement from baseline in first few minutes of walking in the morning: *just barely* statistically significant.

2) At least 60% improvement in pain while walking the first few minutes in the morning: *not* statistically significant.

SECONDARY:

1) AOFAS Ankle-Hindfoot Scale: *not* statistically significant
2) 4-point R&M: *yes* statistically significant
3) SF-12 health status questionnaire: *not* statistically significant
4) Heel pressure test: *not* statistically significant
5) ROM assessment: *not* statistically significant

In summation, of all the tests, the only one that had clear statistical significance was 4-point R&M. The other test results, so conveniently ignored, should at least give pause before any sweeping conclusions as to efficacy should be made. At the least, given Dornier's pre-testing expectations as to success based on its own selected test measures, one could say the results were downright disappointing. That does *not* mean that FDA approval wasn't warranted. But if Dornier approval were not granted, I don't think that would have been an irrational decision either.

Re: an alternative view of ESWT

Dr. Zuckerman on 3/16/05 at 11:09 (171303)

They also stated that the new disc implant that John H has talked about in detailed is considered investigational and not needed . My cousin had this procedure done and is now pain free and off narcotic's. Her life was ruined before she had this implant that Blue Shield claims doesn't contribute to the quality of life.
My thoughs toward this report are there ANY new technologies from any Blue Shield Tech report that they reported considered worth paying for. I couldn't find one one that Blue Shield was willing to accept and pay for. So this is a what I call a report for rejections not approvals.
Elliott your report is excellent however I don't see one important word in this very lenghty post. The word is patient.

Patients will always seek out ESWT regardless of insurance coverage or no insurance coverage. ESWT should always be considered before foot surgery and that has always been my advocation, nothing more nothing less.

Re: an alternative view of ESWT

Tina H on 3/16/05 at 11:36 (171305)

My 31 year old sister in law, mother of 4 small children, has been advised by two different specialists (two opinions) that the artificial disc is the way to solve her chronic back problems, which are aggrevated by her job as a ultrasound technician. Sadly BCBS is denying this and she will likely have the traditional surgery because that is what insurance will pay for even though both doctors feel the disk would be better for her long term quality of life. Really sad when you have an operation that you know is less than ideal goes agains what the doctors advise.

Re: an alternative view of ESWT

Dr. Zuckerman on 3/16/05 at 12:00 (171311)

Tina H,
Get the disc operation. My cousin's life has changed. She was on pain medication ( demeral) for two years and now her life is painfree. This is the point I have been making with Elliott from the beginning. We are treating patients not stats and not studies. The FDA approved this implant divice. Where does Blue Shield tech have the right to go against FDA studies and doctor who have alot more experience then Blue Shield

Re: an alternative view of ESWT

Tina H on 3/16/05 at 12:34 (171316)

Yes, she should have it. Both doctor's office's are fighting with the insurance company, but it's not the kind of opreration a young, working couple can afford to pay for out of their pockets, and if there are complications after, there is a question as to wether any of that would be covered as well. But thanks, it good to hear that your cousin had such a positive experience. I'll relay that to my sister-in-law.

Re: an alternative view of ESWT

Dr. Z on 3/16/05 at 21:04 (171362)

The procedure with Hospital costs must be in the 30 thousand dollar range.

Re: Replacement lumbar disk

Pamela R. M. S. on 3/17/05 at 12:54 (171411)

I was facing a hard choice of fusion, or borrowing money and getting the disk replacement. I did NOT want the problem of 'cascading' disk problems down the road (fusion tends to cause more pressure on the disk above, and it will fail faster). I took a deep breath, borrowed funds from my 401K, and went to Alpha Klinik in Germany and had the disk replacement. I chose that location because the surgeon who does the Charite disk replacements there has more experience with that surgery than anybody else in the world (he had done over 700 of them by the time I saw him, and he has done more since then).

I definitely do not regret my choice - I have my life back. The pain originating from the disk is GONE. From time to time I'll get some nerve root irritation, but most of the time I am completely pain free. Not only that, but I can sit again! I had ongoing issues (even after a diskectomy) for over 11 years, but the 2 years before the surgery were really awful. In addition, after the surgery, I noticed that I got back my normal lumbar curve. My lumbar curve after the discectomy had not been normal, and relacing the disk fixed that.

Re: Cost in Germany

Pamela R. M. S. on 3/17/05 at 12:57 (171413)

To get the surgery done in Germany, I paid about $16,000 for EVERYTHING (medical-cost wise). (Of course, the dollar has degraded in cost against the euro). That included 4 days in the hospital, lumbar corset, discogram, surgeon, anestheologist, etc. - EVERYTHING! Of course, I had airfare expenses getting there and home, and some hotel expenses before and after the hospitalization.

Re: an alternative view of ESWT

elliott on 3/17/05 at 15:47 (171436)

Dr. Z, 'patient' is one word; another is 'provider$'. A better answer than the emotional angle would be to show the loopholes in BCBS's reasoning.

Re: an alternative view of ESWT

Dr. Zuckerman on 3/17/05 at 19:15 (171450)

Its call the human angle.

Re: an alternative view of ESWT

Dr. Z on 3/17/05 at 21:16 (171456)

I don't believe the disc operation is 100% What were you told you chance were

Re: an alternative view of ESWT

Ed Davis. DPM on 3/24/05 at 00:33 (171860)

Elliott:
Perhaps I am the oddball out but I am NOT earning a good living from ESWT.
I would make a lot more in the short term with surgery. Nevertheless:
1) I feel that I am doing the right thing
2) the majority of my patients, given the choice would prefer a non-surgical treamtent to surgery.
3) I beleive that, I am establishing a good reputation in the medical community by doing what i feel is the right thing. Not all docs accept ESWT although the majority who refer to me feel that I am being honest and appreciate the fact that I am avoiding surgery.
washington has very few third parties that cover ESWt so I am givng patient deep discounts with Sonocur are availaing myself of the services of United via their 'discount' offer to patients.
Ed

Re: an alternative view of ESWT

Dr. Z on 3/24/05 at 00:50 (171862)

Ed,
There is nothing wrong with earning a good living by providing a service that is helping your patients. There is no reason to defend the way your make your living as long as it is honest and legal.
You pointed out the fact that this is an ESWT section and that this is where ESWT should be discussed. If patients want plantar fascia releases so be it.
I never understood why this thread was started. This is an ESWT section so this is where ESWT is going to be discussed.

Re: an alternative view of ESWT

elliott on 3/24/05 at 09:40 (171878)

Dr. Z, yes, as you say, there is nothing wrong with earning a good living by providing a service that is helping your patients, one that is honest. I couldn't agree more.

Not sure why you feel this thread was not appropriate for an ESWT board. ESWT's effectiveness, or lack thereof according to the opinion cited, is certainly relevant to the pain sufferers here reading about and considering ESWT. Or are only pro-ESWT views allowed?

Re: an alternative view of ESWT

Dr. Zuckerman on 3/24/05 at 10:26 (171879)

Elliott,
I agree.