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To Elliott

Posted by Ralph on 5/19/05 at 14:11 (175326)

Finally got to reading the BCBS report that you linked to. Thanks for posting it. It's the first time I've seen the definitions used with the Roles and Maudaley Pain Scores. Interestingly enough an Excellent score means NO pain, full movement, and full activity.

I don't remember, in my short time on the board, ESWT treated patients coming back to post an 'Excellent' result in all aspects of pain relief and activity as required in the Roles and Maudaley scoring system to report an excellent pain score.

I think Doctors who choose to survey their own patients need to use the same Roles and Maudaley scoring definitions because they clearly define the difference between poor, fair, good and excellent as these words relate to Pain and results.

It's also interesting to note the similarity in occurances of adverse events from those patients treated with ESWT and those in the Placebo group. The mind works in mysterious ways and at times can product similar effects.

I don't know how extensive the first BCBS report was but over all I think they did a nice job with this one. Using ESWT to lessen first morning pain while being a good thing may not be any more effective than using a night splint to achieve the same thing, but BCBS is looking for more.

BCBS is looking beyond a mere reduction in morning pain. According to their decision in this report while ESWT may reduce morning pain that in itself is still not significant in the over all performance of ESWT in the treatment and cure of P.F. The compared studies don't seem to prove beyond a reasonable doubt that ESWT has the ability to restores one to full movement and activity which in their view is the major 'player' in determining the effectiveness of the treatment. First morning pain comes along for the ride.

Re: To Elliott

john on 5/20/05 at 04:17 (175346)


Isn't it interesting that BCBS did not consider getting rid of heel pain curing plantar fasciitis. I thought that eliminating pain was the goal of heel pain surgery.

It seems absurd to me what BCBS is saying.

Re: To Elliott

Ralph on 5/20/05 at 06:13 (175348)

My interpretation of their words 'returning to full movement and activity' includes being totally pain free all the time, not just merely the elimination of First Step Pain. We know or at least I know from my experience that Night Splints have the abilty to do this. It's the rest of the day that has not been pain free yet, but I'm better than I was without any ESWT.

You've post that you've had 4 ESWT treatments. Not the recommended FDA protocol of one or even the second one (a follow up) but a total of 4 already with I think 2 different machines and you still claim to have P.F. That doesn't fit the defination 'returning to full movement and activity' the bar set by BCBS to prove it effective.

We are all free to believe what we want about ESWT. Personally, I think seeing the BCBS arguement presented on this site is a good thing. It provided balance to the arguements made by the Pods on this site and also insight into the reasons why they continue to deny coverage at least for the time being.

Re: To Elliott

john on 5/20/05 at 07:34 (175349)


I agree that the BCBS argument is a good thing to be presented on this site. I just disagree with their methodology. It seems like the bar for approving ESWT keeps moving further out with each successive report.

Based on what BCBS has said, being completely pain free would not be enough for them to cover the procedure unless there was a 'return to full movement and activity'. I think that this is too high of a standard.

Consider joint surgery. In most cases success does not include full range of motion recovery. In these cases, success means partial range of motion without pain.

Why is 'full movement and activity' required for ESWT? Isn't complete pain relief enough?

Re: To Elliott

john on 5/20/05 at 08:00 (175351)

Sorry the previous message should have been addressed to Ralph.

Re: To Elliott

Ralph on 5/20/05 at 08:30 (175352)

You have a right to how you feel and your opinion of the BCBS argument, but I don't think you can compare a joint replacement with ESWT for P.F. when it comes to full movement and activity.

In knee replacement you are removing a natural body part and trying to replace it with an artificial device that in itself has built in limitations. To date,I don't think an artificial knee can emulate the total workings of the real joint that was removed so it is unrealistic to think you can expect full movement and activity based on the design of the products currently on the market. You'll notice however, progress has been made toward providing more range of movement for the patient with the development of newer appliances.

Re: To Elliott

Ed Davis, DPM on 5/20/05 at 12:43 (175361)


The obvious deficit with most studies is that ESWT is studied as an isolated modality. Plantar fasciitis is a potentially multifaceted modality subject to the treatment triad.

The thing we really need to study is the TISSUE effect of ESWT, that is, how is ESWT affecting the tissue it is applied to. It is either causing it to 'rebuild' or not -- one parameter that really counts and removes the variables inherent in other experimentation.

Re: To Elliott

john on 5/20/05 at 13:33 (175370)


Sorry that the example confused my point. I consider ESWT a success of it provides total pain relief, regardless of 'return to full movement and activity'.

Re: To Elliott

Ralph on 5/20/05 at 14:10 (175374)

Acording to your posts after 4 treatments on 2 different machines you're still in pain. If that is true what you'd consider a success you didn't achieve not even with 2 machines.

I think the real point to be made on this site is that there are two different opinions out there on whether ESWT is an effective treatment for P.F. Without seeing or hearing about the BCBS report folks posting here would not know this. I think it serves as an import tool when judging the treatment.

The point I was trying to make about the knee replacement is that you cannot expect total freedom of movement if todays technology has not figured out how to humanly reproduce all aspects of a human joint.

Every one of us has our own opinion about ESWT. I just think both sides of the issue should be told to readers everytime they ask about ESWT. They should be informed about the BCBS findings too.

Re: To Elliott

elliott on 5/20/05 at 15:59 (175384)

Ralph: BCBS never defined ESWT success or the merit of ESWT to be limited to returning to full movement and activity, which would be way too high a bar indeed (you may be referring only to what Excellent means in the 4-point R & M test, which, even for that test, is not the definition of success, since Good is included). In actuality, BCBS's bar is far lower, and many might find it reasonable.

John: your comments accepting Ralph's analysis at face value proves to me that you did not take the time to actually look at the BCBS report yourself, which I find regrettable given your criticism of BCBS without knowing what they even said. Here is what they actually said:

'The available evidence
suggests patients treated with ESWT have a statistically significant improvement in mean pain
scores on first morning walking compared to patients treated with sham ESWT.However,the
difference is small and not clearly shown to be accompanied by improvement in function.Thus,
ESWT for treatment of plantar fasciitis is judged to not meet the second TEC criterion,as it is
uncertain from the available evidence whether the treatment effect is clinically significant...

In summary,overall the evidence shows a sta-
tistically significant effect on between-group
difference in morning pain measured on a
0 10 VAS.Uncertain is the clinical significance
of the change.The absolute value and effect
size are small.The most complete informa-
tion on NNT to achieve 50 60%reduction in
morning pain is from the 2 published studies
of high-energy ESWT (plus confidential data
provided by Dornier),combined NNT=7 (95%CI:4 15).Improvements in pain measures are
not clearly associated with improvements in
function.Effect size for improvement in pain
with activity was nonsignificant,based on
reporting for 81%of patients in all studies (plus
confidential data provided by Dornier)and 73%
of patients in high-energy ESWT studies (plus
confidential data provided by Dornier).Success
in improvement in Roles and Maudsley score
was reported for fewer than half of patients:
although statistically significant,confidence
intervals were wide.Where reported,improve-
ment in morning pain was not accompanied by
significant difference in quality-of-life measure-
ment (SF-12,physical and mental scales)or use
in pain medication.

John: I was hoping you'd address my 4 reservations of the two high-energy FDA studies.


Re: To Elliott

elliott on 5/23/05 at 23:18 (175596)

Dr. Ed, regarding inducing TISSUE effect, instead of super-expensive ESWT, howzabout whacking the foot with a hammer?!? You think I jest? Check out this fascinating thread appearing on a UK discussion board for pods:


Note that the tone of the pods about ESWT--even among those who use it--is completely different from that of the pods here on heelspurs. That board also seems to move very slowly and the pods overall seem somewhat less informed about all the ESWT studies than we are, also weighing those studies conducted by the British Empire more than others, but they offer an interesting perspective nonetheless. One person from heelspurs is a participant over there (Happy B-day, Donald!). But let's talk about the hammer, shall we? :-)


Re: To Elliott

Dr. Z on 5/23/05 at 23:48 (175600)

It must have been during Tea Time that you were searching for this post. The only hammer that conquered the British heels were called Russians but that's other history lesion Maybe that where you could get you get your next pair of orthosis if you need them. I wonder how long orthosis pods from England would last on heelspurs.com. They have been bring their hammers along as an adjunct treatment.
Yea come get this ESWT yank ? I am having fun with this post I hope you are too !!

Re: To Elliott

Dr. Z on 5/23/05 at 23:59 (175601)

PS: I want control of heelspurs.com back to only ESWT believing people so that curing and hope can continue . Once this is done I will give you back control. Yes this is the twilight Zone. We use all treatments in combination to achieve the best lasting results and ESWT is one of the best among them see your doctor to see if this is right for you You bet this is an ad from one of the manufactors except they are too cheap to spend money on any marketing to the general population.