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Posted by Dr. Z on 5/20/05 at 16:12 (175386)

Excellent - Pain free with all activity
Good_ Some discomfort with all activity.

Activity means function. I have so many patients that are either pain free or that have dramatic pain reduction and can do so many more activities since having ESWT that I just don't understand what we are talking about
Either the wrong questions were asked or never included. Again you can't have a good or excellent result without increased function. Many patients
will curtail activity due to that severe first step morning pain or after sitting for any length of time any time of the day.
Lastly it could be that we have reporting of results but people who have no idea what the plantar fascia pain cycle is . I hope not

Re: shifting research paradigms

Ed Davis, DPM on 5/20/05 at 20:15 (175392)

David:

We both have seen a lot of success with ESWT. Nevertheless, researching this modality tendon by tendon, ligament by ligament makes little sense to me. ESWT is a modality with a specific tissue effect. Either the tissue effect of rebuilding damaged tendon and ligament tissue exists or it does not. All indications we have show that it does. Sonographic evidence of change in plantar fascial thickness is the one easily measured objective criterion we have.

Reseach msut start with objectively documented diseased tendons and/or ligaments, applying ESWT and then documenting the tissue level effect.

There are too many variables to consider when looking at populations of patients with PF such that accurate conclusions are difficult and lead to unecessary controversy.
Ed

Re: shifting research paradigms

Dr. Z on 5/20/05 at 20:43 (175396)

Ed
I am starting to do this with Color doppler neovascularization before, after ESWT. I feel the bottom line is very plain and simple . How many patients with ESWT have excellent or good results with return to desired activity. Just ask the patient and stop with this other BS

Re: shifting research paradigms

Ralph on 5/21/05 at 09:09 (175414)

Dr. Zuckerman,
Would you mind explaining what Color Doppler neovascularizaton is and how you feel it helps you in treament. Most of us have no idea what it is or why it is a better or improved choice.
Thanks

Re: shifting research paradigms

Dr. Z on 5/21/05 at 10:19 (175417)

It is just another parameter to help moniter healing after ESWT. Here is what it is . I perform an ultrasound examination on the plantar fascia where the pain is. I see damage to the fascia I then can turn on the color doppler which shows the amount of blood flow if any to that area. This could help make a better diagnosis and it might after ESWT treatment show if the procedure is working and how well. I am very very early into to this idea.
So lets say if there is no blood flow to the plantar fascia before treatment and there is now blood flow then you can conclude that healing is taking place.

Re: shifting research paradigms

Ed Davis, DPM on 5/21/05 at 14:05 (175423)

David:
Which unit are you using?
Ed

Re: shifting research paradigms

Dr. Z on 5/21/05 at 15:33 (175432)

Univerisal Ultrasound

Re: shifting research paradigms

Ron on 5/23/05 at 19:49 (175567)

> So lets say if there is no blood flow to the plantar fascia
> before treatment and there is now blood flow then you can
> conclude that healing is taking place.

You say you're early into this idea. This article might be of interest to you. I'll send you the whole medical opinion if you show further interest:

_____________

Current Opinion in Orthopaedics: Volume 16(2) April 2005 pp 65-71
Disorders of the Achilles tendon and its insertion
McGuigan, Francis X; Aierstok, Mark D

Tripler Army Medical Center, Department of Orthopaedic Surgery, Honolulu, Hawaii, USA

[Snip]

Ultrasound is another useful imaging device for the determination of tendon abnormality. Hypoechoic areas on ultrasound are consistent with areas of tendinosis. The use of color and power Doppler ultrasonography demonstrated 100% specificity and 50% sensitivity when comparing patients with tendinopathy to controls [11]. Symptoms were correlated with the presence of hypoechoic areas within the tendon and the presence of blood flow. The relatively low cost, compactness, and lack of radiation make ultrasound a useful adjunct for directing therapeutic injections and surgical interventions.

The ability of MRI and ultrasound (power and color) to reliably identify abnormalities and predict clinical outcome in tendinopathy, however, is not universally accepted [12]. In one study, ultrasound only identified abnormal morphology in 65% of symptomatic tendons and 32% of asymptomatic tendons. Baseline MRI identified abnormal morphology in 56% of symptomatic tendons while finding abnormalities in 6% of asymptomatic tendons. Although lesser grades of MRI signal abnormality at baseline were associated with a better clinical status at 12-month follow-up, ultrasonographic appearance did not predict clinical outcome.

[Snip]

Re: shifting research paradigms

elliott on 5/23/05 at 22:19 (175575)

Ron, thanks for posting. This is exactly what was bothering me about Dr. Ed's new standard of just observing tissue effect: it may not be correlated highly enough with patient improvement. The study you quote suggests it may not be that strong an indicator at baseline either. I agree with an earlier post of Dr. Z's that measuring patient improvement is a better way to go.

elliott

Re: shifting research paradigms

Ed Davis, DPM on 5/23/05 at 22:26 (175579)

Ron,
Thanks for the information. Only Professor Jan Rompe has a paper demonstrating ultrasound changes on the plantar fascia in 20 months.
Ed

Re: shifting research paradigms

Ed Davis, DPM on 5/23/05 at 22:31 (175581)

Elliott:
I have performed a lot of ESWT but not a lot of ESWT in isolation. My patients are not experimental subjects. I have presented a simple experimental construct becasue the only hypothesis in question is whether tissue quality is the obstacle in healing of recalcitrant plantar fasciitis. I am a bit puzzled by your preference to use a system that requires studies that have too many variables and seemingly raise the bar for proof of efficacy.
Ed

Re: shifting research paradigms

elliott on 5/23/05 at 22:50 (175587)

Dr. Ed,

For the longest time, docs have used what they call objective measures of success for various treatments, e.g., an improved NCV reading following a TTS release, or x-rays following a foot reconstruction, as evidence of 'success'. Problem is, it is often the case that the patient is in worse nerve agony after the TT release despite the improved NCV, or a year later can't walk more than a block without intense pain despite the improved-looking x-ray. Would you call those surgeries a success? Even docs are aware that at the least, the patient's self-assessment should be included and is highly relevant to say the least. I see the same potential shortcomings in your definition of tissue effect post-ESWT for PF.

elliott

Re: shifting research paradigms

elliott on 5/23/05 at 23:00 (175589)

PS-Dr. Ed, I meant to add that it would help if measures for patient improvement for PF were agreed upon a priori and standardized in order of importance so that the significance of patient improvement would be more meaningful and comparison between machines would be somewhat easier. For example, the Ossatron researchers claimed the heel pressure test was the single most important test of all, and the Ossatron scored best on that test compared to placebos but not so good on the other tests. Dornier scored well on 4-point R&M but not well at all on the heel pressure test as compared to placebo. So how do you compare even just these two machines? Maybe first let the experts get together and reach a consensus, and then and only then conduct the studies.

elliott

Re: shifting research paradigms

Dr. Z on 5/23/05 at 23:35 (175599)

Like I told you in the beginning Excellent/ good is Excellent/ Good. This will save you alot of google work. See I didn't leave out good. I think we must stop with the confusion cause that's all you do with what you are doing now

Re: shifting research paradigms

Dr. Z on 5/25/05 at 23:12 (175742)

Ron,

Would like to read more about this. Interesting enough I have listen to lectures where the ultrasound and MRI looked normal but with closer examination and injection testing tears were noted. So the skill of the examiner is another factor

Re: shifting research paradigms

Ed Davis, DPM on 6/03/05 at 20:15 (176094)

Elliott:

The dilemna occurs when you consider that certain modalities have very specific effects and it is a combination of effects that lead to a potential cure. I generally discuss the treatment triad to try to cover the various aspects involved in PF. I think you run into a problem when the wrong modality is applied to a problem that would have limited benefit from that modality.

Clinicians treat PF or should treat PF based on the predominant objective findings leading to a particular individuals case. So if the primary problem is biomechanical, the clinician must focus on releiving mechanical strain from the fascia. If the primary problem is tissue quality then that can be addressed directly only by a modality designed specifically for that purpose whether it be ESWT, ART, etc.

The more typical scenario in recalcitrant PF is deterioration of tissue quality in the fascia and that often has biomechanical causes. The ways to look at tissue quality, short of a tissue biopsy, are MRI and sonography. There are two things to measure, objectively, in sonography: fascial thickness primraily and less objectively the degree of tissue 'breakdown' as evidenced by hypoechogenicity (dark areas within thte substance of the fascia) and the lack of neat parallel fibers within the substance of the fascia.

The only purely objective way to compare two machines is to compare their specific end effect which is improvement in tissue quality as measured by decrease in fascial thickness, decrease in hypoechogenicity and increase in the morphologic correctness, ie. neat parallel fibers within the substance of the fascia.

The difficulty in prioritizing the factors is inherent in finding a patient population with signifcantly similar 'legs' of the treatment triad. In other words, if we look at a population but that population is composed of individuals with significantly different legs of the treatment triad, then the results will be flawed as we are querying individuals who recieved a pathology specific treatment for varying pathology. Too much variance in the pathology, ie, the makeup of the treatment triad in a population being tested makes outcomes testing innaccurate.
Ed