In April of this year (2019) we added the Storz Shockwave machine to our treatment modalities. It’s been great for treating a lot of my patients who have stubborn tendonopathies, tight muscles, trigger points and fascial adhesions.
The other day I suggested to a patient, Aurelea, that we should try it on her and we got into a lengthy conversation about the therapy. She asked me a lot of great questions that I figured many other patients would also want to know. So, I thought it would be helpful to post the answers online. The following is a transcription of our conversation:
Aurelea: Jeda, you mentioned earlier that you would like me to try Shockwave therapy for my low back and hip pain. You’ve been treating me for many years with acupuncture whenever my back goes out and it really helps. I’d like to know more about the shock wave treatment. Is it a machine that you use or it is a hands-on therapy?
Jeda: It’s a machine that uses air compression to transmit sound waves into the muscle and tissue. It is also known as Extracorporeal Shockwave Therapy (ESWT), which is the use of high energy sound waves.
Aurelea: So how did you know which machine to buy? Why did you choose this particular brand of the machine?
Jeda: I was referred to STORZ through a colleague in Alberta (Dr. David Marsh) that has been using it for 10 years in his practice. STORZ Medical has been making medical equipment since1941, and their focused radial shockwave systems are hand-made in Switzerland and cover many orthopaedic indications for therapy, rehabilitation and performance enhancement. I did a lot of research on their products and they are known as the most successful Extracorporeal Shock Wave Therapy (ESWT) system.
Aurelea: Have there been studies with the shockwave machine, something I can access?
Aurelea: What does it look like? How big is it?
Jeda: It’s about the size of a gaming console like an Xbox or the tower for a personal computer. The hand piece that touches your body is like an ultrasound machine head.
Aurelea: What is a shockwave therapy, exactly?
Jeda: It sounds harsh when we use the word “shock” but it’s really just a pulsed acoustic wave that is transmitted into a targeted area; it’s basically a high pressure followed by a negative pressure. ‘Extracorporeal’ just means that the sound wave is outside, rather than inside the body. It is the same kind of technology that is used in lithotripsy to break up kidney stones, but we don’t do that with this type of machine. This more modern use of shockwave technology is used to treat pathological changes in tendons, ligaments, joint capsules, muscles and bones.
Jeda: The healing process of the body is accelerated by shockwave therapy because it stimulates metabolism, breaks down scar tissue and enhances circulation to regenerate damaged tissue. The energy pulses that are applied to the affected area in short bursts penetrate the tissue and stimulate the cells responsible for bone and connective tissue healing.
Aurelea: That sounds painful. What does it feel like? Does it hurt?
Jeda: It’s not like being at the spa and it isn’t always comfortable, but it doesn’t have to hurt to work. As a general guide, I try not to have the pain of the treatment below 3/10 or above 4/10. The intensity or pain can be reduced in a few ways:
· The type of head that we use on the hand device. There are about 12 different ones to choose from, all used for different applications.
· The pressure coming from the machine, which we want between 2.6 – 3.4 bars (about 37 psi to 49 psi).
· The pressure that is applied by the practitioner to the affected area through the handheld device.
Aurelea: You mentioned the different heads that you can use on the hand device, what are they for?
Jeda: The different heads have different depths and purposes. For example, the gentle white head is used for bony sensitive areas such as elbows, and smaller joints like the fingers, toes, hands, feet, wrists and ankles. Some of the heads are used for deeper applications like Iliotibial IT Band issues, low back tension and for treating larger areas, muscles, larger individuals and athletic/muscular patients, and for myofascial treatment. Other heads are used for trigger point treatments and enthosopathies (tendon and ligament attachments).
Aurelea: So, what kinds of problems would normally be treated with shock wave?
Jeda: I’ve been using it on many different pain, injury and range of motion issues. The studies I mentioned have shown that shockwave therapy is 76% - 91% effective for conditions like:
- Fascial release
- Plantar fasciitis
- Frozen shoulder
- Calcaneal spurs
- Tendon issues such as shoulder, hamstrings, achilles
- Stress fractures
- Jumper’s knee
- Trigger points
- Tennis elbow
- Shin splints
- Morton’s neuroma
- Scar tissue treatment
I’m finding it really helps patients that have stubborn trigger points and muscles that won’t release, fascial adhesions, tendon and joint pain, even with small joints like thumbs and fingers. It’s basically really great for muscle and connective tissue problems.
Aurelea: It sounds like there are a lot of problems that can be treated with shockwave, but what are the overall benefits of adding this kind of therapy to your practice?
Jeda: I decided to add the shock wave because it is so effective for treating these conditions. I am particularly interested in what it can do for tendons and ligaments, myofascial issues and persistent non-healing problems. I help a lot of patients with pain and injury with acupuncture, cupping, supplements, herbs, rehab and the injection therapies, but there are some patients that I know will benefit from a combination of those therapies with shockwave, or even shockwave treatment alone.
Some of the benefits of shock wave is that it is non-surgical, there are No Negative Side Effects, it helps Accelerate Healing, it’s quick and effective, and the treatments are affordable. Patients often start feeling better -- with a reduction in pain and increased mobility -- after the first treatment.
Aurelea: I understand that Shockwave therapy is great for all these things but for someone who has already completed training as a Doctor of Chinese Medicine and someone who has used acupuncture for so many years, why would you choose to expand your practice and how you work with your patients?
Doesn’t this complicate things? Do you think adding Shockwave therapy could inadvertently suggest that acupuncture and herbs and your primary training is no longer valid?
Jeda: I love treating sports injuries and pain, and acupuncture is amazing for this, but I can’t always help everyone as much as I want to. Since I can use Perineural injection treatment (PIT) and Shock wave therapy as part of my scope of practice and the efficacy for these treatments is so high, I wanted to add them to my practice to enhance the outcomes. Sometimes the stubborn issues that aren’t making enough headway with acupuncture will have huge improvements when adding these other modalities. It’s frustrating when you can’t help someone, and you know there are treatments that can, but you don’t have anyone to refer them to.
BodaHealth is also evolving: we’ve added pilates and therapeutic exercise to the treatments that we offer. I like the idea of adding a modality like pilates because it is a way for patients to help themselves beyond just a treatment. They can learn to strengthen and rebalance their systems to clear up and prevent future injuries. I am interested in a collaborative multi-modality approach to health to optimize the health outcomes for our patients.
When what we are doing for a patient is either not working, or not working as well as desired, it is beneficial to refer patients to other practitioners within our clinic so that we can work as a team to offer comprehensive treatment options.
Aurelea: Why did you get interested in Shockwave therapy in particular? As you mentioned, you already have a very diverse arsenal, so what is it that made you add shockwave to the mix?
Jeda: I came across Shockwave literature when I was doing research on laser therapy. I was amazed at the efficacy of the treatments and all the studies that were being done for sports injuries, chronic pain, and elite athletics. Being an active person doing strenuous sports like hockey, mountain biking and skiing, and having my share of injuries, I’ve always been interested in treating sports injuries and pain. A lot of my practice is treating fertility, thyroid and hormone issues but I also love helping people who are suffering with pain and injuries. I do a lot of work with acupuncture to help with circulation, decreasing inflammation, releasing trigger points and breaking up scar tissue. This is also why I studied, and became certified in, injection techniques like Peri-Neural injection treatments (PIT) and Acupoint Injections.
Aurelea: So how would you know when to use Shock wave therapy versus acupuncture or other therapies like the injections?
Jeda: Like I mentioned, I have been an acupuncturist since 2003, so that is usually my first line of treatment when I see a new patient. However, it’s not uncommon for me to use shock wave therapy, acupuncture and injections all on the same patient. Sometimes I use both or all three in the same treatment. For example, I’ve been treating a lot of tennis elbow and have been doing Perineural Injection Treatments (PIT) or acupuncture after the Shockwave treatment. I am getting great results with this. I have also been doing shockwave with patients who aren’t getting as much improvement with the other therapies.
With my experience so far, I have noticed that some issue resolve more quickly with acupuncture, some with Shockwave therapy and others with the Perineural Injections or Acupoint Injections. For example, PIT is great for golfer’s elbow (medial epichondylitis), shockwave therapy is great for plantar fasciitis and low back pain is treated really well with Acupuncture, whereas SI joint issues resolve more quickly with a combination of shockwave and acupuncture. So depending on the issues, I may choose to use a combination of treatments.
Aurelea: Would you treat with two or three different approaches at the same time in the same session, or does a patient book time with you for a specific treatment?
Jeda: It depends on the situation. I can do all three in one session, but it does require a different time allotment for the treatment. The Shockwave treatment takes about 15 minutes per area but the acupuncture sessions are booked at 45 minutes. When I do a health assessment, I let patients know how to book their sessions. Our front-end staff are also helpful in guiding patients on how to book appointments.
Aurelea: As I am sitting here I can feel that stupid spot on the right side of my back. It is so grabby that I feel like saying, “Jeda go grab as many needles as you can and stick them in to release it,” because I know what it feels like when the muscle releases with acupuncture. As I have never had shockwave treatments, would it be an alternative when the acute pain is back? For someone who has a long-term relationship with you for acupuncture treatments, they many not know to ask for Shockwave, so they would need you to tell them or suggest it. It also doesn’t seems like shockwave therapy is that well known as I’ve never seen an ad for it, so how would people know about it?
Jeda: I’ve been telling a lot of long-term patients that come for maintenance acupuncture treatments about the shockwave technology. I want to try to get my patients to the point that the pain they are having does not re-occur. It’s not always possible since usually the issue is due to a lifestyle factor that doesn’t change such as sitting postures (in front of a computer, driving or travel), activities (such as golf or hockey). Often when patients need maintenance we can get rid of a problem and it eventually comes back if the area is not strengthened and the lifestyle factor does not change.
Aurelea: Would there be pricing implications, and does it change what treatment room you are going to be in?
Jeda: The cost of a Shockwave treatment is $105 per treatment area. We built a treatment room that we use for these treatments because the machine makes a bit of a noise, similar to a MRI machine when it is in use. We didn’t want to disturb the serenity of the rest of the clinic, so we put extra sound proofing in that room. We can also do acupuncture, injection and massage therapy in this room, but we always leave the shockwave machine in the same room.
Aurelea: Oh wow, I didn’t realize you had renovated your office. That must have happened quickly! Where did you put the new treatment room?
Jeda: I know, it was all done really quickly. Our neighbours moved out and we expanded into part of that space. We actually built two new treatment rooms: one for the Shockwave therapy, and the other for Pilates.
Aurelea: I can’t wait to seethe changes! Back to my interest in Shockwave therapy, is it covered by extended medical plans?
Jeda: Yes, it is billed under the credentials of your provider so you just have to check if your plan will cover their credentials. For example, if you see me, I have acupuncture credentials, so you have to check if your extended medical covers acupucture.
Aurelea: How many Shockwave treatments do people need? Does it depend on what you are treating?
Jeda: It does depend on the person and the problem, but the protocol is 3 - 4 treatments every 4 – 7 days, then wait 6 weeks and get another treatment or series of treatments, if needed. Some people have long-term recurring issues that will get better for a significant period of time, usually months, but they need maintenance treatments, often 1 – 2x a year, after the initial series of treatments. Some problems go away completely and they don’t need more treatments. Dr. Marsh worked on my tennis elbow once, and it hasn’t bothered me since.
Aurelea: I am looking forward to trying a series of Shockwave treatments. My back has really been bugging me again so I can’t wait to see how it works!
Jeda: I am looking forward to treating you. You’ve asked me a lot of great questions that I am sure others would love to know the answers to. Do you mind if I transcribe and post our conversation?
Aurelea: Not at all!
Jeda: Thank you!