Shock Waves Cure Pain

Nothing gives patients more confidence in a treatment than when their doctor has been successfully treated using the method himself. And in the case of consultant sports physician Dr Patrick Goh this is exactly the case: he was unable to play soccer for months while he suffered with acute heel pain (plantar fasciitis). After undergoing one session of Extracorporeal Shock Wave Treatment (ESWT) his condition was healed.

"There is nothing like having it done on yourself to really understand a procedure,' he says. `I see it (ESWT) as a solution for lots of over use problems we see in athletes that we traditionally use injections for. We know the bad effects of injections and I was happy to find an alternative to these and surgery without the potential of side effects.'

He explains what happens during ESWT treatment. "Basically, we are using ultra sound guided shock waves from a therapy head (which houses the shock wave source) and the ultrasound head will be placed against the area on the body to be treated,' says Dr Goh.

Then he views the area to be treated on the ultrasound monitor and make the necessary adjustments to the equipment or the patient's position to ensure the shock waves are accurately targeted at this area.

The shock wave treatment then begins, starting with the lowest intensity, ramping up gradually until the desired therapy levels are reached. The actual firing of the waves takes between 10-15 minutes.

Most patients require between one to three treatments, with treatment usually a week apart. Some patients get immediate relief of symptoms, for others it takes several weeks.

The pain level during the procedure is tolerable for most people, many describing it as 'good pain' says Dr Goh. He also points out that sometimes patients get an immediate relief of symptoms, only for them to return some hours or days later and `then they scold me'. However, this is normal in ESWT, early loss of pain is usually temporary.

Dr Goh says, as so many sports injuries are in the soft tissues X-rays cannot pick them up, while MRI scans are very expensive. The ESWT machine using ultrasound guidance is invaluable.

A Swiss, Otto Weiss, pioneered the technology although Dornier developed the machine he uses in Germany.

He has used the machine on 600-700 patients over the last couple of years and has only received positive feedback. He has worked extensively with professional athletes, including at the Olympic games and the South East Asia Games. Today he

works from Sportsmed Central at Gleneagles Hospital, Singapore. About half his patients are from overseas as the cost of the treatment in Singapore is considerably less here (at about S$750 per shot) compared to countries such as the USA where it is FDA approved for plantar fasciitis problems.

Studies have shown that the effectiveness of ESWT is equally as good on sports people at national level as `weekend warriors' or less active people. `Weekend warriors syndrome produces a lot of different injuries,' says Dr Goh. `Essentially weekend warriors are people who are sedentary in the week and make up for it at the weekend, taking part in sport as if they are in great condition but are not.' Most of Dr Goh's patients are either weekend warriors or professional sports people.

A typical sufferer of plantar fasciitis is Ken Fagan, an American ex-pat who has been living in Singapore for 12 years. He is older than 35, a little overweight and indulged in occasional sport. Laila White is a sport professional who suffered with Achilles tendonitis. See separate stories.

Although many conditions can benefit from ESWT not everyone can be treated using this method, which is often seen as the third phase of treatment before surgery in cases like plantar fasciitis. ESWT should not be used on people with coagulation disorders, or in areas where there are tumors or focal infections- growth plates (in children), the skull, spine and people with pacemakers and pregnant women should not undergo it.

"I see high demand from patients like national athletes but also from people who like to keep active, like Ken. It {ESWT} has such an advantage over injections or surgery. With injections you can weaken the structure, achieving a quick drop in pain but a high recurrence rate. With ESWT the injury may take time to heal but it is more likely to be permanent.'

Back in Action

LAILA White just needed one Extracorporeal Shock Wave Therapy (ESWT) treatment to cure her Achilles tendonitis problem.

'I could not get out of bed, every time I put my feet on the floor it hurt,' says the 38-year-old personal trainer and consultant. She teaches aerobics and kickboxing, exercising daily for up to 5-6 hours.

The situation got so desperate that when her podiatrist recommended Dr Patrick Goh and the ESWT she didn't hesitate. In addition to the stress put on her tendons by all her exercise, Laila has what she calls 'retarded feet'.

'I have a high arch and I am also highly pronated. I have to have customized insoles for my sports shoes to accommodate this,' she says.

Dr Goh suggested doing one ankle first but I let him do the two at one session,' says Laila. Although the treatment - which took only 10 minutes to complete - was quite painful, Laila says it was worth it.

"I do not remember it [the recovery] being immediate, it worked later. Now I have not problem at all. It is amazing because I could hardly walk, I was tiptoeing around. Of course, I had to go to work. It was the getting out of bed, the first step each morning that was the worst. And also when I was resting."

She estimates is took two to three months for her Achilles tendons to recover. 'It didn't happen overnight, one day I just noticed that they didn't hurt any more.'

"What I liked about Dr Goh was that he said he would do the treatment only twice, more was no point. He wanted to let it [the treatment] set in.'

'It is very costly, about S$750 per ankle but honestly, looking back, I think it's worth it, otherwise I could not work.'

Weekend Warrior Syndrome

American Ken Fagan developed plantar fasciitis in his right foot in July 2004. He tried everything to alleviate it without success, until he came across ESWT.

"I tried steroid injections in my heel, they were painful. I tried taping the foot as instructed by an orthopaedic surgeon, I tried exercises and stretching, none of them had any positive effect,' says Ken.

'And at the insistence of my secretary, I tried cupping and needles in my stomach. My general practitioner suggested I see Patrick Goh as he had a technology that might work.

So I came over and I had my first treatment in July 2005 and he was right. After one treatment there was no immediate cure, nor after the second but it improved considerably over time and the pain slowly went away. Today I have nothing.'

According to Dr. Goh, all the inflammation is gone in Ken's foot, although there is a little bulk scar tissue, which will gradually get thinner.

"It was incredibly, painful; when I woke up in the morning it was very painful', says Ken. He largely puts his condition down to 'wearing bad shoes and walking too far in sandals. I needed good cushioning and the marble floors in Asia do not help'.

He says life is now so much more enjoyable. Unfortunately, he says some surgeons do not seem to believe in ESWT. He says its huge advantage is that if it [ESWT] fails the condition will not get worse. Dr Goh was the fifth doctor he saw for his problem.

So how did he find the treatment? `You could feel the waves impacting against the injury so you feel it for a few minutes. But is it good pain, something you want to scratch but you cannot reach. You feel like it is working,' he says.

If patients request it, Dr Goh can use a local anaesthetic but he says he prefers not to use it as it helps if patients can localize the pain for him and give him feedback. He directs waves at a tangent to the bone rather than directly hit it, as this is less painful for the patient.

Source : Singapore Medicine

How does ESWT work?

Shock wave therapy was originally developed as a novel method for breaking up kidney stones in the body from outside the body, without the need for surgery. Approved the FDA in the early 1980s, today it is a standard treatment of choice for urinary stones.

Since the early 1990s shock waves have also been found to be effective for the treatment of many chronic painful tendon conditions.

Recent research has shown that:

  1. ESWT results in overstimulation of the nerves carrying pain signals, often resulting in a noticeable drop in pain immediately after treatment. Although not yet a cure, this immediate reduction in pain is welcomed by many pain sufferers.
  2. In the medium to long term, ESWT results in angiogenesis - or the formation of new blood vessels at the tendons. The improvement in blood supply is thought to enhance the natural long term healing of the damaged structure.

Advantages of ESWT Treatment

  1. It is non-invasive as treatment is delivered entirely outside the body.
  2. It is drug-free, thus eliminating drug related side effects. Occasionally painkillers might be prescribed if pain occurs or recurs after treatment.
  3. It can be done as a quick outpatient procedure. Most cases require about 30 minutes.
  4. Low risk - there are virtually no known side effects.
  5. In the event of failure, it does not leave the injury worse. This is unlike other treatments such as corticosteriod injections or surgery which has this possibility.

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Hi, i just wanted to know if i had a small part pain example a bunion do i require 2ooo shocks times 5 or just 1000 shocks times 5? because i heared if i have too much of the shockwave treatment at the smallest part will also cause some breakege of my bone?

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