WEBVTT
1
00:00:15.119 --> 00:00:19.239
Hi guys, Welcome to another episode
of The Factor podcast. I'm your host
2
00:00:19.359 --> 00:00:23.000
Jessica Riddle. If this is your
first time tuning in, welcome and thank
3
00:00:23.039 --> 00:00:27.719
you for listening. Today we kick
off a new two part training featuring doctor
4
00:00:27.839 --> 00:00:34.399
David Rudnick on shockwave therapy for post
surgical care, from post surgical applications to
5
00:00:34.560 --> 00:00:40.119
enhancing tissue healing and even optimizing rehab
for athletes. This two part series is
6
00:00:40.159 --> 00:00:45.039
full of great information and insight,
especially if you've been considering adding a shockwave
7
00:00:45.079 --> 00:00:49.439
device to your treatment toolkit. In
this episode, we cover a wide array
8
00:00:49.479 --> 00:00:54.880
of topics, including the mechanisms of
shockwave therapy, patient responses, and specific
9
00:00:54.960 --> 00:00:59.960
case studies where shockwave had a tremendous
impact on athletes with delayed bone healing,
10
00:01:00.479 --> 00:01:04.560
as well as other cases where improvement
and conditions such as impingement, syndromes and
11
00:01:04.719 --> 00:01:11.079
degenerative tendon and muscle damage was seen. Doctor Rednick will also share valuable insights
12
00:01:11.079 --> 00:01:17.359
from his extensive experience, offering actionable
strategies for maximizing the benefits of shockwave devices.
13
00:01:17.840 --> 00:01:21.920
So be sure to bookmark this episode
or hit that download button. This
14
00:01:21.959 --> 00:01:25.640
is one you'll definitely want to listen
to more than once and take some good
15
00:01:25.680 --> 00:01:38.400
notes. Let's dive in Jessica.
Thanks so much. Hello everybody, so
16
00:01:38.439 --> 00:01:42.319
again, thank you all for attending, and let's get on. So a
17
00:01:42.359 --> 00:01:47.200
little background about myself. I'm a
sports certified sports medicine chiropractor. I have
18
00:01:47.239 --> 00:01:52.480
a diplomat to the American acadea ford
of Sports Physicians. I practice here in
19
00:01:52.599 --> 00:01:57.879
South Florida in Boyton Beach. I
have a sports medicine focus to practice.
20
00:01:59.079 --> 00:02:05.159
Most of my patients are active individuals, whether they're just doing fitness for recreation
21
00:02:05.879 --> 00:02:09.599
or performing at an elite level,
and we treat a lot of youth athletes
22
00:02:09.639 --> 00:02:14.719
as well. All ranges from wreck
to semi pro to pro. So our
23
00:02:14.759 --> 00:02:19.639
objective today is going to be obviously
going through some anatomy and some physiology of
24
00:02:19.719 --> 00:02:23.599
the conditions that we're going to be
treating. Shockwave is a phenomenal modality and
25
00:02:23.639 --> 00:02:30.759
I don't think it's covered enough both
in the literature and in the lecture realm.
26
00:02:30.039 --> 00:02:35.280
As far as the treatments that we're
going to be reviewing today with regards
27
00:02:35.319 --> 00:02:39.840
to post surgical and fracture. We
obviously see quite a bit of post surgical
28
00:02:40.039 --> 00:02:45.039
in my practice and hence why I
am covering it as well as fracture care,
29
00:02:45.479 --> 00:02:49.560
and we co manage a lot of
those with other physicians and they refer
30
00:02:50.039 --> 00:02:53.159
their patients to us for that management. So I think it's a unique angle
31
00:02:53.240 --> 00:02:58.879
that we're taking with this modality.
And obviously we use it on the typical
32
00:02:59.159 --> 00:03:04.319
tendinopathy and partial tears and things that
you typically see in the literature with regards
33
00:03:04.360 --> 00:03:07.400
to shockwave, but we're using it
for some wide range stuff as well.
34
00:03:07.479 --> 00:03:13.000
We see excellent results. So what's
the role. There's increasing evidence with shockwave
35
00:03:13.080 --> 00:03:16.879
and muscular skeletal applications as well as
post surgical. There's two different types of
36
00:03:16.919 --> 00:03:22.159
shockwave out there, whether you're using
radial or focus, and we're going to
37
00:03:22.159 --> 00:03:27.479
be covering the application of both.
I currently use a radial shockwave in my
38
00:03:27.639 --> 00:03:31.879
office, but we'll be obtaining a
focused shockwave in the next month or so
39
00:03:32.400 --> 00:03:38.919
to reach some more wide ranged conditions. So basically, the difference with radial
40
00:03:38.960 --> 00:03:42.120
and focus we're going to get here
in the next few slides, But is
41
00:03:42.360 --> 00:03:46.479
not just how the acoustic wave is
delivered and the engineering of that, but
42
00:03:46.639 --> 00:03:52.120
also the depth of penetration, which
is critical because if you're trying to treat
43
00:03:52.159 --> 00:03:54.039
a certain tissue at a certain depth, and you have the wrong modality,
44
00:03:54.159 --> 00:04:00.960
you're not going to gain benefit with
that. So radial is a more superficial
45
00:04:01.240 --> 00:04:06.800
goes down about two and a half
inches about six centimeters in depth, where
46
00:04:06.960 --> 00:04:13.560
focused can get up to twelve centimeters
about five to six inches in depth,
47
00:04:14.000 --> 00:04:16.680
So a much wider range of conditions
that you can treat, and a lot
48
00:04:16.720 --> 00:04:23.560
deeper as well. So here's focus
versus radial and how they're both applied to
49
00:04:23.720 --> 00:04:29.199
the tissue and how the mechanism of
the acoustic wave is generated within each.
50
00:04:29.759 --> 00:04:35.079
Interestingly, Focused, despite the depth
of penetration, the sound that it emits
51
00:04:35.160 --> 00:04:41.160
is much less, it's not as
loud as radial, and generally I find
52
00:04:41.199 --> 00:04:46.600
that our patients actually don't have as
much discomfort with Focused as they do with
53
00:04:46.720 --> 00:04:54.319
radial because of the projectile versus the
electro hydraulic principle versus radio versus focused,
54
00:04:54.560 --> 00:04:59.079
but both produced a very similar effect
on the tissue. It's just how that
55
00:04:59.120 --> 00:05:02.680
acoustic wave is being emitted is the
major difference between the two. So a
56
00:05:02.759 --> 00:05:06.480
quick chart. I know that a
lot of studies will when we get into
57
00:05:06.519 --> 00:05:11.959
our parameters and how we're treating the
tissue and what settings we're using on the
58
00:05:12.000 --> 00:05:15.360
shockwave. A lot of studies will
present in bars, a lot of studies
59
00:05:15.399 --> 00:05:20.720
will present in milli jewels or milli
jewels per a millimeters squared, and knowing
60
00:05:20.959 --> 00:05:26.199
the conversion is going to help you
transmit that study that you're reading into a
61
00:05:26.279 --> 00:05:30.519
proper clinical application on your unit,
depending on whether you're using a focused or
62
00:05:30.519 --> 00:05:33.720
a radial. So there's the conversion
rate. Take a screenshot of it and
63
00:05:34.040 --> 00:05:40.199
it will help you when we get
into some studies later in knowing our conversion
64
00:05:40.279 --> 00:05:45.240
rates. So for those of you
that are not using shockwave in your practices
65
00:05:45.279 --> 00:05:49.959
currently, the top image on the
slide there is a focused unit and you
66
00:05:49.959 --> 00:05:56.879
can see how the acoustic wave is
emitted from that unit, where it's a
67
00:05:57.279 --> 00:06:02.600
very narrow wave that's emitted from that
unit versus the radial is a lot more
68
00:06:02.639 --> 00:06:09.560
broad and has a more widespread acoustic
wave that's emitted. But the depth is
69
00:06:09.639 --> 00:06:13.439
the key, and we're going to
see that on some subsequent slides. So
70
00:06:14.040 --> 00:06:18.279
the top is a radial and you
can see as a quick impulse that dies
71
00:06:18.319 --> 00:06:25.040
out fairly quickly and will spread out
over a larger area versus the focus is
72
00:06:25.079 --> 00:06:30.360
the exact opposite. It has a
wider width that becomes more focused once it
73
00:06:30.519 --> 00:06:34.040
enters the tissue and the depth.
So you can see the radial goes into
74
00:06:34.120 --> 00:06:41.720
the mid to deeper muscle belly,
where focus reach through the muscle belly and
75
00:06:42.000 --> 00:06:46.279
into the deeper tissue and even into
and through bone in some cases depending on
76
00:06:46.279 --> 00:06:50.079
the unit that you're using. So
what are we trying to achieve when we
77
00:06:50.360 --> 00:06:56.800
get the shockwave over tissue? And
here's another applicant or another visual on the
78
00:06:56.800 --> 00:07:00.120
depth of penetration and how that acoustic
wave is being applied to the tissue you.
79
00:07:00.560 --> 00:07:02.959
So, again, if your shockwave
works well, when you know what
80
00:07:03.000 --> 00:07:08.160
tissue you're trying to target, why
you're trying to target it, what clinical
81
00:07:08.199 --> 00:07:12.480
effect you're trying to obtain from it. And if you're trying to achieve a
82
00:07:12.920 --> 00:07:16.160
higher depth over a spine, a
radial shockwave is not going to do you,
83
00:07:16.399 --> 00:07:21.199
but a focused will. Maybe in
a more petite individual or a pediatric
84
00:07:21.319 --> 00:07:26.279
you might be able to get down
to that deeper entity around bone with a
85
00:07:26.360 --> 00:07:30.360
radial, but focused is generally your
go to there. So what are we
86
00:07:30.399 --> 00:07:35.120
trying to achieve when we use a
shockwave device, Basically we're creating a hyperstimulation
87
00:07:35.279 --> 00:07:42.720
in an analgesic effect, and the
effect has a big proponent on pain immediately,
88
00:07:43.079 --> 00:07:45.759
and you can actually see that while
you're using it over a patient.
89
00:07:45.800 --> 00:07:48.759
They're responding favorably as you're using it, so they may have a lot of
90
00:07:48.800 --> 00:07:53.680
discomfort while you're starting that treatment over
that region, which is good. You
91
00:07:53.720 --> 00:07:57.639
do want them to respond that way
because you know you're over that injured or
92
00:07:58.199 --> 00:08:01.639
inflamed or tender tissue that you're trying
to target. But you'll see immediately,
93
00:08:01.920 --> 00:08:07.480
within probably a few couple of minutes
and sometimes even seconds, they'll produce that
94
00:08:07.560 --> 00:08:13.639
analgesic effect, and that is absolutely
key because not only does the patient feel
95
00:08:13.639 --> 00:08:16.879
the benefits of it, but you
know that you're on that target tissue.
96
00:08:16.199 --> 00:08:22.040
And it's something we love with regards
as shockwave because you get that instant gratification
97
00:08:22.879 --> 00:08:28.959
and the trust that the patient is
starting to develop in that that modality is
98
00:08:30.480 --> 00:08:33.720
going to be good for them because
you can talk to them about the path
99
00:08:33.720 --> 00:08:37.840
of physiology and the case studies and
whatnot. All they want to feel is
100
00:08:37.960 --> 00:08:43.519
improvement and pain reduction and function improvement. And if you can get that pain
101
00:08:43.559 --> 00:08:46.600
reduction immediately. While you're treating something, you're going to get a huge buy
102
00:08:46.639 --> 00:08:52.720
in and a confidence level from the
patient, which we know optimism always rules,
103
00:08:52.120 --> 00:08:56.159
and their their outcomes are going to
be much higher down the line.
104
00:08:56.799 --> 00:09:01.039
So what are we doing biological effect
wise? We're producing a lot of enzymatic
105
00:09:01.440 --> 00:09:07.440
activity in the tissue and we're producing
a lot of cellular effects. So you
106
00:09:07.559 --> 00:09:15.480
have the VGF growth factors that you're
upregulating. You're upregulating nitric oxide, so
107
00:09:15.519 --> 00:09:20.279
you're getting a lot of angiogenesis in
the area. You're upregulating collagen formation,
108
00:09:20.480 --> 00:09:26.960
you're upgrading regulating osteoplastic formation. We're
going to get into how that effects on
109
00:09:26.039 --> 00:09:33.240
bone osteoclast information ALC FOSS. You're
up regulating in sulin light growth factors.
110
00:09:33.600 --> 00:09:39.000
So there's a lot of cellular activity
that is being produced in the cells and
111
00:09:39.639 --> 00:09:45.679
you'll see those things are actually being
upregulated even after the treatment. And that's
112
00:09:45.679 --> 00:09:48.039
why when you typically do shockwave and
you'll see this in a lot of the
113
00:09:48.080 --> 00:09:56.840
studies, a lot of the effects
are after the effect is the pain modulation
114
00:09:56.159 --> 00:10:01.480
is immediate, but and the something
as a range of motion effects are obbediate.
115
00:10:01.919 --> 00:10:07.559
But the cellular tissue healing is occurring
even after that patient leaves your office,
116
00:10:07.799 --> 00:10:11.679
and the frequency of utilizing shockwave is
much less than some other types of
117
00:10:11.679 --> 00:10:15.600
treatments, where you may be only
treating that person one or two times a
118
00:10:15.639 --> 00:10:18.519
week, sometimes three, depending on
the condition, but a lot of the
119
00:10:18.519 --> 00:10:24.799
studies point to even just one or
two treatments a week is effective at improving
120
00:10:24.840 --> 00:10:35.840
the tissue healing in that region.
The holiday season is upon us and it
121
00:10:35.879 --> 00:10:39.279
is truly the most wonderful time of
the year. And while we had a
122
00:10:39.279 --> 00:10:43.279
ton of fun with Black Friday and
Cyber Monday, we've been counting down the
123
00:10:43.360 --> 00:10:48.879
days until December's arrival and the kickoff
of our twenty twenty three Season of Giving.
124
00:10:48.399 --> 00:10:52.799
Each week we will be sending out
a new special offer, freebie,
125
00:10:52.879 --> 00:10:56.679
or exclusive limited time flash sale.
It's a ton of fun and this year
126
00:10:56.720 --> 00:11:01.159
is even more extra with the launch
of four new certification programs and the new
127
00:11:01.240 --> 00:11:05.759
Factor F five handlebar, a soft
tissue tool unlike any other. So be
128
00:11:05.840 --> 00:11:09.960
sure to click the Season of Giving
link in the show notes to get all
129
00:11:09.000 --> 00:11:13.919
of the details. Join us in
celebrating the spirit of giving this holiday season.
130
00:11:15.360 --> 00:11:24.279
Happy Holidays from Factor so we're going
to go through several regions of the
131
00:11:24.320 --> 00:11:28.720
body, their post surgical applications and
their conditions, the path of physiology,
132
00:11:28.759 --> 00:11:33.919
and how we're utilizing shock wave over
those are cuff. Probably my most favorite
133
00:11:33.960 --> 00:11:39.240
area to treat in general is the
shoulder. In the shoulder girdle. FE
134
00:11:39.240 --> 00:11:43.480
a lot of overhead athletes in our
office, and I love overhead athletes because
135
00:11:43.519 --> 00:11:48.000
most of the time, their pain
generators are not where they're feeling pain.
136
00:11:48.320 --> 00:11:52.519
They're coming from some other mechanical issue, and I love kind of diving into
137
00:11:52.559 --> 00:12:00.440
those and figuring out the why in
those individuals. So typically what we're treating
138
00:12:00.480 --> 00:12:05.600
with regards to post surgical is that
degenerative patient sometimes the impingement one and just
139
00:12:05.639 --> 00:12:09.879
the tissue overload in the middle to
older individual who's needing to get an arthroscopy
140
00:12:09.960 --> 00:12:16.120
done on the rotator cuff or a
tenonesis where they're taking the bicep tendon repositioning
141
00:12:16.159 --> 00:12:22.240
that bicep tend to take load off
of the glenoid labram and as opposed to
142
00:12:22.360 --> 00:12:26.080
repairing the labrum. I don't know
if everyone's seeing those types of surgeries in
143
00:12:26.080 --> 00:12:28.879
their office, but they're pretty neat
where that individual comes in with a chronic
144
00:12:28.960 --> 00:12:35.519
labrum tear, and the surgeon's not
necessarily repairing that labram tear in that individual
145
00:12:35.559 --> 00:12:39.360
because of their age or their activity
level, but they're doing the tenonesis and
146
00:12:39.840 --> 00:12:46.080
creating a mechanical alteration on the labrum
by repositioning the bicep tendon, and that
147
00:12:46.159 --> 00:12:54.840
individual responds really well to rehab and
obviously to shockwave post surgical so arthroscopic repair.
148
00:12:54.320 --> 00:12:58.559
I think something that I've done in
my practice and my career over the
149
00:12:58.639 --> 00:13:05.679
years has been to view a surgery
by it doesn't matter the surgeon, but
150
00:13:05.799 --> 00:13:09.039
obviously they're typically ones that we're referring
back and forth from. But I've been
151
00:13:09.039 --> 00:13:16.000
able to witness that surgery in a
OAR, and so I can understand not
152
00:13:16.240 --> 00:13:18.600
just what it looks like on paper, but what that patient is going through
153
00:13:18.679 --> 00:13:24.679
interoperatively and seeing what that tissue is
going through from a trauma standpoint, surgical
154
00:13:24.679 --> 00:13:28.879
trauma standpoint, how the repair is
being performed, and then I can discuss
155
00:13:28.919 --> 00:13:33.399
the outcomes of that patient with that
patient not just from a physical therapy standpoint,
156
00:13:33.720 --> 00:13:37.399
but what that tissue went through and
what their outcomes are going to be
157
00:13:37.440 --> 00:13:41.279
based on the modalities that we're going
to be using and why the rehabit structured
158
00:13:41.279 --> 00:13:43.440
a certain way. So if anybody
ever has an opportunity to do that,
159
00:13:43.879 --> 00:13:46.279
if you're doing that, phenomenal.
If you're not doing that, I would
160
00:13:46.360 --> 00:13:50.840
encourage it because it'll give you a
whole other understanding of why that patient is
161
00:13:52.480 --> 00:13:56.320
hurting, why that patient is responding
quickly. There's a lot of different factors
162
00:13:56.399 --> 00:14:01.879
if you can get into that r
and witness these surgeries so quick arthroscopic repair
163
00:14:01.960 --> 00:14:07.320
obviously, there's different variations and with
everybody, whether there's morosceoarthritic implications with that
164
00:14:07.440 --> 00:14:15.120
patient or if they're just dealing with
degenerative tendin and muscle damage that is needing
165
00:14:15.159 --> 00:14:18.960
to be repaired. All right,
getting down ready, what's happening with that
166
00:14:18.120 --> 00:14:24.519
acoustic wave hits tissue. You're increasing
collagen formation. Obviously, we love that.
167
00:14:24.600 --> 00:14:28.120
If you have a microtar in an
area, or even a partial tear
168
00:14:28.240 --> 00:14:31.080
up to even fifty to seventy percent, you're going to increase collagen. Increasing
169
00:14:31.120 --> 00:14:35.320
collagen helps to lay down new tissue. You're going to heal that area,
170
00:14:35.320 --> 00:14:39.919
That tendon's going to become stronger to
tensile load, and then therefore you're going
171
00:14:39.000 --> 00:14:43.559
to be able to build that up
with rehab and obviously blood flow. Angiogenesis
172
00:14:43.879 --> 00:14:50.039
without angiogenesis, without oxygen and new
blood formation into that new blood vessel formation
173
00:14:50.120 --> 00:14:54.279
into that region, you're not going
to get tissue healing. So think about
174
00:14:54.279 --> 00:14:58.799
your patients that have some comorbidities like
diabetes or some thyroid issues or some other
175
00:15:00.279 --> 00:15:05.360
peripheral circulatory issues. That individual is
going to heal a lot slower than your
176
00:15:05.440 --> 00:15:11.639
patient who doesn't have those comorbidities.
But with extracorporeal shockwave, we can help
177
00:15:11.720 --> 00:15:16.559
produce and enhance that not just in
the healthy patient, but in the comorbid
178
00:15:16.600 --> 00:15:22.639
patient as well. And that oxygen
flow, that new blood vessel formation is
179
00:15:22.679 --> 00:15:26.600
going to significantly improve the tissue healing, because that's all overall what we're trying
180
00:15:26.600 --> 00:15:31.919
to get at pain reduction is nice. People like pain reduction, but is
181
00:15:31.960 --> 00:15:35.360
that pain going to stay away?
And the answer is typically not if you
182
00:15:35.360 --> 00:15:39.279
don't get the tissue to heal and
you remove the mechanical deficit if it's a
183
00:15:39.360 --> 00:15:46.600
movement based issue. So we get
any phenomenal effect from shockwave with regards to
184
00:15:46.720 --> 00:15:50.320
those cellular activities, all right,
neat little study, it was done in
185
00:15:50.399 --> 00:15:56.559
rodents tissue tissue. It was actually
an interesting study because they surgically repaired these
186
00:15:56.639 --> 00:16:03.799
rotator cuffs in rats and then put
them on treadmills and we're able to measure
187
00:16:03.360 --> 00:16:08.480
their improved load to failure in these
their GIT was obviously improving as well on
188
00:16:08.679 --> 00:16:15.720
the treadmill, but clinically in human
model we're seeing the load improvement improve and
189
00:16:15.759 --> 00:16:21.600
obviously in our athletes a lot of
times with these overused syndromes and youth and
190
00:16:22.279 --> 00:16:26.159
other active individuals, the tissues just
breaking down. The capacity is not high
191
00:16:26.279 --> 00:16:30.600
enough to handle the load that's being
applied to it. And if you could
192
00:16:30.639 --> 00:16:36.840
improve that load to or that capacity, you can improve the amount of load
193
00:16:36.879 --> 00:16:41.039
that's being applied to a tissue and
reduce their risk factors for reinjury or injuries
194
00:16:41.039 --> 00:16:44.840
in the future in other areas.
So neat little study, and we're going
195
00:16:44.919 --> 00:16:48.039
to dive into a bunch of other
ones as well. So treatment parameters with
196
00:16:48.080 --> 00:16:53.080
regards to rotator cuff. When we
see our patients post surgically, we can
197
00:16:53.480 --> 00:17:00.840
apply shockwave fairly quickly. Most patients
are not coming into us until about seven
198
00:17:00.440 --> 00:17:07.839
to ten to fourteen days post surgery
in most cases, so most of that
199
00:17:07.039 --> 00:17:12.799
really acute pain has diminished at seven
to ten days. They may be just
200
00:17:12.839 --> 00:17:18.240
taking some insets at the time.
And when we start to incorporate shockwave,
201
00:17:18.279 --> 00:17:23.079
we actually discourage the end said use
because it will counteract the effects of shockwave
202
00:17:23.559 --> 00:17:29.759
on that tissue, and the patient's
going to receive the analgesic effect of shockwaves,
203
00:17:29.799 --> 00:17:32.920
so they're not even going to need
to be reaching for the pain medication
204
00:17:33.279 --> 00:17:37.720
necessary. But this pain, this
analgesic effect is happening via the pain gate
205
00:17:37.759 --> 00:17:42.759
theory of blocking pain sensation from the
peripheral structures and not allowing the sensation to
206
00:17:42.759 --> 00:17:48.279
be felt, which is like I
said earlier, is awesome for that patient
207
00:17:48.279 --> 00:17:51.279
to go, oh my gosh,
I can feel pain relief just from this
208
00:17:51.839 --> 00:17:53.680
modality, and that allows me to
move a little bit better and then obviously
209
00:17:55.039 --> 00:17:59.400
feel confident with strengthening and reap later
on, as opposed to having fear factor
210
00:17:59.720 --> 00:18:03.480
with movement. So we're not just
going to hit over the surgical incision to
211
00:18:03.559 --> 00:18:08.319
reduce scar formation and adhesion over that
region, and with arthroscopic repair you're not
212
00:18:08.359 --> 00:18:12.319
getting that much scar formation, which
is fantastic, But if you're having an
213
00:18:12.359 --> 00:18:18.119
open bank art procedure, or we'll
see in some other surgical procedures the scar
214
00:18:18.319 --> 00:18:22.960
is a lot larger and thicker,
but we're able to reduce that scar formation
215
00:18:22.279 --> 00:18:29.200
pretty immediately over that region with shockwave. Again, parameters, these are guidelines,
216
00:18:29.279 --> 00:18:32.079
and I think with shockwave and the
more you use shockwave, you're going
217
00:18:32.119 --> 00:18:36.920
to see that things are varied and
you can dip outside the treatment parameters.
218
00:18:37.319 --> 00:18:41.920
So don't take these as they are
set in stone. It's a sliding scale
219
00:18:41.000 --> 00:18:48.160
and everything is to patient tolerance and
you're trying to achieve a specific tissue or
220
00:18:48.160 --> 00:18:52.680
a desired effect physiologically, so the
parameters can range. And again obviously,
221
00:18:52.680 --> 00:18:56.359
if if we're doing two and a
half bar or zero point one two milli
222
00:18:56.440 --> 00:19:03.240
dules per millionos squared over a acute
or subcute region or actually immediately post surgical,
223
00:19:03.319 --> 00:19:07.119
that patient may not be able to
tolerate that. So we're going to
224
00:19:07.240 --> 00:19:11.480
change our head that we're using on
the hand piece on the shockwave. We're
225
00:19:11.519 --> 00:19:15.160
going to be sliding that bar up
and down depending on their tolerance level,
226
00:19:15.680 --> 00:19:18.160
so we don't create an increased pain
sensation it wants to. We want to
227
00:19:18.240 --> 00:19:22.920
keep it in a tolerable range for
that patient. So we're treating that patient
228
00:19:22.960 --> 00:19:27.279
for about three to six weeks post
surgically with shockwave, and that's one to
229
00:19:27.319 --> 00:19:30.559
two days a week, so you'll
see a lot of the studies are once
230
00:19:30.599 --> 00:19:34.400
a week on shockwave application, so
you're only treating them three to six times
231
00:19:34.440 --> 00:19:40.119
to get that desired effect, and
then sometimes the patient's plateaued midway through,
232
00:19:40.480 --> 00:19:45.400
we'll come back and start to treat
that region. Nothing is over the site
233
00:19:45.440 --> 00:19:49.079
of pain only. We are treating
that entire shoulder girdle, sometimes down into
234
00:19:49.079 --> 00:19:53.759
the lower lat we're treating the peck. We're treating all that tissue that could
235
00:19:53.759 --> 00:20:00.000
be affecting that person's range of motion
and overall mechanics, so they're not producing
236
00:20:00.039 --> 00:20:07.000
any guarding mechanisms in that region.
This was an ac joint over that we
237
00:20:07.000 --> 00:20:11.359
were treating on a patient that had
the bridement, but her surgery was quite
238
00:20:11.680 --> 00:20:14.799
a while ago, but still had
a lot of adhesion in the region.
239
00:20:15.240 --> 00:20:18.519
This was actually a seventy four year
old tennis player. She plays three to
240
00:20:18.559 --> 00:20:22.240
four days a week and actually does
personal training with us in our office two
241
00:20:22.319 --> 00:20:26.039
to three days a week, so
she's a highly active seventy four year old
242
00:20:26.440 --> 00:20:30.799
and maybe even seventy five now,
since that video was taken and she had
243
00:20:30.839 --> 00:20:37.200
come in with some still some adhesion
and some impingement type syndromes post surgically where
244
00:20:37.240 --> 00:20:41.160
she had the bribement of that a
sea joint to open up the space to
245
00:20:41.240 --> 00:20:47.680
produce less impingement. She responded extremely
favorably to shockwave. The head that we
246
00:20:47.799 --> 00:20:51.640
used on this patient was the C
fifteen, which is the ceramic head,
247
00:20:52.039 --> 00:20:56.480
which is our mid we use a
silicone head or the nano we use the
248
00:20:56.559 --> 00:21:02.839
D twenty head, which is a
titanium head, and this is the ceramics
249
00:21:02.920 --> 00:21:07.000
so it produces a mile to moderate
amount of energy through it, a lot
250
00:21:07.039 --> 00:21:11.079
more tolerable over a bony area and
particularly over a post surgical area, a
251
00:21:11.119 --> 00:21:17.240
lot more tolerable for that patient than
using a larger titanium head like a D
252
00:21:17.319 --> 00:21:21.200
twenty or even larger than that.
All right, so post surgical rehab,
253
00:21:21.720 --> 00:21:26.039
all of the studies, all of
the studies, all of the studies incorporate
254
00:21:26.400 --> 00:21:33.039
have the most benefit with rehab and
loading the tissue as opposed to just shockwave
255
00:21:33.079 --> 00:21:37.440
alone. You get good benefits with
shockwave alone, but when it's combined with
256
00:21:37.559 --> 00:21:42.519
rehab, the benefits are exponential,
particularly with regards to the upper extremity.
257
00:21:42.759 --> 00:21:51.039
The DASH scores improve the patient's mechanics
significally improve not just the pain reduction,
258
00:21:51.400 --> 00:21:53.640
which we all love pain reduction,
but we want that patient to stay out
259
00:21:53.640 --> 00:21:59.279
of pain, and that's going to
be produced with improving tissue load so that
260
00:22:00.039 --> 00:22:03.079
particularly our active patients are not re
injuring that region. So day one to
261
00:22:03.200 --> 00:22:10.559
six we're hitting that patient typically with
regards to shockwave for pain modulation, scar
262
00:22:10.680 --> 00:22:15.160
tissue reduction, and range of motion
improvement right away, tissue healing, more
263
00:22:15.200 --> 00:22:18.640
college information right around that area to
help them with range and being able to
264
00:22:18.640 --> 00:22:23.200
load tissue. We're seeing a lot
of times now the surgeons are recommending not
265
00:22:23.359 --> 00:22:27.279
to be in a sling or a
brace for as long as they used to
266
00:22:27.359 --> 00:22:32.279
be in. Obviously the labor and
patients are going to be in a sling
267
00:22:32.319 --> 00:22:37.519
for a little bit longer, but
our typical arthrooscopy or even our tenonsi's patients
268
00:22:37.559 --> 00:22:41.160
are going to be in there less, and it's purely a tolerance level thing.
269
00:22:41.319 --> 00:22:44.640
So we're seeing them come out of
this thing a lot quicker. So
270
00:22:44.880 --> 00:22:49.200
obviously a lot less adhesion is being
produced, a lot less tissue guarding and
271
00:22:49.440 --> 00:22:56.720
hypertonicity is being implemented into that shoulder
girdle. So new research and new applications
272
00:22:56.720 --> 00:23:02.240
post surgically really helps with our rehab. So here's the nitty gritty. I
273
00:23:02.319 --> 00:23:04.440
love this phase of rehab. The
patient's starting to get some pain reduction.
274
00:23:04.920 --> 00:23:08.640
They're starting to see that there's a
light at the end of the tunnel that's
275
00:23:08.680 --> 00:23:12.119
seven to day seven to day twenty
eight. They're starting to feel, oh
276
00:23:12.160 --> 00:23:15.119
my gosh, I can see that
this is going to be a benefit.
277
00:23:15.559 --> 00:23:22.240
And applying that shockwave at this point
has been critical improving range of motion.
278
00:23:22.640 --> 00:23:26.599
We have a couple of patients right
now that we're getting some post surgical adhesive
279
00:23:26.599 --> 00:23:32.079
capsulitis that was starting to form and
that can be very detrimental in their overall
280
00:23:32.079 --> 00:23:38.200
improvement. And we have reduced those
comorbidities in that patient that's producing the adhesive
281
00:23:38.200 --> 00:23:47.359
capsulelitis very quickly with early implication of
shockwave into that region to reduce capsular thickening.
282
00:23:47.759 --> 00:23:52.519
Another post surgery that we see quite
frequently is our ORF procedures, our
283
00:23:52.599 --> 00:23:59.559
open reduction internal fixation. This patient, I believe this one was a soccer
284
00:23:59.640 --> 00:24:06.160
player, seventeen year old sixteen or
seventeen year old soccer player who had a
285
00:24:06.319 --> 00:24:10.720
trauma collided with another player. These
are our academy players, so they're playing
286
00:24:10.759 --> 00:24:15.160
at an extremely high level. The
game is extremely fast, and this individual
287
00:24:15.240 --> 00:24:19.920
collided with another player. They went
leg to leg. He lost, unfortunately,
288
00:24:21.359 --> 00:24:27.039
so he had a open fracture of
the tibia and multiple fractures of fibula
289
00:24:27.200 --> 00:24:33.519
as well. The reason that shockwave
was highly beneficial to this patient was because
290
00:24:34.000 --> 00:24:41.279
they had delayed bone healing around that
hardware, and that would have ended up
291
00:24:41.400 --> 00:24:45.359
causing that patient to have to go
in for a bone graft. Psychologically,
292
00:24:45.519 --> 00:24:49.200
this individual was already having a tough
time with the acute nature and the traumatic
293
00:24:49.279 --> 00:24:56.079
nature of the injury at the height
of his youth athletic career and being looked
294
00:24:56.079 --> 00:25:02.400
at by colleges and academies and whatnot, so the psychological effects were far outweighing
295
00:25:02.480 --> 00:25:04.519
the physical. The physical, in
my opinion, is very easy to get
296
00:25:04.559 --> 00:25:07.920
this patient back, but he was
dealing with the psychological and then to have
297
00:25:08.039 --> 00:25:12.119
the delayed bone healing over that region
and possibly happening to go in for a
298
00:25:12.119 --> 00:25:18.200
bone graft, which was going to
delay his return by several several months was
299
00:25:18.480 --> 00:25:22.240
a huge weight on him. So
with talking with the surgeon, and this
300
00:25:22.279 --> 00:25:26.000
is a surgeon that we worked with
many times in the past, we suggested
301
00:25:26.000 --> 00:25:30.279
that we use shockwave over the bone
to produce some bone healing so they did
302
00:25:30.319 --> 00:25:33.160
not have to go in and do
a bone graft on this patient. And
303
00:25:33.319 --> 00:25:37.839
the surgeons are well. This surgeon
is highly conservative in that manner. He
304
00:25:37.920 --> 00:25:44.039
seemed the effects of it in the
past, so we get excellent ousteoblastic activity
305
00:25:44.240 --> 00:25:48.079
in that region and he was comfortable
with us doing that at that point with
306
00:25:48.160 --> 00:25:52.680
the patient. They give us about
three to four weeks to work on that
307
00:25:52.759 --> 00:25:57.799
individual, and we are doing shockwave
a lot more frequently than with tendon and
308
00:25:57.880 --> 00:26:03.039
muscle ligament. We're doing about three
to four days a week on this individual
309
00:26:03.119 --> 00:26:07.759
to produce osteoplastic activity. And particularly
because we had a limited amount of time
310
00:26:08.279 --> 00:26:11.519
with this individual before, you need
to possibly go in for a graph,
311
00:26:12.000 --> 00:26:18.880
but you can see that there is
a lot of palace formation around that surgical
312
00:26:18.920 --> 00:26:23.400
site, particularly on the image on
the right, and they had extremely favorable
313
00:26:23.400 --> 00:26:29.960
outcomes. So about three weeks post
he had about forty to fifty percent bone
314
00:26:30.000 --> 00:26:34.680
healing, and at six weeks post
utilization of shockwave. He had eighty percent
315
00:26:34.839 --> 00:26:40.960
bone formation in that region and he
avoided a bone graph. And I'm happy
316
00:26:41.039 --> 00:26:45.039
to say that this visual is back
to high level soccer, has no pain
317
00:26:45.119 --> 00:26:49.880
over the surgical site and is going
to be playing in college coming next year.
318
00:26:49.960 --> 00:26:55.839
So excellent successful case. If you're
not using it on bone and fractures
319
00:26:55.880 --> 00:27:00.279
or post surgical fractures, a new
realm for you to uprate in that region
320
00:27:00.480 --> 00:27:15.279
tury into your practice. That's it
for today's training. Be sure to keep
321
00:27:15.279 --> 00:27:18.000
an eye on your inbox and follow
us on social media for more details on
322
00:27:18.039 --> 00:27:23.039
our season of giving that kicks off
today through December thirty first. And if
323
00:27:23.039 --> 00:27:26.559
you're not on our mailing list,
what are you waiting for? Click the
324
00:27:26.599 --> 00:27:30.599
sign up link in our show notes
to receive our weekly Factor five Things Friday
325
00:27:30.640 --> 00:27:34.960
email, where we share free resources
to grow your business and elevate your patient
326
00:27:36.039 --> 00:27:41.920
care, along with exclusive discounts and
early access offers for our new certification programs,
327
00:27:41.240 --> 00:27:45.359
free webinars, and hands on courses. All of this is packaged in
328
00:27:45.400 --> 00:27:49.759
a nice, no fluff, simple
five Things format that's easy to skim and
329
00:27:49.799 --> 00:27:55.160
scroll. Be sure to tune in
for episode seventy where we wrap up part
330
00:27:55.160 --> 00:27:59.720
two of our training on shockwave therapy
and talk more about its benefits for athletes
331
00:27:59.720 --> 00:28:03.640
with for you syndromes, as well
as the research surrounding the use of shockwave
332
00:28:03.000 --> 00:28:07.119
to reduce scar formation and post operative
symptoms. You won't want to miss it.
333
00:28:07.359 --> 00:28:15.200
Episode seventy drops in two weeks.
We'll see then. Hey guys,
334
00:28:15.279 --> 00:28:18.319
if you like what you heard today, I encourage you to visit our website
335
00:28:18.319 --> 00:28:26.880
at Factor hyphenstore dot com that's spelled
fak tr hyphenstore dot com to find out
336
00:28:26.920 --> 00:28:30.119
more information about all that we have
to offer. We have a variety of
337
00:28:30.160 --> 00:28:34.000
online offerings as well as our hands
on Factor Rehab System course scheduled in cities
338
00:28:34.039 --> 00:28:37.559
around the globe. Be sure to
also check out our event calendar and bookmark
339
00:28:37.640 --> 00:28:41.720
any of these upcoming live webinar dates
coming up in the near future so you
340
00:28:41.759 --> 00:28:45.880
can join us live. And of
course, the biggest compliment we can receive
341
00:28:45.000 --> 00:28:48.079
is for you to help us spread
the word to your friends, colleagues,
342
00:28:48.119 --> 00:28:52.480
and classmates. You'll find all the
important links, as well as info about
343
00:28:52.480 --> 00:28:56.039
our sponsors in the show notes,
so be sure to check those out.
1
00:00:15.119 --> 00:00:19.239
Hi guys, Welcome to another episode
of The Factor podcast. I'm your host
2
00:00:19.359 --> 00:00:23.000
Jessica Riddle. If this is your
first time tuning in, welcome and thank
3
00:00:23.039 --> 00:00:27.719
you for listening. Today we kick
off a new two part training featuring doctor
4
00:00:27.839 --> 00:00:34.399
David Rudnick on shockwave therapy for post
surgical care, from post surgical applications to
5
00:00:34.560 --> 00:00:40.119
enhancing tissue healing and even optimizing rehab
for athletes. This two part series is
6
00:00:40.159 --> 00:00:45.039
full of great information and insight,
especially if you've been considering adding a shockwave
7
00:00:45.079 --> 00:00:49.439
device to your treatment toolkit. In
this episode, we cover a wide array
8
00:00:49.479 --> 00:00:54.880
of topics, including the mechanisms of
shockwave therapy, patient responses, and specific
9
00:00:54.960 --> 00:00:59.960
case studies where shockwave had a tremendous
impact on athletes with delayed bone healing,
10
00:01:00.479 --> 00:01:04.560
as well as other cases where improvement
and conditions such as impingement, syndromes and
11
00:01:04.719 --> 00:01:11.079
degenerative tendon and muscle damage was seen. Doctor Rednick will also share valuable insights
12
00:01:11.079 --> 00:01:17.359
from his extensive experience, offering actionable
strategies for maximizing the benefits of shockwave devices.
13
00:01:17.840 --> 00:01:21.920
So be sure to bookmark this episode
or hit that download button. This
14
00:01:21.959 --> 00:01:25.640
is one you'll definitely want to listen
to more than once and take some good
15
00:01:25.680 --> 00:01:38.400
notes. Let's dive in Jessica.
Thanks so much. Hello everybody, so
16
00:01:38.439 --> 00:01:42.319
again, thank you all for attending, and let's get on. So a
17
00:01:42.359 --> 00:01:47.200
little background about myself. I'm a
sports certified sports medicine chiropractor. I have
18
00:01:47.239 --> 00:01:52.480
a diplomat to the American acadea ford
of Sports Physicians. I practice here in
19
00:01:52.599 --> 00:01:57.879
South Florida in Boyton Beach. I
have a sports medicine focus to practice.
20
00:01:59.079 --> 00:02:05.159
Most of my patients are active individuals, whether they're just doing fitness for recreation
21
00:02:05.879 --> 00:02:09.599
or performing at an elite level,
and we treat a lot of youth athletes
22
00:02:09.639 --> 00:02:14.719
as well. All ranges from wreck
to semi pro to pro. So our
23
00:02:14.759 --> 00:02:19.639
objective today is going to be obviously
going through some anatomy and some physiology of
24
00:02:19.719 --> 00:02:23.599
the conditions that we're going to be
treating. Shockwave is a phenomenal modality and
25
00:02:23.639 --> 00:02:30.759
I don't think it's covered enough both
in the literature and in the lecture realm.
26
00:02:30.039 --> 00:02:35.280
As far as the treatments that we're
going to be reviewing today with regards
27
00:02:35.319 --> 00:02:39.840
to post surgical and fracture. We
obviously see quite a bit of post surgical
28
00:02:40.039 --> 00:02:45.039
in my practice and hence why I
am covering it as well as fracture care,
29
00:02:45.479 --> 00:02:49.560
and we co manage a lot of
those with other physicians and they refer
30
00:02:50.039 --> 00:02:53.159
their patients to us for that management. So I think it's a unique angle
31
00:02:53.240 --> 00:02:58.879
that we're taking with this modality.
And obviously we use it on the typical
32
00:02:59.159 --> 00:03:04.319
tendinopathy and partial tears and things that
you typically see in the literature with regards
33
00:03:04.360 --> 00:03:07.400
to shockwave, but we're using it
for some wide range stuff as well.
34
00:03:07.479 --> 00:03:13.000
We see excellent results. So what's
the role. There's increasing evidence with shockwave
35
00:03:13.080 --> 00:03:16.879
and muscular skeletal applications as well as
post surgical. There's two different types of
36
00:03:16.919 --> 00:03:22.159
shockwave out there, whether you're using
radial or focus, and we're going to
37
00:03:22.159 --> 00:03:27.479
be covering the application of both.
I currently use a radial shockwave in my
38
00:03:27.639 --> 00:03:31.879
office, but we'll be obtaining a
focused shockwave in the next month or so
39
00:03:32.400 --> 00:03:38.919
to reach some more wide ranged conditions. So basically, the difference with radial
40
00:03:38.960 --> 00:03:42.120
and focus we're going to get here
in the next few slides, But is
41
00:03:42.360 --> 00:03:46.479
not just how the acoustic wave is
delivered and the engineering of that, but
42
00:03:46.639 --> 00:03:52.120
also the depth of penetration, which
is critical because if you're trying to treat
43
00:03:52.159 --> 00:03:54.039
a certain tissue at a certain depth, and you have the wrong modality,
44
00:03:54.159 --> 00:04:00.960
you're not going to gain benefit with
that. So radial is a more superficial
45
00:04:01.240 --> 00:04:06.800
goes down about two and a half
inches about six centimeters in depth, where
46
00:04:06.960 --> 00:04:13.560
focused can get up to twelve centimeters
about five to six inches in depth,
47
00:04:14.000 --> 00:04:16.680
So a much wider range of conditions
that you can treat, and a lot
48
00:04:16.720 --> 00:04:23.560
deeper as well. So here's focus
versus radial and how they're both applied to
49
00:04:23.720 --> 00:04:29.199
the tissue and how the mechanism of
the acoustic wave is generated within each.
50
00:04:29.759 --> 00:04:35.079
Interestingly, Focused, despite the depth
of penetration, the sound that it emits
51
00:04:35.160 --> 00:04:41.160
is much less, it's not as
loud as radial, and generally I find
52
00:04:41.199 --> 00:04:46.600
that our patients actually don't have as
much discomfort with Focused as they do with
53
00:04:46.720 --> 00:04:54.319
radial because of the projectile versus the
electro hydraulic principle versus radio versus focused,
54
00:04:54.560 --> 00:04:59.079
but both produced a very similar effect
on the tissue. It's just how that
55
00:04:59.120 --> 00:05:02.680
acoustic wave is being emitted is the
major difference between the two. So a
56
00:05:02.759 --> 00:05:06.480
quick chart. I know that a
lot of studies will when we get into
57
00:05:06.519 --> 00:05:11.959
our parameters and how we're treating the
tissue and what settings we're using on the
58
00:05:12.000 --> 00:05:15.360
shockwave. A lot of studies will
present in bars, a lot of studies
59
00:05:15.399 --> 00:05:20.720
will present in milli jewels or milli
jewels per a millimeters squared, and knowing
60
00:05:20.959 --> 00:05:26.199
the conversion is going to help you
transmit that study that you're reading into a
61
00:05:26.279 --> 00:05:30.519
proper clinical application on your unit,
depending on whether you're using a focused or
62
00:05:30.519 --> 00:05:33.720
a radial. So there's the conversion
rate. Take a screenshot of it and
63
00:05:34.040 --> 00:05:40.199
it will help you when we get
into some studies later in knowing our conversion
64
00:05:40.279 --> 00:05:45.240
rates. So for those of you
that are not using shockwave in your practices
65
00:05:45.279 --> 00:05:49.959
currently, the top image on the
slide there is a focused unit and you
66
00:05:49.959 --> 00:05:56.879
can see how the acoustic wave is
emitted from that unit, where it's a
67
00:05:57.279 --> 00:06:02.600
very narrow wave that's emitted from that
unit versus the radial is a lot more
68
00:06:02.639 --> 00:06:09.560
broad and has a more widespread acoustic
wave that's emitted. But the depth is
69
00:06:09.639 --> 00:06:13.439
the key, and we're going to
see that on some subsequent slides. So
70
00:06:14.040 --> 00:06:18.279
the top is a radial and you
can see as a quick impulse that dies
71
00:06:18.319 --> 00:06:25.040
out fairly quickly and will spread out
over a larger area versus the focus is
72
00:06:25.079 --> 00:06:30.360
the exact opposite. It has a
wider width that becomes more focused once it
73
00:06:30.519 --> 00:06:34.040
enters the tissue and the depth.
So you can see the radial goes into
74
00:06:34.120 --> 00:06:41.720
the mid to deeper muscle belly,
where focus reach through the muscle belly and
75
00:06:42.000 --> 00:06:46.279
into the deeper tissue and even into
and through bone in some cases depending on
76
00:06:46.279 --> 00:06:50.079
the unit that you're using. So
what are we trying to achieve when we
77
00:06:50.360 --> 00:06:56.800
get the shockwave over tissue? And
here's another applicant or another visual on the
78
00:06:56.800 --> 00:07:00.120
depth of penetration and how that acoustic
wave is being applied to the tissue you.
79
00:07:00.560 --> 00:07:02.959
So, again, if your shockwave
works well, when you know what
80
00:07:03.000 --> 00:07:08.160
tissue you're trying to target, why
you're trying to target it, what clinical
81
00:07:08.199 --> 00:07:12.480
effect you're trying to obtain from it. And if you're trying to achieve a
82
00:07:12.920 --> 00:07:16.160
higher depth over a spine, a
radial shockwave is not going to do you,
83
00:07:16.399 --> 00:07:21.199
but a focused will. Maybe in
a more petite individual or a pediatric
84
00:07:21.319 --> 00:07:26.279
you might be able to get down
to that deeper entity around bone with a
85
00:07:26.360 --> 00:07:30.360
radial, but focused is generally your
go to there. So what are we
86
00:07:30.399 --> 00:07:35.120
trying to achieve when we use a
shockwave device, Basically we're creating a hyperstimulation
87
00:07:35.279 --> 00:07:42.720
in an analgesic effect, and the
effect has a big proponent on pain immediately,
88
00:07:43.079 --> 00:07:45.759
and you can actually see that while
you're using it over a patient.
89
00:07:45.800 --> 00:07:48.759
They're responding favorably as you're using it, so they may have a lot of
90
00:07:48.800 --> 00:07:53.680
discomfort while you're starting that treatment over
that region, which is good. You
91
00:07:53.720 --> 00:07:57.639
do want them to respond that way
because you know you're over that injured or
92
00:07:58.199 --> 00:08:01.639
inflamed or tender tissue that you're trying
to target. But you'll see immediately,
93
00:08:01.920 --> 00:08:07.480
within probably a few couple of minutes
and sometimes even seconds, they'll produce that
94
00:08:07.560 --> 00:08:13.639
analgesic effect, and that is absolutely
key because not only does the patient feel
95
00:08:13.639 --> 00:08:16.879
the benefits of it, but you
know that you're on that target tissue.
96
00:08:16.199 --> 00:08:22.040
And it's something we love with regards
as shockwave because you get that instant gratification
97
00:08:22.879 --> 00:08:28.959
and the trust that the patient is
starting to develop in that that modality is
98
00:08:30.480 --> 00:08:33.720
going to be good for them because
you can talk to them about the path
99
00:08:33.720 --> 00:08:37.840
of physiology and the case studies and
whatnot. All they want to feel is
100
00:08:37.960 --> 00:08:43.519
improvement and pain reduction and function improvement. And if you can get that pain
101
00:08:43.559 --> 00:08:46.600
reduction immediately. While you're treating something, you're going to get a huge buy
102
00:08:46.639 --> 00:08:52.720
in and a confidence level from the
patient, which we know optimism always rules,
103
00:08:52.120 --> 00:08:56.159
and their their outcomes are going to
be much higher down the line.
104
00:08:56.799 --> 00:09:01.039
So what are we doing biological effect
wise? We're producing a lot of enzymatic
105
00:09:01.440 --> 00:09:07.440
activity in the tissue and we're producing
a lot of cellular effects. So you
106
00:09:07.559 --> 00:09:15.480
have the VGF growth factors that you're
upregulating. You're upregulating nitric oxide, so
107
00:09:15.519 --> 00:09:20.279
you're getting a lot of angiogenesis in
the area. You're upregulating collagen formation,
108
00:09:20.480 --> 00:09:26.960
you're upgrading regulating osteoplastic formation. We're
going to get into how that effects on
109
00:09:26.039 --> 00:09:33.240
bone osteoclast information ALC FOSS. You're
up regulating in sulin light growth factors.
110
00:09:33.600 --> 00:09:39.000
So there's a lot of cellular activity
that is being produced in the cells and
111
00:09:39.639 --> 00:09:45.679
you'll see those things are actually being
upregulated even after the treatment. And that's
112
00:09:45.679 --> 00:09:48.039
why when you typically do shockwave and
you'll see this in a lot of the
113
00:09:48.080 --> 00:09:56.840
studies, a lot of the effects
are after the effect is the pain modulation
114
00:09:56.159 --> 00:10:01.480
is immediate, but and the something
as a range of motion effects are obbediate.
115
00:10:01.919 --> 00:10:07.559
But the cellular tissue healing is occurring
even after that patient leaves your office,
116
00:10:07.799 --> 00:10:11.679
and the frequency of utilizing shockwave is
much less than some other types of
117
00:10:11.679 --> 00:10:15.600
treatments, where you may be only
treating that person one or two times a
118
00:10:15.639 --> 00:10:18.519
week, sometimes three, depending on
the condition, but a lot of the
119
00:10:18.519 --> 00:10:24.799
studies point to even just one or
two treatments a week is effective at improving
120
00:10:24.840 --> 00:10:35.840
the tissue healing in that region.
The holiday season is upon us and it
121
00:10:35.879 --> 00:10:39.279
is truly the most wonderful time of
the year. And while we had a
122
00:10:39.279 --> 00:10:43.279
ton of fun with Black Friday and
Cyber Monday, we've been counting down the
123
00:10:43.360 --> 00:10:48.879
days until December's arrival and the kickoff
of our twenty twenty three Season of Giving.
124
00:10:48.399 --> 00:10:52.799
Each week we will be sending out
a new special offer, freebie,
125
00:10:52.879 --> 00:10:56.679
or exclusive limited time flash sale.
It's a ton of fun and this year
126
00:10:56.720 --> 00:11:01.159
is even more extra with the launch
of four new certification programs and the new
127
00:11:01.240 --> 00:11:05.759
Factor F five handlebar, a soft
tissue tool unlike any other. So be
128
00:11:05.840 --> 00:11:09.960
sure to click the Season of Giving
link in the show notes to get all
129
00:11:09.000 --> 00:11:13.919
of the details. Join us in
celebrating the spirit of giving this holiday season.
130
00:11:15.360 --> 00:11:24.279
Happy Holidays from Factor so we're going
to go through several regions of the
131
00:11:24.320 --> 00:11:28.720
body, their post surgical applications and
their conditions, the path of physiology,
132
00:11:28.759 --> 00:11:33.919
and how we're utilizing shock wave over
those are cuff. Probably my most favorite
133
00:11:33.960 --> 00:11:39.240
area to treat in general is the
shoulder. In the shoulder girdle. FE
134
00:11:39.240 --> 00:11:43.480
a lot of overhead athletes in our
office, and I love overhead athletes because
135
00:11:43.519 --> 00:11:48.000
most of the time, their pain
generators are not where they're feeling pain.
136
00:11:48.320 --> 00:11:52.519
They're coming from some other mechanical issue, and I love kind of diving into
137
00:11:52.559 --> 00:12:00.440
those and figuring out the why in
those individuals. So typically what we're treating
138
00:12:00.480 --> 00:12:05.600
with regards to post surgical is that
degenerative patient sometimes the impingement one and just
139
00:12:05.639 --> 00:12:09.879
the tissue overload in the middle to
older individual who's needing to get an arthroscopy
140
00:12:09.960 --> 00:12:16.120
done on the rotator cuff or a
tenonesis where they're taking the bicep tendon repositioning
141
00:12:16.159 --> 00:12:22.240
that bicep tend to take load off
of the glenoid labram and as opposed to
142
00:12:22.360 --> 00:12:26.080
repairing the labrum. I don't know
if everyone's seeing those types of surgeries in
143
00:12:26.080 --> 00:12:28.879
their office, but they're pretty neat
where that individual comes in with a chronic
144
00:12:28.960 --> 00:12:35.519
labrum tear, and the surgeon's not
necessarily repairing that labram tear in that individual
145
00:12:35.559 --> 00:12:39.360
because of their age or their activity
level, but they're doing the tenonesis and
146
00:12:39.840 --> 00:12:46.080
creating a mechanical alteration on the labrum
by repositioning the bicep tendon, and that
147
00:12:46.159 --> 00:12:54.840
individual responds really well to rehab and
obviously to shockwave post surgical so arthroscopic repair.
148
00:12:54.320 --> 00:12:58.559
I think something that I've done in
my practice and my career over the
149
00:12:58.639 --> 00:13:05.679
years has been to view a surgery
by it doesn't matter the surgeon, but
150
00:13:05.799 --> 00:13:09.039
obviously they're typically ones that we're referring
back and forth from. But I've been
151
00:13:09.039 --> 00:13:16.000
able to witness that surgery in a
OAR, and so I can understand not
152
00:13:16.240 --> 00:13:18.600
just what it looks like on paper, but what that patient is going through
153
00:13:18.679 --> 00:13:24.679
interoperatively and seeing what that tissue is
going through from a trauma standpoint, surgical
154
00:13:24.679 --> 00:13:28.879
trauma standpoint, how the repair is
being performed, and then I can discuss
155
00:13:28.919 --> 00:13:33.399
the outcomes of that patient with that
patient not just from a physical therapy standpoint,
156
00:13:33.720 --> 00:13:37.399
but what that tissue went through and
what their outcomes are going to be
157
00:13:37.440 --> 00:13:41.279
based on the modalities that we're going
to be using and why the rehabit structured
158
00:13:41.279 --> 00:13:43.440
a certain way. So if anybody
ever has an opportunity to do that,
159
00:13:43.879 --> 00:13:46.279
if you're doing that, phenomenal.
If you're not doing that, I would
160
00:13:46.360 --> 00:13:50.840
encourage it because it'll give you a
whole other understanding of why that patient is
161
00:13:52.480 --> 00:13:56.320
hurting, why that patient is responding
quickly. There's a lot of different factors
162
00:13:56.399 --> 00:14:01.879
if you can get into that r
and witness these surgeries so quick arthroscopic repair
163
00:14:01.960 --> 00:14:07.320
obviously, there's different variations and with
everybody, whether there's morosceoarthritic implications with that
164
00:14:07.440 --> 00:14:15.120
patient or if they're just dealing with
degenerative tendin and muscle damage that is needing
165
00:14:15.159 --> 00:14:18.960
to be repaired. All right,
getting down ready, what's happening with that
166
00:14:18.120 --> 00:14:24.519
acoustic wave hits tissue. You're increasing
collagen formation. Obviously, we love that.
167
00:14:24.600 --> 00:14:28.120
If you have a microtar in an
area, or even a partial tear
168
00:14:28.240 --> 00:14:31.080
up to even fifty to seventy percent, you're going to increase collagen. Increasing
169
00:14:31.120 --> 00:14:35.320
collagen helps to lay down new tissue. You're going to heal that area,
170
00:14:35.320 --> 00:14:39.919
That tendon's going to become stronger to
tensile load, and then therefore you're going
171
00:14:39.000 --> 00:14:43.559
to be able to build that up
with rehab and obviously blood flow. Angiogenesis
172
00:14:43.879 --> 00:14:50.039
without angiogenesis, without oxygen and new
blood formation into that new blood vessel formation
173
00:14:50.120 --> 00:14:54.279
into that region, you're not going
to get tissue healing. So think about
174
00:14:54.279 --> 00:14:58.799
your patients that have some comorbidities like
diabetes or some thyroid issues or some other
175
00:15:00.279 --> 00:15:05.360
peripheral circulatory issues. That individual is
going to heal a lot slower than your
176
00:15:05.440 --> 00:15:11.639
patient who doesn't have those comorbidities.
But with extracorporeal shockwave, we can help
177
00:15:11.720 --> 00:15:16.559
produce and enhance that not just in
the healthy patient, but in the comorbid
178
00:15:16.600 --> 00:15:22.639
patient as well. And that oxygen
flow, that new blood vessel formation is
179
00:15:22.679 --> 00:15:26.600
going to significantly improve the tissue healing, because that's all overall what we're trying
180
00:15:26.600 --> 00:15:31.919
to get at pain reduction is nice. People like pain reduction, but is
181
00:15:31.960 --> 00:15:35.360
that pain going to stay away?
And the answer is typically not if you
182
00:15:35.360 --> 00:15:39.279
don't get the tissue to heal and
you remove the mechanical deficit if it's a
183
00:15:39.360 --> 00:15:46.600
movement based issue. So we get
any phenomenal effect from shockwave with regards to
184
00:15:46.720 --> 00:15:50.320
those cellular activities, all right,
neat little study, it was done in
185
00:15:50.399 --> 00:15:56.559
rodents tissue tissue. It was actually
an interesting study because they surgically repaired these
186
00:15:56.639 --> 00:16:03.799
rotator cuffs in rats and then put
them on treadmills and we're able to measure
187
00:16:03.360 --> 00:16:08.480
their improved load to failure in these
their GIT was obviously improving as well on
188
00:16:08.679 --> 00:16:15.720
the treadmill, but clinically in human
model we're seeing the load improvement improve and
189
00:16:15.759 --> 00:16:21.600
obviously in our athletes a lot of
times with these overused syndromes and youth and
190
00:16:22.279 --> 00:16:26.159
other active individuals, the tissues just
breaking down. The capacity is not high
191
00:16:26.279 --> 00:16:30.600
enough to handle the load that's being
applied to it. And if you could
192
00:16:30.639 --> 00:16:36.840
improve that load to or that capacity, you can improve the amount of load
193
00:16:36.879 --> 00:16:41.039
that's being applied to a tissue and
reduce their risk factors for reinjury or injuries
194
00:16:41.039 --> 00:16:44.840
in the future in other areas.
So neat little study, and we're going
195
00:16:44.919 --> 00:16:48.039
to dive into a bunch of other
ones as well. So treatment parameters with
196
00:16:48.080 --> 00:16:53.080
regards to rotator cuff. When we
see our patients post surgically, we can
197
00:16:53.480 --> 00:17:00.840
apply shockwave fairly quickly. Most patients
are not coming into us until about seven
198
00:17:00.440 --> 00:17:07.839
to ten to fourteen days post surgery
in most cases, so most of that
199
00:17:07.039 --> 00:17:12.799
really acute pain has diminished at seven
to ten days. They may be just
200
00:17:12.839 --> 00:17:18.240
taking some insets at the time.
And when we start to incorporate shockwave,
201
00:17:18.279 --> 00:17:23.079
we actually discourage the end said use
because it will counteract the effects of shockwave
202
00:17:23.559 --> 00:17:29.759
on that tissue, and the patient's
going to receive the analgesic effect of shockwaves,
203
00:17:29.799 --> 00:17:32.920
so they're not even going to need
to be reaching for the pain medication
204
00:17:33.279 --> 00:17:37.720
necessary. But this pain, this
analgesic effect is happening via the pain gate
205
00:17:37.759 --> 00:17:42.759
theory of blocking pain sensation from the
peripheral structures and not allowing the sensation to
206
00:17:42.759 --> 00:17:48.279
be felt, which is like I
said earlier, is awesome for that patient
207
00:17:48.279 --> 00:17:51.279
to go, oh my gosh,
I can feel pain relief just from this
208
00:17:51.839 --> 00:17:53.680
modality, and that allows me to
move a little bit better and then obviously
209
00:17:55.039 --> 00:17:59.400
feel confident with strengthening and reap later
on, as opposed to having fear factor
210
00:17:59.720 --> 00:18:03.480
with movement. So we're not just
going to hit over the surgical incision to
211
00:18:03.559 --> 00:18:08.319
reduce scar formation and adhesion over that
region, and with arthroscopic repair you're not
212
00:18:08.359 --> 00:18:12.319
getting that much scar formation, which
is fantastic, But if you're having an
213
00:18:12.359 --> 00:18:18.119
open bank art procedure, or we'll
see in some other surgical procedures the scar
214
00:18:18.319 --> 00:18:22.960
is a lot larger and thicker,
but we're able to reduce that scar formation
215
00:18:22.279 --> 00:18:29.200
pretty immediately over that region with shockwave. Again, parameters, these are guidelines,
216
00:18:29.279 --> 00:18:32.079
and I think with shockwave and the
more you use shockwave, you're going
217
00:18:32.119 --> 00:18:36.920
to see that things are varied and
you can dip outside the treatment parameters.
218
00:18:37.319 --> 00:18:41.920
So don't take these as they are
set in stone. It's a sliding scale
219
00:18:41.000 --> 00:18:48.160
and everything is to patient tolerance and
you're trying to achieve a specific tissue or
220
00:18:48.160 --> 00:18:52.680
a desired effect physiologically, so the
parameters can range. And again obviously,
221
00:18:52.680 --> 00:18:56.359
if if we're doing two and a
half bar or zero point one two milli
222
00:18:56.440 --> 00:19:03.240
dules per millionos squared over a acute
or subcute region or actually immediately post surgical,
223
00:19:03.319 --> 00:19:07.119
that patient may not be able to
tolerate that. So we're going to
224
00:19:07.240 --> 00:19:11.480
change our head that we're using on
the hand piece on the shockwave. We're
225
00:19:11.519 --> 00:19:15.160
going to be sliding that bar up
and down depending on their tolerance level,
226
00:19:15.680 --> 00:19:18.160
so we don't create an increased pain
sensation it wants to. We want to
227
00:19:18.240 --> 00:19:22.920
keep it in a tolerable range for
that patient. So we're treating that patient
228
00:19:22.960 --> 00:19:27.279
for about three to six weeks post
surgically with shockwave, and that's one to
229
00:19:27.319 --> 00:19:30.559
two days a week, so you'll
see a lot of the studies are once
230
00:19:30.599 --> 00:19:34.400
a week on shockwave application, so
you're only treating them three to six times
231
00:19:34.440 --> 00:19:40.119
to get that desired effect, and
then sometimes the patient's plateaued midway through,
232
00:19:40.480 --> 00:19:45.400
we'll come back and start to treat
that region. Nothing is over the site
233
00:19:45.440 --> 00:19:49.079
of pain only. We are treating
that entire shoulder girdle, sometimes down into
234
00:19:49.079 --> 00:19:53.759
the lower lat we're treating the peck. We're treating all that tissue that could
235
00:19:53.759 --> 00:20:00.000
be affecting that person's range of motion
and overall mechanics, so they're not producing
236
00:20:00.039 --> 00:20:07.000
any guarding mechanisms in that region.
This was an ac joint over that we
237
00:20:07.000 --> 00:20:11.359
were treating on a patient that had
the bridement, but her surgery was quite
238
00:20:11.680 --> 00:20:14.799
a while ago, but still had
a lot of adhesion in the region.
239
00:20:15.240 --> 00:20:18.519
This was actually a seventy four year
old tennis player. She plays three to
240
00:20:18.559 --> 00:20:22.240
four days a week and actually does
personal training with us in our office two
241
00:20:22.319 --> 00:20:26.039
to three days a week, so
she's a highly active seventy four year old
242
00:20:26.440 --> 00:20:30.799
and maybe even seventy five now,
since that video was taken and she had
243
00:20:30.839 --> 00:20:37.200
come in with some still some adhesion
and some impingement type syndromes post surgically where
244
00:20:37.240 --> 00:20:41.160
she had the bribement of that a
sea joint to open up the space to
245
00:20:41.240 --> 00:20:47.680
produce less impingement. She responded extremely
favorably to shockwave. The head that we
246
00:20:47.799 --> 00:20:51.640
used on this patient was the C
fifteen, which is the ceramic head,
247
00:20:52.039 --> 00:20:56.480
which is our mid we use a
silicone head or the nano we use the
248
00:20:56.559 --> 00:21:02.839
D twenty head, which is a
titanium head, and this is the ceramics
249
00:21:02.920 --> 00:21:07.000
so it produces a mile to moderate
amount of energy through it, a lot
250
00:21:07.039 --> 00:21:11.079
more tolerable over a bony area and
particularly over a post surgical area, a
251
00:21:11.119 --> 00:21:17.240
lot more tolerable for that patient than
using a larger titanium head like a D
252
00:21:17.319 --> 00:21:21.200
twenty or even larger than that.
All right, so post surgical rehab,
253
00:21:21.720 --> 00:21:26.039
all of the studies, all of
the studies, all of the studies incorporate
254
00:21:26.400 --> 00:21:33.039
have the most benefit with rehab and
loading the tissue as opposed to just shockwave
255
00:21:33.079 --> 00:21:37.440
alone. You get good benefits with
shockwave alone, but when it's combined with
256
00:21:37.559 --> 00:21:42.519
rehab, the benefits are exponential,
particularly with regards to the upper extremity.
257
00:21:42.759 --> 00:21:51.039
The DASH scores improve the patient's mechanics
significally improve not just the pain reduction,
258
00:21:51.400 --> 00:21:53.640
which we all love pain reduction,
but we want that patient to stay out
259
00:21:53.640 --> 00:21:59.279
of pain, and that's going to
be produced with improving tissue load so that
260
00:22:00.039 --> 00:22:03.079
particularly our active patients are not re
injuring that region. So day one to
261
00:22:03.200 --> 00:22:10.559
six we're hitting that patient typically with
regards to shockwave for pain modulation, scar
262
00:22:10.680 --> 00:22:15.160
tissue reduction, and range of motion
improvement right away, tissue healing, more
263
00:22:15.200 --> 00:22:18.640
college information right around that area to
help them with range and being able to
264
00:22:18.640 --> 00:22:23.200
load tissue. We're seeing a lot
of times now the surgeons are recommending not
265
00:22:23.359 --> 00:22:27.279
to be in a sling or a
brace for as long as they used to
266
00:22:27.359 --> 00:22:32.279
be in. Obviously the labor and
patients are going to be in a sling
267
00:22:32.319 --> 00:22:37.519
for a little bit longer, but
our typical arthrooscopy or even our tenonsi's patients
268
00:22:37.559 --> 00:22:41.160
are going to be in there less, and it's purely a tolerance level thing.
269
00:22:41.319 --> 00:22:44.640
So we're seeing them come out of
this thing a lot quicker. So
270
00:22:44.880 --> 00:22:49.200
obviously a lot less adhesion is being
produced, a lot less tissue guarding and
271
00:22:49.440 --> 00:22:56.720
hypertonicity is being implemented into that shoulder
girdle. So new research and new applications
272
00:22:56.720 --> 00:23:02.240
post surgically really helps with our rehab. So here's the nitty gritty. I
273
00:23:02.319 --> 00:23:04.440
love this phase of rehab. The
patient's starting to get some pain reduction.
274
00:23:04.920 --> 00:23:08.640
They're starting to see that there's a
light at the end of the tunnel that's
275
00:23:08.680 --> 00:23:12.119
seven to day seven to day twenty
eight. They're starting to feel, oh
276
00:23:12.160 --> 00:23:15.119
my gosh, I can see that
this is going to be a benefit.
277
00:23:15.559 --> 00:23:22.240
And applying that shockwave at this point
has been critical improving range of motion.
278
00:23:22.640 --> 00:23:26.599
We have a couple of patients right
now that we're getting some post surgical adhesive
279
00:23:26.599 --> 00:23:32.079
capsulitis that was starting to form and
that can be very detrimental in their overall
280
00:23:32.079 --> 00:23:38.200
improvement. And we have reduced those
comorbidities in that patient that's producing the adhesive
281
00:23:38.200 --> 00:23:47.359
capsulelitis very quickly with early implication of
shockwave into that region to reduce capsular thickening.
282
00:23:47.759 --> 00:23:52.519
Another post surgery that we see quite
frequently is our ORF procedures, our
283
00:23:52.599 --> 00:23:59.559
open reduction internal fixation. This patient, I believe this one was a soccer
284
00:23:59.640 --> 00:24:06.160
player, seventeen year old sixteen or
seventeen year old soccer player who had a
285
00:24:06.319 --> 00:24:10.720
trauma collided with another player. These
are our academy players, so they're playing
286
00:24:10.759 --> 00:24:15.160
at an extremely high level. The
game is extremely fast, and this individual
287
00:24:15.240 --> 00:24:19.920
collided with another player. They went
leg to leg. He lost, unfortunately,
288
00:24:21.359 --> 00:24:27.039
so he had a open fracture of
the tibia and multiple fractures of fibula
289
00:24:27.200 --> 00:24:33.519
as well. The reason that shockwave
was highly beneficial to this patient was because
290
00:24:34.000 --> 00:24:41.279
they had delayed bone healing around that
hardware, and that would have ended up
291
00:24:41.400 --> 00:24:45.359
causing that patient to have to go
in for a bone graft. Psychologically,
292
00:24:45.519 --> 00:24:49.200
this individual was already having a tough
time with the acute nature and the traumatic
293
00:24:49.279 --> 00:24:56.079
nature of the injury at the height
of his youth athletic career and being looked
294
00:24:56.079 --> 00:25:02.400
at by colleges and academies and whatnot, so the psychological effects were far outweighing
295
00:25:02.480 --> 00:25:04.519
the physical. The physical, in
my opinion, is very easy to get
296
00:25:04.559 --> 00:25:07.920
this patient back, but he was
dealing with the psychological and then to have
297
00:25:08.039 --> 00:25:12.119
the delayed bone healing over that region
and possibly happening to go in for a
298
00:25:12.119 --> 00:25:18.200
bone graft, which was going to
delay his return by several several months was
299
00:25:18.480 --> 00:25:22.240
a huge weight on him. So
with talking with the surgeon, and this
300
00:25:22.279 --> 00:25:26.000
is a surgeon that we worked with
many times in the past, we suggested
301
00:25:26.000 --> 00:25:30.279
that we use shockwave over the bone
to produce some bone healing so they did
302
00:25:30.319 --> 00:25:33.160
not have to go in and do
a bone graft on this patient. And
303
00:25:33.319 --> 00:25:37.839
the surgeons are well. This surgeon
is highly conservative in that manner. He
304
00:25:37.920 --> 00:25:44.039
seemed the effects of it in the
past, so we get excellent ousteoblastic activity
305
00:25:44.240 --> 00:25:48.079
in that region and he was comfortable
with us doing that at that point with
306
00:25:48.160 --> 00:25:52.680
the patient. They give us about
three to four weeks to work on that
307
00:25:52.759 --> 00:25:57.799
individual, and we are doing shockwave
a lot more frequently than with tendon and
308
00:25:57.880 --> 00:26:03.039
muscle ligament. We're doing about three
to four days a week on this individual
309
00:26:03.119 --> 00:26:07.759
to produce osteoplastic activity. And particularly
because we had a limited amount of time
310
00:26:08.279 --> 00:26:11.519
with this individual before, you need
to possibly go in for a graph,
311
00:26:12.000 --> 00:26:18.880
but you can see that there is
a lot of palace formation around that surgical
312
00:26:18.920 --> 00:26:23.400
site, particularly on the image on
the right, and they had extremely favorable
313
00:26:23.400 --> 00:26:29.960
outcomes. So about three weeks post
he had about forty to fifty percent bone
314
00:26:30.000 --> 00:26:34.680
healing, and at six weeks post
utilization of shockwave. He had eighty percent
315
00:26:34.839 --> 00:26:40.960
bone formation in that region and he
avoided a bone graph. And I'm happy
316
00:26:41.039 --> 00:26:45.039
to say that this visual is back
to high level soccer, has no pain
317
00:26:45.119 --> 00:26:49.880
over the surgical site and is going
to be playing in college coming next year.
318
00:26:49.960 --> 00:26:55.839
So excellent successful case. If you're
not using it on bone and fractures
319
00:26:55.880 --> 00:27:00.279
or post surgical fractures, a new
realm for you to uprate in that region
320
00:27:00.480 --> 00:27:15.279
tury into your practice. That's it
for today's training. Be sure to keep
321
00:27:15.279 --> 00:27:18.000
an eye on your inbox and follow
us on social media for more details on
322
00:27:18.039 --> 00:27:23.039
our season of giving that kicks off
today through December thirty first. And if
323
00:27:23.039 --> 00:27:26.559
you're not on our mailing list,
what are you waiting for? Click the
324
00:27:26.599 --> 00:27:30.599
sign up link in our show notes
to receive our weekly Factor five Things Friday
325
00:27:30.640 --> 00:27:34.960
email, where we share free resources
to grow your business and elevate your patient
326
00:27:36.039 --> 00:27:41.920
care, along with exclusive discounts and
early access offers for our new certification programs,
327
00:27:41.240 --> 00:27:45.359
free webinars, and hands on courses. All of this is packaged in
328
00:27:45.400 --> 00:27:49.759
a nice, no fluff, simple
five Things format that's easy to skim and
329
00:27:49.799 --> 00:27:55.160
scroll. Be sure to tune in
for episode seventy where we wrap up part
330
00:27:55.160 --> 00:27:59.720
two of our training on shockwave therapy
and talk more about its benefits for athletes
331
00:27:59.720 --> 00:28:03.640
with for you syndromes, as well
as the research surrounding the use of shockwave
332
00:28:03.000 --> 00:28:07.119
to reduce scar formation and post operative
symptoms. You won't want to miss it.
333
00:28:07.359 --> 00:28:15.200
Episode seventy drops in two weeks.
We'll see then. Hey guys,
334
00:28:15.279 --> 00:28:18.319
if you like what you heard today, I encourage you to visit our website
335
00:28:18.319 --> 00:28:26.880
at Factor hyphenstore dot com that's spelled
fak tr hyphenstore dot com to find out
336
00:28:26.920 --> 00:28:30.119
more information about all that we have
to offer. We have a variety of
337
00:28:30.160 --> 00:28:34.000
online offerings as well as our hands
on Factor Rehab System course scheduled in cities
338
00:28:34.039 --> 00:28:37.559
around the globe. Be sure to
also check out our event calendar and bookmark
339
00:28:37.640 --> 00:28:41.720
any of these upcoming live webinar dates
coming up in the near future so you
340
00:28:41.759 --> 00:28:45.880
can join us live. And of
course, the biggest compliment we can receive
341
00:28:45.000 --> 00:28:48.079
is for you to help us spread
the word to your friends, colleagues,
342
00:28:48.119 --> 00:28:52.480
and classmates. You'll find all the
important links, as well as info about
343
00:28:52.480 --> 00:28:56.039
our sponsors in the show notes,
so be sure to check those out.
