WEBVTT
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Hi guys, Welcome to another episode
of The Factor podcast. I'm your host
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Jessica Riddle. If this is your
first time tuning in, welcome and thank
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you for listening. Today we wrap
up our two part training on shockwave therapy
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for post surgical care with doctor David
Rednick. In part one, we covered
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a wide array of topics, including
the mechanisms of shockwave therapy, patient responses
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to care, and specific case studies
where shockwave therapy had a tremendous impact on
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athletes with delayed bone healing. In
today's episode, we chat about the successful
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implementation of shockwave therapy for various orthopedic
cases and talk more about its potential to
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reduce the economic burden on the healthcare
system and improve patient outcomes. One intriguing
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aspect highlighted in this episode that I
really loved was how doctor Rednick integrates movement
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and rehab protocols like Factor with shockwave
therapy. He emphasized the importance of dynamic
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application, where the therapy is actually
used in conjunction with specific movements to enhance
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muscle activation and promote tissue healing.
This dynamic approach not only fosters greater patient
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awareness of their condition, but it
also contributes to more effective rehab outcomes.
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This is one episode you'll definitely want
to listen to more than once. So
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go ahead, hit the download button, let's cue the intro music and get
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started. So this was obviously a
case of non union, and we incorporated
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the shockwave based on the literature and
had excellent outcomes. So the prevalence of
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non union fracture ranges from two and
a half to forty six percent. I
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love percentages like that makes no sense. Obviously it's a huge range. But
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as you can see, this substantial
economic burden on the health system because of
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the bonograft and other health complications and
prolonged physiotherapy that can arise from it.
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So if we can reduce the cost
just to the patient but to the health
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systems, that's always economic medicine and
we're going to achieve a lot of goals,
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not just physical in those cases.
Here's a great study on through the
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Journal of Orthopedics and Surgery and research
on shockwave and non unions. If anybody
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can take screenshots of these, take
pictures of the studies, if anybody wants
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these studies, I have tons of
them, not just these, but tons
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others, So please, I'll give
you my contact information at the end of
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the presentation. Please reach out to
me and I will be more than happy
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to share our litercy sure that we've
built in our library on shockwave application.
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You'll see most of these studies are
fairly new. This one was twenty twenty
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one, so we try to stay
extremely current and only go with the newest
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literature. What's happening in the bone
when we use shockwave over bone over these
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or procedures. We're using it over
stress fractures, which is highly applicable.
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We're using it over stress related injuries
in youth baseball players. We're using it
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over fractures that are non surgical that
could be enhanced with osteoblastic activity and shockwave
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management. So the applications are endless
when it comes to when it comes to
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bone and I think an underutilized area. So we're getting that adhesion kinase total,
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ahesion kinase that's being activated substantially,
the osteoblasts are being activated substantially,
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and again once that patient leaves that
office, that cellular activity is being enhanced
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every hour, so you don't have
to just be hitting it and hitting it
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and hitting it those cells and enzymatic
activity is being enhanced when they're sleeping.
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Obviously, diet and following through with
your rehab protocols or integral as well.
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The patient's going to improve that much
more. But the cellular activity is happening,
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So get your interluken ten enhancement and
the taliprotease down regulation. You're getting
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so much in zomatic activity in that
tissue that you're going to get tissue dealing
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in that individual. Here is another
individual. This was a patient of ours
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who was competing in a obstacle course
race and had a fracture of tip fib
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They did not need to stabilize tib
in this individual. They only did fibula,
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which was good just faster bone healing. They didn't have to put a
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rod all the way up the tibia
like you saw on the other patient.
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This individual had a significant down time
with regards to being immobilized first wheelchair,
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walking, cast and boot so there's
a lot of atrophy in the region and
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just the late tissue healing. This
person not have a non union issue,
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but we were able to reduce the
myofascial restrictions in that region on the plantar
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fascia the Achilles the gas struck Solius
and be able to get that person to
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have a little more range of motion, so they're gain improved a little faster.
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Their Dorsey flextion improves substantially faster with
application of shockwave. So quick diagram
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of what's happening periosteally when you produce
shockwave or apply shockwave in this region.
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So the image on your left is
pre treatment and the image on your right
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shows substantial thickening of that periostium on
that slide, on that bone slide,
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and you're getting stimulation of what's called
the Cambian layer, which is the deeper
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layer of bone versus the outer fibrous
layer of bone, and that deeper layer
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of bone is going to produce a
much stronger, longer term enhancement of that
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region. So you're getting all the
way down to that Cambian layer with shockwave,
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which is fantastic just producing the outer
fibrous layer of bone. This was
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a video of us working on that
soccer player over the surgical site. Sorry
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it doesn't work, but we were
just showing the application in this individual.
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We used that C fifteen head just
because of the superficial nature of that tissue.
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Now, when we got to the
gastruk solius or tib interior, we
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did use the larger D twenty head
over that region to reach the deeper tissue.
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This is a radio unit the superficial
regions. It does work very well.
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If we were to do it over
a deeper region, focused shockwave would
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be a little bit more applicable to
get down to the deeper bone. This
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is I wish I could play this. This is the individual a soccer player.
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I don't remember whether we were three
months post here or where we were.
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He improved very quickly. He was
back to running I think at like
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four months maybe five months post and
yeah, he improved very quickly. But
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this was fairly early on with his
pliometric work that we were doing with the
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light up pods, the blaze pods, f agility and an explosion, and
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then obviously Box jumps to work on
bliometric activity. So we do extensive rehab.
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We don't just get patients where they
can get out of a car,
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out of a chair, out of
a bed without pain and just do normal
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daily activities, activities of daily living
without problems. That person is going to
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go through a very focused sports specific
rehab program with us with gradual return to
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play, and it would be guided
accordingly. We talked to them after each
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practice for each game via email,
via phone, via text, And the
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psychological component of a trauma like this
is great. I know they're going to
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progress physically well. I want to
know how they're doing mentally, and their
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outcomes are going to be substantially higher. So I know this is not just
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a shockwave presentation but a rehab presentation, and the psychological rehab that we do
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with our athletes and our active individuals
is paramount in their recovery. All right,
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Hip Arthur plasty we do this generally
our older population we don't see as
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much as our younger population, but
hip Arthur plasty people improve very quickly with
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hip versus n and incorporating shockwave on
these individuals enhances their ability to get functioning
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just in normal activities daily living substantially
faster. So we're focusing that shockwave over
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the pure formance, over gloutmeaed over
aductor, a lot more tender over adductor.
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In the hip arthroplasty population. We're
going to do quad, We're going
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to do hamstring. We're not just
going to do the surgical incision site,
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which obviously is critical because you're going
to reduce scar formation in that general tightness
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that that patient feels when they sit
down and they go to stand up and
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start to ambulate, but over the
surrounding musculature to work on tissue elasticity and
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extensibility so that individual has less load
transfer onto that surgical incision site early on,
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and they build their confidence with movement. So OHA. Obviously, if
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you see an older population, you're
going to see a lot of OA.
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We push these patients, I feel
a lot more than general physiotherapy. Some
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actually come to us from physiotherapy once
they're like three four weeks in because they
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don't feel like they're being pushed.
The more active population, the surgeons will
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send them to us before even sending
them to their own physiotherapy sites because of
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the that we're going to push that
patient a lot more than just some bandwork
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and some floor work early on.
We're gonna we're gonna push them to their
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limits and can get a bunch favorable
more favorable outcome and reduce their comorbidity and
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their sedentaryness post surgery. Interesting in
the older population, the more you can
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get them moving early on and reduce
their sedentariness the better. So if you've
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never witnessed a hip arthroplasty surgery,
I would highly encourage it. It's barbaric
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and people wonder why they hurt post. I mean, these surgeons are phenomenal
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at what they do. They could
do this in their sleep, but it's
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a barbaric procedure. There's drilling into
bone, and there's hammering, and there's
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there's moving the hip around passively under
anesthesia. So there's a lot of trauma
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to the tissues. So we can
get that anti inflammatory effect with the nitric
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oxide production and the interluken production and
the enhancing the college information with shockwave very
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quickly quickly and producing that extracellular matrix
of tissue with the acoustic wave. So
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range of motion is going to improve, pains are going to reduce. Remember
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your anatomy, there's a lot of
musculature that works around that hip, and
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especially in the older population, if
we can produce new blood vessel formation,
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endothelial activation, and angiogenic production in
that region, we're going to improve that
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patient's outcomes drastically. Generally, we
find a thirty to fifty percent reduction in
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in rehab time. When applying shockwave
to a region, I'll discuss how we
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discuss when we're going to utilize that
on a patient in a little bit later.
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So, tissue inflammation, here's your
nitric oxide production to reduce inflammation,
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endothelial nitric oxide synthase and necrosis factor
bait suppression, which is going to improve
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tissue healing drastically in that individual.
And again, if you need these studies,
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give messages me afterwards. I know
we're coming close on time, but
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I want to make sure we get
time for questions. I got quite a
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few more slides. So trigger points. I know this is not surgical,
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but well it can be because you
can produce trigger points in upper trapezis during
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rotator cuff rehab and in regions of
the body. But even our non surgical
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patients, applying shockwave on that trigger
point is almost an immediate effect. We
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utilize dry needling in our practice as
well, and we see a very similar
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effect of shockwave and dry needling,
and when done in combination, the effects
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are substantially better. But even just
one or the other, that patient's going
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to produce a pretty much an immediate
effect in that male fashional trigger point in
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that region. So we do work
on those with regards to our post surgical
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patients so they don't produce those compensatory
factors, such as our cuff patients that
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are utilizing upper trap because their scalpula
is not migrating laterally and they're not getting
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normal serraenus activation, so they're using
upper trap to produce shoulder abduction, inflection
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and end up with the upper trapezius
elevator, scaling and SCM trigger points.
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So we will do this modality over
the region as well. So location,
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location, location, know your anatomy. And something that we also utilize shockwave
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or do with shockwave is movement.
We will have that person abduct or flex
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or externally, rotate, internally,
rotate in an extremity to enhance the muscle
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activation in that region to get this
to some of the deeper fibers, and
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that patient will sometimes feel the effects
of that a lot more drastically than if
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they were just in a static position. So play with movement. We'll sometimes
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have a patient squatting and working over
the thrackle lumbard junction while they're squatting.
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If low back pain is an issue
with their squat and deadlift, and they'll
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be able to reproduce their pain during
that movement pattern. And then you're treating
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that tissue in a dynamic situation,
which enhances the patient's awareness of that region
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and gets the brain talking to that
tissue in a dynamic situation and producing the
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energy Jesuical effect at that moment.
The outcomes are phenomenal. So if you're
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not utilizing movement with shockwave, get
going on it. Total hip arthroplasty rehab
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protocol early on. This is phase
one, week one to three. We're
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moving them. We're getting them on
the bike. We're getting them doing unweighted
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clamshells, short oar quad exercises,
deal slides, calf phrases, sometimes assisted,
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sometimes unassisted, depending on that patient's
fitness level. Well, we're moving
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them quick. We'll do that shockwave
right on glut pereformance while that patient is
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doing a movement like a sideline abduction
exercise to enhance the effects on that tissue
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dynamically. Here's phase two. We're
getting into some wall sits, some sit
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to stand, need a chess Trannella
berg exercises, standing four way hip.
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If they're super functional. We'll even
get them doing some single leg Romanian deadlifts
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that are assisted. Whatever that patient
can tolerate underload without compensation, We're gon
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we're gonna get them doing asap later
stages obviously GATE reducing that lateral sway,
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reducing the especially if that patient was
dealing with OA for quite some time,
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they're obviously developing that limp related to
unloading that that hip. So we're trying
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to reduce that old compensatory pattern that
they've developed from the OA, and now
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that the joint is more functional,
re having them from a gate standpoint is
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absolutely critical so they can reduce stress
on the knees and other regions of the
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body while they're getting back to their
normal activities. Phase four basically just getting
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them back to their normal activities,
maybe getting them on the tennis court,
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just following around a little bit,
hitting some golf balls in the range up,
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regulating their functional capacity, producing an
optimistic outlook on that individual. Trying
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to build them out, not break
them down. So if they can do
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it without pain without compensation, the
more the merrier. Obviously higher impact stuff
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WI go. But they can stand
on a tennis court or a pickle ball
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court and just volley back and forth
without high impact so they can start getting
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the mechanics back with whatever their activity
level is. This is another cool post
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surgical application that we've stumbled upon.
Being in South Florida, we have a
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group of of females that just want
to look their best and go through these
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mommy makeovers that include breast augmentations and
or breastlifts and obviously abdominoplastyse tummy tucks.
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So we stumbled on this about a
year or so ago and started doing Shockwave
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on a couple of our domino plasty
patients that had some more intense fibrous pain
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and milefascial pain post surgically, so
we started incorporating it. We've read in
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the literature that it's great for reducing
star tissue formation and tissue elasticity, and
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obviously we're getting that analgesic effect immediately
on that individual and they were feeling this
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pulling sensation. So we started to
incorporate it and almost immediately they got that
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analgesic effect that sharper pulling sensation subsided, and we would work through the entire
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abdomen and improve angiogenic benefits in that
region and that person's function and pain just
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reduced very very quickly. So we've
been advertising it with our plastic surgeons that
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we work with and they're seeing the
benefit of it. And obviously, whenever
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we do shockwave over a post surgical
region, we are communicating that with the
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surgeon via office notes and verbally on
the phone. Now, if it's a
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surgeon that knows what we do and
what we implement with their post phyfical patients,
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if it's somebody that we've referred to
them and they're referring back to us,
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that communications assumed. But in somebody
like an a dominoplasty patient that's coming
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to us for other things, some
other mild fashional pains, or just in
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conversation, hey, we can do
this. We are going to talk to
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the surgeon, communicate and co manage
that and make sure that they're aware and
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comfortable that we're going to incorporate that. So post the doominoplasty reduction and scar
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formation reduction and post operative symptoms,
increased angiogenesis to systemic growth factors, suppression,
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phenomenal outcomes. Never would have thought
I would be incorporating that, but
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we're doing getting great results. And
just another avenue that you can incorporate your
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shockwave with. This happened to be
that patient. The parameters are on your
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right. We worked through with the
C fifteen head and then graduated to D
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twenty for the deeper tissue. We
were at a very high hurts. The
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lower the hurts, the deeper the
acoustic wave is going to go. So
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initially we were very superficial over the
scar and then some of the dominances we
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were dropping the herts down to seven, eight nine and trying to increase stars
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as much as we could to tolerance
for that patient. Another I did not
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put it in here, but actually
I wanted to share another case study of
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a patient that was more recent,
and I didn't have any time to put
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it in here, but it was
a actually was a jiu jitsu athlete who
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didn't get hurt in jiu jitsu.
He was actually running into a grocery store
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and slipped in the parking lot on
an oil slick and fractured his paatella in
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multiple places and had a fixation surgery. To repair the patella fracture, they
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put in a star plate which involves
the guide wires into the patella and then
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a star plate over the patella with
usually three two to three screws per fracture
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site. So this individual had about
six to eight screws I believe into a
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paatella and he was producing an adhased
joint fairly early on in rehab, which
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would have caused him to have to
go for manipulation in their anesthesia. But
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we talked about the implications of that
versus the cost benefit of shockwave, and
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we would know fairly quickly whether we
were going to gain range in that individual.
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So we focused shockwave over or used
radial shockwave focused over the retinaculum and
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the distal quad in this individual,
and we were sitting at about eighty degrees
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of flextion and that was uncomfortable for
the individual the patient, and post treatment,
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just one treatment, we were able
to gain ten degrees just post shockwave
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and about six to eight sessions in
I don't even know if we did that
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many, maybe just six sessions in
we were able to get that patient to
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one hundred and fifteen degrees, where
three weeks of work only got us to
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eighty ninety and it was very uncomfortable. But the focus over the retinaculum was
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highly beneficial for reducing the adhesion and
the thickening of that tissue and pain awareness
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production awareness in that region and getting
them one hundred and fifteen hundred and twenty
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degrees which got them a lot more
functional. We could start on the weight
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braining activities a lot easier for them
on the stationary bike, So just implementing
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Shockwave and avoided a more difficult MUA
procedure and more costly procedure for them.
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So another cool implication of shockwave post
surgically. The holiday season is upon us
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and it is truly the most wonderful
time of the year. And while we
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had a ton of fun with Black
Friday and Cyber Monday, we've been counting
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down the days until December's arrival and
the kickoff of our twenty twenty three Season
250
00:22:19.640 --> 00:22:23.119
of Giving. Each week we will
be sending out a new special offer,
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00:22:23.519 --> 00:22:27.480
freebie, or exclusive limited time flash
sale. It's a ton of fun and
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00:22:27.519 --> 00:22:32.960
this year is even more extra with
the launch of four new certification programs and
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the new Factor F five handlebar,
a soft tissue tool unlike any other.
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00:22:37.720 --> 00:22:41.759
So be sure to click the Season
of Giving link in the show notes to
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00:22:41.799 --> 00:22:45.680
get all of the details join us
in celebrating the spirit of giving this holiday
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00:22:45.720 --> 00:22:55.799
season. Happy holidays from factor.
All right, so that is the end
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of what I have. I'd love
to hear any questions, jessicare going in
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read the these back to me if
you guys have them, great. My
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email address, let me give you
that real quick is David Rudnick SO D
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A v I. D Rudnick r
U, D N I C K d
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C at gmail dot com. David
Reudnick DC at gmail dot com. Email
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me ask me any questions you have
on clinical applications. I'll be more than
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happy to send research if you want, or anything you want to ask me
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more than happy to oblige you.
There you go, Jessica to thank chat.
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Thanks. Yes, I posted that
in the chat for everyone. Doctor
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David Rednick d C. And David
Rednick DC at gmail dot com is the
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email address there. So we did
have a few questions that came in.
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I'll go ahead and read some of
those now. One of the first ones
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we received was can you talk on
the use of shockwave after percutaneous needle tenotomy
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with units such as ten X.
Specifically, they said shockwave on the area
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of procedure. Do you wait for
a period after procedure to do the shockwave
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treatment? How long? And do
you know of any research regarding this.
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I'm not so familiar with percutaneous ten
X procedures, but let's actually and I
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did not cover this, I and
I should have, and I'm glad everyone's
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still logged in, and hopefully one's
logged in. But there are some precautions
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with regards to shockwave. One of
them is actually cortizone. You want to
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wait about six weeks before using extracorporeal
shockwave over an area that was treated with
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cortizone. Now, obviously that's right
on that region. So if a person
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had their plantar fascia treated with cortizone, we could still treat the surrounding area
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like the gastruk, the solius,
the poster, your tib and perenials to
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support that region from a mile fashion
standpoint, but right on the area that
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was injected, you're going to avoid
that for about six up to six weeks.
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Obviously, pregnancy, you're going to
avoid, lung tissue, you're going
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to avoid particularly with focused shockwave.
But the ten X, I would say
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typically any area that was treated with
types of things like that at least are
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week or two I would say is
safe and something that you can talk to
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the individual that performed the procedure and
see if they have any input on that
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specific one. Wonderful, thank you. Another question was regarding treatment over bone.
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What specific parameters are we looking at
in terms of energy hurts or number
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of shots or number of pulses,
and how do you determine the exact placement
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of the head for treatment technique is
absolutely critical because this acoustic wave comes out
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at a certain angle, and if
you don't angle it correctly, particularly around
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something that's curvilinear or like a tibia
that has a rounded nature to it and
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it's not flat, you're going to
miss your target tissue. So usually feedback
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from the patient. You do shock
wave of over a non injured area and
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the person is not going to have
as much of a pain response as they
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are over the injured tissue. So
feedback from the patient is absolutely critical.
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To know your angle, know your
anatomy. If you know your anatomy,
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you can position that ahead accordingly,
and then just the more you utilize it,
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the better you're going to get at
the positioning of that head. As
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far as number of pulses, generally
the literature points to two thousand to three
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thousand pulses. Obviously, if it's
a greater depth, you're going to use
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lower hurts in that individual. If
it's a more superficial bone like around a
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wrist or an elbow, you're going
to use a higher number of hurts because
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you don't necessarily need to get the
depth that you would on deeper bone.
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The bar or the amount of jewels
that you're going to be utilizing is going
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to be to patient tolerance. That's
pretty much it. You're not going to
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blast them with three and a half
bar if they can't handle it. And
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usually with bone, just producing that
mechanical mechanical effect on that issue is going
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to produce the osteoblastic activity that you're
looking for, so it doesn't necessarily have
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to be high. But the literature
does say the higher the better. Actually
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with bones, so whatever the patient
can tolerate focused is a lot better with
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regards to outcomes on bone than radial. But the more superficial areas like a
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wrist or an elbow, a patella, or a medial or lateral malliolis are
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going to respond to both modalities.
Very good. Thank you. When you
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have a patient that's coming in and
you might be utilizing a shockwave treatment on
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them for the first time, how
do you explain what shockwave is to your
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patients in a way that makes sense
to them and helps them prepare for the
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loud noise that sometimes accompanies the treatment
or even the discomfort. Obviously, you
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got to know your patient, right. Some patients don't care. They just
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want to get better. They don't
want to hear the why, they don't
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want to hear the what. They
just they lay down and they take it
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and they're just looking for the effect. So you got to know audience.
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Some ask a ton of questions.
They want to know the who, what,
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where, and when and why.
Obviously we're not getting down to the
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deeper physics and the path of physiology. Some like to know that stuff,
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and we'll talk to them about it, just like we're talking this webinar.
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But basically, when I guess,
first of all, when we're going to
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use it, let's say that obviously
there's a cost involved with it and it's
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not a covered entity when insurance.
Now we have to talk outside of clinical
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parameters and talk as practice owners and
clinicians that are incorporating a cost based treatment
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to a patient, but that person's
going to typically end up spending less money
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on treatment in the long run when
they incorporate shockwave into most entities. So
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we just say, it's so much
quicker modality, and we're going to do
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a trial with it, and if
we're not gaining the physiological improvement and the
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functional improvement that we're looking for in
three visits typically, which is not very
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many, we're going to probably discontinue
that treatment. And if we're gaining that
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that ed effect, we're going to
then continue through normal clinical protocols. So
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we just talked to them about this
is the newer research, this is the
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newer technology out there, and we
try to stay up on that. And
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I'm not a big on physiotherapy modalities
like we don't use ultrasan and we don't
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use muscle stem and view those things
very very sparingly, if any. So
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we're only going to incorporate passive modalities
that we find are highly effective, and
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this is what's out there, so
shockwavesit we use dry needling, we use
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our milefascil techniques. So they're coming
in with a trust factor already typically being
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referred by another patient or a physician, and they know they're coming to us
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already for a specific outcome, and
whatever we need to do, there's a
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trust factor there to make that person
better. They're pretty much usually on board,
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absolutely, And one thing you said
was so key there is that it
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really depends upon the patient themselves and
how they typically are when it comes to
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a lot of treatments. Do you
find that post surgical patients tend to be
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the most hesitant to get this treatment? Are they the ones that tend to
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guard a bit and still have a
little bit of fear, especially after an
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injury or I would say surely they're
a lot of pain, right, especially
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when they are acute. Now,
if we're doing it more in a subacute
356
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realm and they're three, four or
five weeks post surgery, there's a little
357
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less hesitancy with it. But obviously
the sound of it is very abrupt.
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But we use that silicone head that
nanohead over the onnier areas because it's a
359
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lot less abrasive and the person can
tolerate a lot better. Or we use
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the C fifteen at a much more
tolerable parameter Kurtz and bar setting for that
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individual, and they see we'll do
it on an area that was not surgically
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repaired initially, just so they can
kind of feel what it should feel like,
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and then we'll find their tolerance level
over that tissue. But yeah,
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they are, but a lot of
them are also very They're ready to just
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get better and whatever's going to enhance
that healing faster, they will be on
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board and just suck it up.
One thing you had talked about earlier was
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the treatment of adhesive capsule ititis or
commonly known as frozen shoulder. I know
368
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that this is a very difficult condition
to treat, but there as you mentioned,
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the literature has shown that shockwave can
be successful. How quickly are you
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seeing improvements in range of motion or
reductions of pain with this particular condition.
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Yeah, so obviously depends on the
stage. If we can catch that patient
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at a earlier stage, we can
avoid a lot of the later stage issues
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in that individual. So if that
person's coming in with just pain and the
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sinovitis in the early stage, we
could help reduce that inflammation and that synovial
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fluid effect that's going on and hopefully
reduce the thickening of the capsule in that
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individual, which we'll obviously end up
keeping that person from hoving the typical stage
377
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two, stage three range of motion
deficits, because you could catch a person
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very early on and they're not coming
in with fifty percent loss in all planes
379
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of range of motion like you typically
see with the with a frozen shoulder patient,
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but they're coming in with a sinovitis
presentation. So shockwave would be very
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applicable in that individual, and you're
obviously not going to incorporate rehab early on
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in that individual because you could produce
you could end up pushing them into later
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stages of adhesive capsulitis and producing more
of the range of motion deficits. So
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it's a very fine line. So
if we can reduce that synovial fluid inflammation
385
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and the pain and then slowly progress
in the rehab, the earlier the better,
386
00:32:46.119 --> 00:32:52.799
but yeah, excellent results obviously,
very very painful. Focused shockwave is
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fantastic for the hesive capsulitis. I
think even a little bit better than radial
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depending on the body habitus of patient
and radio can get into there as well.
389
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We're going to hit the deep ra
areas of the subscap and get in
390
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some really uncomfortable positions. But if
they can tolerate it, the outcomes are
391
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incredible. And the patient sees that
immediately, they'll set up and they will
392
00:33:15.720 --> 00:33:19.799
go and take their shoulder through active
assisted or even active range of motion,
393
00:33:20.279 --> 00:33:23.079
and there's range of motion improvement.
And you don't need to convince somebody when
394
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they see objective improvement. Immediately they
go, whatever you did last time,
395
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do again, and they'll tolerate the
pain absolutely. And it's key. Like
396
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you said, everybody's just trying.
They're trying to get better, they're trying
397
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to feel better, they're trying to
move better as quickly as possible. Have
398
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there been any conditions you've treated with
shockwave that were surprising in terms of how
399
00:33:45.559 --> 00:33:49.720
well they responded to the treatment,
or you've received a better outcome than you
400
00:33:49.799 --> 00:33:53.680
expected. I think we generally try
to do it on the areas that have
401
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high validity and we're not just experimenting. Let me comment on the opposite end
402
00:33:59.599 --> 00:34:06.359
of that question. I would say
neoste arthritis is my least responsive. So
403
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just a pure primary NEOA patient,
they're my least responsive to shockwave. But
404
00:34:13.599 --> 00:34:21.719
typically the tendinopathy patients are very responsive. I guess my later upicondulosis and medio
405
00:34:21.800 --> 00:34:25.280
upicondylosis patients because before Shockwave, I
would say, if I didn't have to
406
00:34:25.320 --> 00:34:30.880
see a medial lateralpicondylosis patient again,
I would be okay with that, because
407
00:34:30.920 --> 00:34:35.880
generally the people that don't come in
day one with that condition, they come
408
00:34:35.920 --> 00:34:38.159
in day one hundred and one.
They've been dealing with for some time.
409
00:34:38.599 --> 00:34:43.119
There's a lot of adhesion around the
area, there's a lot more micro tears
410
00:34:43.119 --> 00:34:45.880
that have been produced, there's a
lot of compensatory issues that have been built
411
00:34:45.920 --> 00:34:52.239
around that, and the compliance is
low because it doesn't impact them every moment
412
00:34:52.280 --> 00:34:55.199
of every day. It impacts them
during certain activities, so maybe the person
413
00:34:55.239 --> 00:35:00.559
avoids that activity, maybe they've compensated
around it. So usually people don't want
414
00:35:00.599 --> 00:35:06.880
to sit and do ecentric exercises and
loading on a forum that it's boring,
415
00:35:07.199 --> 00:35:10.920
it's boring rehab. So usually the
outcomes are that I've seen have been more
416
00:35:12.000 --> 00:35:17.039
poor in the chronic epicondylosis patient.
But incorporating Shockwave and particularly with that android
417
00:35:17.079 --> 00:35:22.159
needling and applications, I've said,
I've seen a much greater outcome in that
418
00:35:22.239 --> 00:35:28.280
population, So I guess if I
were to answer that question apicondalosis. So
419
00:35:28.320 --> 00:35:30.360
again, thank you so much,
Doctor Rednet. We really appreciate you presenting
420
00:35:30.360 --> 00:35:44.000
today. Thank you everyone for joining
us. Be sure to tune in on
421
00:35:44.039 --> 00:35:47.840
December twenty ninth for our last episode
of twenty twenty three. I'll have a
422
00:35:47.840 --> 00:35:52.280
few special guests on that serve on
the sports medicine team for USA Gymnastics.
423
00:35:52.960 --> 00:35:57.960
We'll chat about the path to working
with elite athletes and the crucial components of
424
00:35:58.000 --> 00:36:02.079
what it's like to work on a
diverse healthcare team where several professions and specialties
425
00:36:02.119 --> 00:36:07.280
are represented. You won't want to
miss it. Episode seventy drops in two
426
00:36:07.320 --> 00:36:10.039
weeks. Be sure to check our
show notes and click the link to get
427
00:36:10.039 --> 00:36:14.559
on our season of giving email list
so you can get a new free offer,
428
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discount, or exclusive flash sale access
in your inbox each Friday. There's
429
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only a few Fridays remaining in December, so be sure to go now to
430
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the show notes, click the link
get on that list so that you can
431
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get one starting today. Like always, you'll also find the webinar replay link
432
00:36:31.199 --> 00:36:36.000
for the training that was featured in
today's episode. You can click the link,
433
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view the full presentation, and view
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438
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to all of you around the globe, we wish you a very merry and
439
00:37:00.599 --> 00:37:05.840
happy holiday. Hey guys, if
you like what you heard today, I
440
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encourage you to visit our website at
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441
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tr hyphenstore dot com to find out
more information about all that we have to
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offer. We have a variety of
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sure to check those out.
1
00:00:15.119 --> 00:00:19.079
Hi guys, Welcome to another episode
of The Factor podcast. I'm your host
2
00:00:19.199 --> 00:00:22.800
Jessica Riddle. If this is your
first time tuning in, welcome and thank
3
00:00:22.839 --> 00:00:27.600
you for listening. Today we wrap
up our two part training on shockwave therapy
4
00:00:27.640 --> 00:00:33.079
for post surgical care with doctor David
Rednick. In part one, we covered
5
00:00:33.119 --> 00:00:38.679
a wide array of topics, including
the mechanisms of shockwave therapy, patient responses
6
00:00:38.679 --> 00:00:43.359
to care, and specific case studies
where shockwave therapy had a tremendous impact on
7
00:00:43.479 --> 00:00:49.039
athletes with delayed bone healing. In
today's episode, we chat about the successful
8
00:00:49.039 --> 00:00:55.079
implementation of shockwave therapy for various orthopedic
cases and talk more about its potential to
9
00:00:55.119 --> 00:01:00.159
reduce the economic burden on the healthcare
system and improve patient outcomes. One intriguing
10
00:01:00.200 --> 00:01:06.519
aspect highlighted in this episode that I
really loved was how doctor Rednick integrates movement
11
00:01:06.640 --> 00:01:12.319
and rehab protocols like Factor with shockwave
therapy. He emphasized the importance of dynamic
12
00:01:12.400 --> 00:01:19.400
application, where the therapy is actually
used in conjunction with specific movements to enhance
13
00:01:19.480 --> 00:01:26.079
muscle activation and promote tissue healing.
This dynamic approach not only fosters greater patient
14
00:01:26.120 --> 00:01:30.079
awareness of their condition, but it
also contributes to more effective rehab outcomes.
15
00:01:32.159 --> 00:01:36.439
This is one episode you'll definitely want
to listen to more than once. So
16
00:01:36.560 --> 00:01:40.120
go ahead, hit the download button, let's cue the intro music and get
17
00:01:40.159 --> 00:01:53.439
started. So this was obviously a
case of non union, and we incorporated
18
00:01:53.480 --> 00:01:59.400
the shockwave based on the literature and
had excellent outcomes. So the prevalence of
19
00:01:59.400 --> 00:02:02.159
non union fracture ranges from two and
a half to forty six percent. I
20
00:02:02.159 --> 00:02:07.479
love percentages like that makes no sense. Obviously it's a huge range. But
21
00:02:07.840 --> 00:02:13.840
as you can see, this substantial
economic burden on the health system because of
22
00:02:13.879 --> 00:02:20.360
the bonograft and other health complications and
prolonged physiotherapy that can arise from it.
23
00:02:20.479 --> 00:02:24.840
So if we can reduce the cost
just to the patient but to the health
24
00:02:24.879 --> 00:02:30.800
systems, that's always economic medicine and
we're going to achieve a lot of goals,
25
00:02:30.840 --> 00:02:36.960
not just physical in those cases.
Here's a great study on through the
26
00:02:37.039 --> 00:02:42.360
Journal of Orthopedics and Surgery and research
on shockwave and non unions. If anybody
27
00:02:42.400 --> 00:02:46.680
can take screenshots of these, take
pictures of the studies, if anybody wants
28
00:02:46.199 --> 00:02:50.680
these studies, I have tons of
them, not just these, but tons
29
00:02:50.759 --> 00:02:53.639
others, So please, I'll give
you my contact information at the end of
30
00:02:53.680 --> 00:02:58.479
the presentation. Please reach out to
me and I will be more than happy
31
00:02:58.479 --> 00:03:04.960
to share our litercy sure that we've
built in our library on shockwave application.
32
00:03:05.319 --> 00:03:07.840
You'll see most of these studies are
fairly new. This one was twenty twenty
33
00:03:07.879 --> 00:03:12.919
one, so we try to stay
extremely current and only go with the newest
34
00:03:13.080 --> 00:03:19.080
literature. What's happening in the bone
when we use shockwave over bone over these
35
00:03:19.159 --> 00:03:23.759
or procedures. We're using it over
stress fractures, which is highly applicable.
36
00:03:24.400 --> 00:03:31.319
We're using it over stress related injuries
in youth baseball players. We're using it
37
00:03:31.479 --> 00:03:39.199
over fractures that are non surgical that
could be enhanced with osteoblastic activity and shockwave
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00:03:39.400 --> 00:03:44.840
management. So the applications are endless
when it comes to when it comes to
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00:03:44.919 --> 00:03:50.199
bone and I think an underutilized area. So we're getting that adhesion kinase total,
40
00:03:50.240 --> 00:03:54.879
ahesion kinase that's being activated substantially,
the osteoblasts are being activated substantially,
41
00:03:54.919 --> 00:04:00.639
and again once that patient leaves that
office, that cellular activity is being enhanced
42
00:04:00.199 --> 00:04:03.280
every hour, so you don't have
to just be hitting it and hitting it
43
00:04:03.280 --> 00:04:09.000
and hitting it those cells and enzymatic
activity is being enhanced when they're sleeping.
44
00:04:09.479 --> 00:04:14.120
Obviously, diet and following through with
your rehab protocols or integral as well.
45
00:04:14.240 --> 00:04:17.800
The patient's going to improve that much
more. But the cellular activity is happening,
46
00:04:18.639 --> 00:04:26.639
So get your interluken ten enhancement and
the taliprotease down regulation. You're getting
47
00:04:26.680 --> 00:04:30.199
so much in zomatic activity in that
tissue that you're going to get tissue dealing
48
00:04:30.600 --> 00:04:38.079
in that individual. Here is another
individual. This was a patient of ours
49
00:04:38.120 --> 00:04:45.240
who was competing in a obstacle course
race and had a fracture of tip fib
50
00:04:45.560 --> 00:04:49.279
They did not need to stabilize tib
in this individual. They only did fibula,
51
00:04:49.920 --> 00:04:54.040
which was good just faster bone healing. They didn't have to put a
52
00:04:54.079 --> 00:04:56.800
rod all the way up the tibia
like you saw on the other patient.
53
00:04:57.199 --> 00:05:03.399
This individual had a significant down time
with regards to being immobilized first wheelchair,
54
00:05:04.040 --> 00:05:09.040
walking, cast and boot so there's
a lot of atrophy in the region and
55
00:05:09.279 --> 00:05:12.720
just the late tissue healing. This
person not have a non union issue,
56
00:05:13.040 --> 00:05:19.399
but we were able to reduce the
myofascial restrictions in that region on the plantar
57
00:05:19.519 --> 00:05:25.399
fascia the Achilles the gas struck Solius
and be able to get that person to
58
00:05:25.399 --> 00:05:28.319
have a little more range of motion, so they're gain improved a little faster.
59
00:05:28.800 --> 00:05:34.600
Their Dorsey flextion improves substantially faster with
application of shockwave. So quick diagram
60
00:05:34.680 --> 00:05:41.759
of what's happening periosteally when you produce
shockwave or apply shockwave in this region.
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00:05:42.120 --> 00:05:47.240
So the image on your left is
pre treatment and the image on your right
62
00:05:47.319 --> 00:05:54.360
shows substantial thickening of that periostium on
that slide, on that bone slide,
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00:05:54.800 --> 00:05:59.000
and you're getting stimulation of what's called
the Cambian layer, which is the deeper
64
00:05:59.079 --> 00:06:04.240
layer of bone versus the outer fibrous
layer of bone, and that deeper layer
65
00:06:04.279 --> 00:06:10.639
of bone is going to produce a
much stronger, longer term enhancement of that
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00:06:10.680 --> 00:06:14.639
region. So you're getting all the
way down to that Cambian layer with shockwave,
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00:06:14.879 --> 00:06:20.079
which is fantastic just producing the outer
fibrous layer of bone. This was
68
00:06:20.079 --> 00:06:26.079
a video of us working on that
soccer player over the surgical site. Sorry
69
00:06:26.079 --> 00:06:29.800
it doesn't work, but we were
just showing the application in this individual.
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00:06:29.839 --> 00:06:34.160
We used that C fifteen head just
because of the superficial nature of that tissue.
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00:06:34.240 --> 00:06:38.560
Now, when we got to the
gastruk solius or tib interior, we
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00:06:38.639 --> 00:06:43.480
did use the larger D twenty head
over that region to reach the deeper tissue.
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00:06:44.480 --> 00:06:47.560
This is a radio unit the superficial
regions. It does work very well.
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00:06:47.839 --> 00:06:53.160
If we were to do it over
a deeper region, focused shockwave would
75
00:06:53.160 --> 00:06:57.079
be a little bit more applicable to
get down to the deeper bone. This
76
00:06:57.399 --> 00:07:00.680
is I wish I could play this. This is the individual a soccer player.
77
00:07:01.399 --> 00:07:06.639
I don't remember whether we were three
months post here or where we were.
78
00:07:08.120 --> 00:07:14.199
He improved very quickly. He was
back to running I think at like
79
00:07:14.839 --> 00:07:20.040
four months maybe five months post and
yeah, he improved very quickly. But
80
00:07:20.120 --> 00:07:26.480
this was fairly early on with his
pliometric work that we were doing with the
81
00:07:26.560 --> 00:07:30.680
light up pods, the blaze pods, f agility and an explosion, and
82
00:07:30.680 --> 00:07:35.959
then obviously Box jumps to work on
bliometric activity. So we do extensive rehab.
83
00:07:36.480 --> 00:07:39.959
We don't just get patients where they
can get out of a car,
84
00:07:40.040 --> 00:07:43.560
out of a chair, out of
a bed without pain and just do normal
85
00:07:44.360 --> 00:07:47.639
daily activities, activities of daily living
without problems. That person is going to
86
00:07:47.639 --> 00:07:54.040
go through a very focused sports specific
rehab program with us with gradual return to
87
00:07:54.079 --> 00:07:59.160
play, and it would be guided
accordingly. We talked to them after each
88
00:07:59.240 --> 00:08:03.160
practice for each game via email,
via phone, via text, And the
89
00:08:03.639 --> 00:08:09.199
psychological component of a trauma like this
is great. I know they're going to
90
00:08:09.319 --> 00:08:11.879
progress physically well. I want to
know how they're doing mentally, and their
91
00:08:11.959 --> 00:08:16.480
outcomes are going to be substantially higher. So I know this is not just
92
00:08:16.519 --> 00:08:22.240
a shockwave presentation but a rehab presentation, and the psychological rehab that we do
93
00:08:22.319 --> 00:08:26.519
with our athletes and our active individuals
is paramount in their recovery. All right,
94
00:08:26.600 --> 00:08:33.399
Hip Arthur plasty we do this generally
our older population we don't see as
95
00:08:33.519 --> 00:08:39.639
much as our younger population, but
hip Arthur plasty people improve very quickly with
96
00:08:39.720 --> 00:08:48.440
hip versus n and incorporating shockwave on
these individuals enhances their ability to get functioning
97
00:08:48.519 --> 00:08:54.600
just in normal activities daily living substantially
faster. So we're focusing that shockwave over
98
00:08:54.200 --> 00:08:58.960
the pure formance, over gloutmeaed over
aductor, a lot more tender over adductor.
99
00:09:00.120 --> 00:09:03.080
In the hip arthroplasty population. We're
going to do quad, We're going
100
00:09:03.159 --> 00:09:07.879
to do hamstring. We're not just
going to do the surgical incision site,
101
00:09:07.919 --> 00:09:13.519
which obviously is critical because you're going
to reduce scar formation in that general tightness
102
00:09:13.519 --> 00:09:16.440
that that patient feels when they sit
down and they go to stand up and
103
00:09:16.480 --> 00:09:22.759
start to ambulate, but over the
surrounding musculature to work on tissue elasticity and
104
00:09:22.840 --> 00:09:28.120
extensibility so that individual has less load
transfer onto that surgical incision site early on,
105
00:09:28.360 --> 00:09:33.919
and they build their confidence with movement. So OHA. Obviously, if
106
00:09:33.960 --> 00:09:37.720
you see an older population, you're
going to see a lot of OA.
107
00:09:37.679 --> 00:09:45.559
We push these patients, I feel
a lot more than general physiotherapy. Some
108
00:09:45.840 --> 00:09:50.360
actually come to us from physiotherapy once
they're like three four weeks in because they
109
00:09:50.360 --> 00:09:54.440
don't feel like they're being pushed.
The more active population, the surgeons will
110
00:09:54.440 --> 00:09:58.720
send them to us before even sending
them to their own physiotherapy sites because of
111
00:09:58.759 --> 00:10:03.320
the that we're going to push that
patient a lot more than just some bandwork
112
00:10:03.679 --> 00:10:07.440
and some floor work early on.
We're gonna we're gonna push them to their
113
00:10:07.440 --> 00:10:13.720
limits and can get a bunch favorable
more favorable outcome and reduce their comorbidity and
114
00:10:13.759 --> 00:10:18.759
their sedentaryness post surgery. Interesting in
the older population, the more you can
115
00:10:18.759 --> 00:10:24.720
get them moving early on and reduce
their sedentariness the better. So if you've
116
00:10:24.759 --> 00:10:30.960
never witnessed a hip arthroplasty surgery,
I would highly encourage it. It's barbaric
117
00:10:31.679 --> 00:10:35.559
and people wonder why they hurt post. I mean, these surgeons are phenomenal
118
00:10:35.559 --> 00:10:39.159
at what they do. They could
do this in their sleep, but it's
119
00:10:39.200 --> 00:10:43.200
a barbaric procedure. There's drilling into
bone, and there's hammering, and there's
120
00:10:43.480 --> 00:10:48.840
there's moving the hip around passively under
anesthesia. So there's a lot of trauma
121
00:10:48.919 --> 00:10:54.120
to the tissues. So we can
get that anti inflammatory effect with the nitric
122
00:10:54.120 --> 00:11:03.480
oxide production and the interluken production and
the enhancing the college information with shockwave very
123
00:11:03.519 --> 00:11:09.679
quickly quickly and producing that extracellular matrix
of tissue with the acoustic wave. So
124
00:11:11.000 --> 00:11:13.440
range of motion is going to improve, pains are going to reduce. Remember
125
00:11:13.480 --> 00:11:18.159
your anatomy, there's a lot of
musculature that works around that hip, and
126
00:11:18.320 --> 00:11:22.639
especially in the older population, if
we can produce new blood vessel formation,
127
00:11:22.799 --> 00:11:30.559
endothelial activation, and angiogenic production in
that region, we're going to improve that
128
00:11:30.600 --> 00:11:35.720
patient's outcomes drastically. Generally, we
find a thirty to fifty percent reduction in
129
00:11:35.720 --> 00:11:41.279
in rehab time. When applying shockwave
to a region, I'll discuss how we
130
00:11:43.320 --> 00:11:46.679
discuss when we're going to utilize that
on a patient in a little bit later.
131
00:11:48.200 --> 00:11:52.879
So, tissue inflammation, here's your
nitric oxide production to reduce inflammation,
132
00:11:54.519 --> 00:12:03.559
endothelial nitric oxide synthase and necrosis factor
bait suppression, which is going to improve
133
00:12:03.639 --> 00:12:07.840
tissue healing drastically in that individual.
And again, if you need these studies,
134
00:12:07.240 --> 00:12:11.159
give messages me afterwards. I know
we're coming close on time, but
135
00:12:11.200 --> 00:12:15.159
I want to make sure we get
time for questions. I got quite a
136
00:12:15.200 --> 00:12:18.480
few more slides. So trigger points. I know this is not surgical,
137
00:12:18.600 --> 00:12:24.159
but well it can be because you
can produce trigger points in upper trapezis during
138
00:12:24.240 --> 00:12:28.120
rotator cuff rehab and in regions of
the body. But even our non surgical
139
00:12:28.159 --> 00:12:33.480
patients, applying shockwave on that trigger
point is almost an immediate effect. We
140
00:12:33.559 --> 00:12:37.879
utilize dry needling in our practice as
well, and we see a very similar
141
00:12:37.919 --> 00:12:43.919
effect of shockwave and dry needling,
and when done in combination, the effects
142
00:12:45.000 --> 00:12:50.600
are substantially better. But even just
one or the other, that patient's going
143
00:12:50.639 --> 00:12:54.240
to produce a pretty much an immediate
effect in that male fashional trigger point in
144
00:12:54.279 --> 00:12:58.159
that region. So we do work
on those with regards to our post surgical
145
00:12:58.200 --> 00:13:05.360
patients so they don't produce those compensatory
factors, such as our cuff patients that
146
00:13:05.440 --> 00:13:11.519
are utilizing upper trap because their scalpula
is not migrating laterally and they're not getting
147
00:13:11.679 --> 00:13:16.639
normal serraenus activation, so they're using
upper trap to produce shoulder abduction, inflection
148
00:13:18.320 --> 00:13:24.919
and end up with the upper trapezius
elevator, scaling and SCM trigger points.
149
00:13:24.960 --> 00:13:28.840
So we will do this modality over
the region as well. So location,
150
00:13:28.960 --> 00:13:35.600
location, location, know your anatomy. And something that we also utilize shockwave
151
00:13:35.840 --> 00:13:41.919
or do with shockwave is movement.
We will have that person abduct or flex
152
00:13:41.159 --> 00:13:46.200
or externally, rotate, internally,
rotate in an extremity to enhance the muscle
153
00:13:46.240 --> 00:13:50.240
activation in that region to get this
to some of the deeper fibers, and
154
00:13:50.279 --> 00:13:56.440
that patient will sometimes feel the effects
of that a lot more drastically than if
155
00:13:56.480 --> 00:14:01.080
they were just in a static position. So play with movement. We'll sometimes
156
00:14:01.080 --> 00:14:05.879
have a patient squatting and working over
the thrackle lumbard junction while they're squatting.
157
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If low back pain is an issue
with their squat and deadlift, and they'll
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be able to reproduce their pain during
that movement pattern. And then you're treating
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that tissue in a dynamic situation,
which enhances the patient's awareness of that region
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and gets the brain talking to that
tissue in a dynamic situation and producing the
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energy Jesuical effect at that moment.
The outcomes are phenomenal. So if you're
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not utilizing movement with shockwave, get
going on it. Total hip arthroplasty rehab
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protocol early on. This is phase
one, week one to three. We're
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moving them. We're getting them on
the bike. We're getting them doing unweighted
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clamshells, short oar quad exercises,
deal slides, calf phrases, sometimes assisted,
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sometimes unassisted, depending on that patient's
fitness level. Well, we're moving
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them quick. We'll do that shockwave
right on glut pereformance while that patient is
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doing a movement like a sideline abduction
exercise to enhance the effects on that tissue
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dynamically. Here's phase two. We're
getting into some wall sits, some sit
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to stand, need a chess Trannella
berg exercises, standing four way hip.
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If they're super functional. We'll even
get them doing some single leg Romanian deadlifts
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that are assisted. Whatever that patient
can tolerate underload without compensation, We're gon
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we're gonna get them doing asap later
stages obviously GATE reducing that lateral sway,
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reducing the especially if that patient was
dealing with OA for quite some time,
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they're obviously developing that limp related to
unloading that that hip. So we're trying
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to reduce that old compensatory pattern that
they've developed from the OA, and now
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that the joint is more functional,
re having them from a gate standpoint is
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absolutely critical so they can reduce stress
on the knees and other regions of the
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body while they're getting back to their
normal activities. Phase four basically just getting
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them back to their normal activities,
maybe getting them on the tennis court,
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just following around a little bit,
hitting some golf balls in the range up,
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regulating their functional capacity, producing an
optimistic outlook on that individual. Trying
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to build them out, not break
them down. So if they can do
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it without pain without compensation, the
more the merrier. Obviously higher impact stuff
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WI go. But they can stand
on a tennis court or a pickle ball
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court and just volley back and forth
without high impact so they can start getting
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the mechanics back with whatever their activity
level is. This is another cool post
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surgical application that we've stumbled upon.
Being in South Florida, we have a
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group of of females that just want
to look their best and go through these
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mommy makeovers that include breast augmentations and
or breastlifts and obviously abdominoplastyse tummy tucks.
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So we stumbled on this about a
year or so ago and started doing Shockwave
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on a couple of our domino plasty
patients that had some more intense fibrous pain
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and milefascial pain post surgically, so
we started incorporating it. We've read in
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the literature that it's great for reducing
star tissue formation and tissue elasticity, and
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obviously we're getting that analgesic effect immediately
on that individual and they were feeling this
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pulling sensation. So we started to
incorporate it and almost immediately they got that
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analgesic effect that sharper pulling sensation subsided, and we would work through the entire
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abdomen and improve angiogenic benefits in that
region and that person's function and pain just
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reduced very very quickly. So we've
been advertising it with our plastic surgeons that
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we work with and they're seeing the
benefit of it. And obviously, whenever
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we do shockwave over a post surgical
region, we are communicating that with the
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surgeon via office notes and verbally on
the phone. Now, if it's a
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surgeon that knows what we do and
what we implement with their post phyfical patients,
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if it's somebody that we've referred to
them and they're referring back to us,
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that communications assumed. But in somebody
like an a dominoplasty patient that's coming
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to us for other things, some
other mild fashional pains, or just in
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conversation, hey, we can do
this. We are going to talk to
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the surgeon, communicate and co manage
that and make sure that they're aware and
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comfortable that we're going to incorporate that. So post the doominoplasty reduction and scar
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formation reduction and post operative symptoms,
increased angiogenesis to systemic growth factors, suppression,
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phenomenal outcomes. Never would have thought
I would be incorporating that, but
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we're doing getting great results. And
just another avenue that you can incorporate your
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shockwave with. This happened to be
that patient. The parameters are on your
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right. We worked through with the
C fifteen head and then graduated to D
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twenty for the deeper tissue. We
were at a very high hurts. The
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lower the hurts, the deeper the
acoustic wave is going to go. So
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initially we were very superficial over the
scar and then some of the dominances we
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were dropping the herts down to seven, eight nine and trying to increase stars
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as much as we could to tolerance
for that patient. Another I did not
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put it in here, but actually
I wanted to share another case study of
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a patient that was more recent,
and I didn't have any time to put
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it in here, but it was
a actually was a jiu jitsu athlete who
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didn't get hurt in jiu jitsu.
He was actually running into a grocery store
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and slipped in the parking lot on
an oil slick and fractured his paatella in
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multiple places and had a fixation surgery. To repair the patella fracture, they
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put in a star plate which involves
the guide wires into the patella and then
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a star plate over the patella with
usually three two to three screws per fracture
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site. So this individual had about
six to eight screws I believe into a
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paatella and he was producing an adhased
joint fairly early on in rehab, which
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would have caused him to have to
go for manipulation in their anesthesia. But
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we talked about the implications of that
versus the cost benefit of shockwave, and
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we would know fairly quickly whether we
were going to gain range in that individual.
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So we focused shockwave over or used
radial shockwave focused over the retinaculum and
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the distal quad in this individual,
and we were sitting at about eighty degrees
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of flextion and that was uncomfortable for
the individual the patient, and post treatment,
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just one treatment, we were able
to gain ten degrees just post shockwave
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and about six to eight sessions in
I don't even know if we did that
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many, maybe just six sessions in
we were able to get that patient to
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one hundred and fifteen degrees, where
three weeks of work only got us to
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eighty ninety and it was very uncomfortable. But the focus over the retinaculum was
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highly beneficial for reducing the adhesion and
the thickening of that tissue and pain awareness
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production awareness in that region and getting
them one hundred and fifteen hundred and twenty
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degrees which got them a lot more
functional. We could start on the weight
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braining activities a lot easier for them
on the stationary bike, So just implementing
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Shockwave and avoided a more difficult MUA
procedure and more costly procedure for them.
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So another cool implication of shockwave post
surgically. The holiday season is upon us
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and it is truly the most wonderful
time of the year. And while we
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had a ton of fun with Black
Friday and Cyber Monday, we've been counting
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down the days until December's arrival and
the kickoff of our twenty twenty three Season
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of Giving. Each week we will
be sending out a new special offer,
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freebie, or exclusive limited time flash
sale. It's a ton of fun and
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this year is even more extra with
the launch of four new certification programs and
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the new Factor F five handlebar,
a soft tissue tool unlike any other.
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So be sure to click the Season
of Giving link in the show notes to
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00:22:41.799 --> 00:22:45.680
get all of the details join us
in celebrating the spirit of giving this holiday
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season. Happy holidays from factor.
All right, so that is the end
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of what I have. I'd love
to hear any questions, jessicare going in
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read the these back to me if
you guys have them, great. My
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email address, let me give you
that real quick is David Rudnick SO D
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A v I. D Rudnick r
U, D N I C K d
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C at gmail dot com. David
Reudnick DC at gmail dot com. Email
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me ask me any questions you have
on clinical applications. I'll be more than
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happy to send research if you want, or anything you want to ask me
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more than happy to oblige you.
There you go, Jessica to thank chat.
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Thanks. Yes, I posted that
in the chat for everyone. Doctor
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David Rednick d C. And David
Rednick DC at gmail dot com is the
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email address there. So we did
have a few questions that came in.
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I'll go ahead and read some of
those now. One of the first ones
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we received was can you talk on
the use of shockwave after percutaneous needle tenotomy
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with units such as ten X.
Specifically, they said shockwave on the area
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of procedure. Do you wait for
a period after procedure to do the shockwave
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treatment? How long? And do
you know of any research regarding this.
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I'm not so familiar with percutaneous ten
X procedures, but let's actually and I
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did not cover this, I and
I should have, and I'm glad everyone's
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still logged in, and hopefully one's
logged in. But there are some precautions
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with regards to shockwave. One of
them is actually cortizone. You want to
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wait about six weeks before using extracorporeal
shockwave over an area that was treated with
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cortizone. Now, obviously that's right
on that region. So if a person
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had their plantar fascia treated with cortizone, we could still treat the surrounding area
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like the gastruk, the solius,
the poster, your tib and perenials to
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support that region from a mile fashion
standpoint, but right on the area that
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was injected, you're going to avoid
that for about six up to six weeks.
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Obviously, pregnancy, you're going to
avoid, lung tissue, you're going
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to avoid particularly with focused shockwave.
But the ten X, I would say
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typically any area that was treated with
types of things like that at least are
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week or two I would say is
safe and something that you can talk to
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the individual that performed the procedure and
see if they have any input on that
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specific one. Wonderful, thank you. Another question was regarding treatment over bone.
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What specific parameters are we looking at
in terms of energy hurts or number
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of shots or number of pulses,
and how do you determine the exact placement
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of the head for treatment technique is
absolutely critical because this acoustic wave comes out
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at a certain angle, and if
you don't angle it correctly, particularly around
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something that's curvilinear or like a tibia
that has a rounded nature to it and
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it's not flat, you're going to
miss your target tissue. So usually feedback
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from the patient. You do shock
wave of over a non injured area and
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the person is not going to have
as much of a pain response as they
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are over the injured tissue. So
feedback from the patient is absolutely critical.
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To know your angle, know your
anatomy. If you know your anatomy,
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you can position that ahead accordingly,
and then just the more you utilize it,
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the better you're going to get at
the positioning of that head. As
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far as number of pulses, generally
the literature points to two thousand to three
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thousand pulses. Obviously, if it's
a greater depth, you're going to use
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lower hurts in that individual. If
it's a more superficial bone like around a
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wrist or an elbow, you're going
to use a higher number of hurts because
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you don't necessarily need to get the
depth that you would on deeper bone.
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The bar or the amount of jewels
that you're going to be utilizing is going
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to be to patient tolerance. That's
pretty much it. You're not going to
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blast them with three and a half
bar if they can't handle it. And
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usually with bone, just producing that
mechanical mechanical effect on that issue is going
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to produce the osteoblastic activity that you're
looking for, so it doesn't necessarily have
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to be high. But the literature
does say the higher the better. Actually
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with bones, so whatever the patient
can tolerate focused is a lot better with
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regards to outcomes on bone than radial. But the more superficial areas like a
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wrist or an elbow, a patella, or a medial or lateral malliolis are
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going to respond to both modalities.
Very good. Thank you. When you
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have a patient that's coming in and
you might be utilizing a shockwave treatment on
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them for the first time, how
do you explain what shockwave is to your
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patients in a way that makes sense
to them and helps them prepare for the
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loud noise that sometimes accompanies the treatment
or even the discomfort. Obviously, you
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got to know your patient, right. Some patients don't care. They just
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want to get better. They don't
want to hear the why, they don't
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want to hear the what. They
just they lay down and they take it
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and they're just looking for the effect. So you got to know audience.
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Some ask a ton of questions.
They want to know the who, what,
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where, and when and why.
Obviously we're not getting down to the
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deeper physics and the path of physiology. Some like to know that stuff,
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and we'll talk to them about it, just like we're talking this webinar.
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But basically, when I guess,
first of all, when we're going to
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use it, let's say that obviously
there's a cost involved with it and it's
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not a covered entity when insurance.
Now we have to talk outside of clinical
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parameters and talk as practice owners and
clinicians that are incorporating a cost based treatment
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to a patient, but that person's
going to typically end up spending less money
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on treatment in the long run when
they incorporate shockwave into most entities. So
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we just say, it's so much
quicker modality, and we're going to do
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a trial with it, and if
we're not gaining the physiological improvement and the
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functional improvement that we're looking for in
three visits typically, which is not very
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many, we're going to probably discontinue
that treatment. And if we're gaining that
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that ed effect, we're going to
then continue through normal clinical protocols. So
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we just talked to them about this
is the newer research, this is the
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newer technology out there, and we
try to stay up on that. And
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I'm not a big on physiotherapy modalities
like we don't use ultrasan and we don't
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use muscle stem and view those things
very very sparingly, if any. So
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we're only going to incorporate passive modalities
that we find are highly effective, and
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this is what's out there, so
shockwavesit we use dry needling, we use
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our milefascil techniques. So they're coming
in with a trust factor already typically being
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referred by another patient or a physician, and they know they're coming to us
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already for a specific outcome, and
whatever we need to do, there's a
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trust factor there to make that person
better. They're pretty much usually on board,
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absolutely, And one thing you said
was so key there is that it
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really depends upon the patient themselves and
how they typically are when it comes to
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a lot of treatments. Do you
find that post surgical patients tend to be
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the most hesitant to get this treatment? Are they the ones that tend to
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guard a bit and still have a
little bit of fear, especially after an
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injury or I would say surely they're
a lot of pain, right, especially
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when they are acute. Now,
if we're doing it more in a subacute
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realm and they're three, four or
five weeks post surgery, there's a little
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less hesitancy with it. But obviously
the sound of it is very abrupt.
358
00:30:27.039 --> 00:30:33.440
But we use that silicone head that
nanohead over the onnier areas because it's a
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00:30:33.440 --> 00:30:37.279
lot less abrasive and the person can
tolerate a lot better. Or we use
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00:30:37.319 --> 00:30:41.960
the C fifteen at a much more
tolerable parameter Kurtz and bar setting for that
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00:30:42.079 --> 00:30:48.000
individual, and they see we'll do
it on an area that was not surgically
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00:30:48.039 --> 00:30:52.400
repaired initially, just so they can
kind of feel what it should feel like,
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00:30:52.799 --> 00:30:55.799
and then we'll find their tolerance level
over that tissue. But yeah,
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00:30:55.839 --> 00:30:59.759
they are, but a lot of
them are also very They're ready to just
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00:30:59.759 --> 00:31:03.200
get better and whatever's going to enhance
that healing faster, they will be on
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00:31:03.279 --> 00:31:07.640
board and just suck it up.
One thing you had talked about earlier was
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00:31:07.799 --> 00:31:11.960
the treatment of adhesive capsule ititis or
commonly known as frozen shoulder. I know
368
00:31:12.039 --> 00:31:17.480
that this is a very difficult condition
to treat, but there as you mentioned,
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00:31:17.519 --> 00:31:21.759
the literature has shown that shockwave can
be successful. How quickly are you
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00:31:21.799 --> 00:31:26.359
seeing improvements in range of motion or
reductions of pain with this particular condition.
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00:31:26.599 --> 00:31:30.920
Yeah, so obviously depends on the
stage. If we can catch that patient
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00:31:30.119 --> 00:31:37.000
at a earlier stage, we can
avoid a lot of the later stage issues
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00:31:37.039 --> 00:31:41.480
in that individual. So if that
person's coming in with just pain and the
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00:31:41.559 --> 00:31:48.480
sinovitis in the early stage, we
could help reduce that inflammation and that synovial
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00:31:48.519 --> 00:31:55.920
fluid effect that's going on and hopefully
reduce the thickening of the capsule in that
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00:31:56.039 --> 00:32:01.519
individual, which we'll obviously end up
keeping that person from hoving the typical stage
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00:32:01.559 --> 00:32:07.359
two, stage three range of motion
deficits, because you could catch a person
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00:32:07.480 --> 00:32:12.359
very early on and they're not coming
in with fifty percent loss in all planes
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00:32:12.359 --> 00:32:15.359
of range of motion like you typically
see with the with a frozen shoulder patient,
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00:32:15.400 --> 00:32:21.599
but they're coming in with a sinovitis
presentation. So shockwave would be very
381
00:32:21.599 --> 00:32:27.200
applicable in that individual, and you're
obviously not going to incorporate rehab early on
382
00:32:27.400 --> 00:32:31.480
in that individual because you could produce
you could end up pushing them into later
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00:32:31.519 --> 00:32:37.920
stages of adhesive capsulitis and producing more
of the range of motion deficits. So
384
00:32:37.960 --> 00:32:42.039
it's a very fine line. So
if we can reduce that synovial fluid inflammation
385
00:32:42.519 --> 00:32:46.039
and the pain and then slowly progress
in the rehab, the earlier the better,
386
00:32:46.119 --> 00:32:52.799
but yeah, excellent results obviously,
very very painful. Focused shockwave is
387
00:32:52.240 --> 00:32:57.759
fantastic for the hesive capsulitis. I
think even a little bit better than radial
388
00:32:58.039 --> 00:33:02.160
depending on the body habitus of patient
and radio can get into there as well.
389
00:33:02.160 --> 00:33:06.880
We're going to hit the deep ra
areas of the subscap and get in
390
00:33:06.920 --> 00:33:10.400
some really uncomfortable positions. But if
they can tolerate it, the outcomes are
391
00:33:10.799 --> 00:33:15.680
incredible. And the patient sees that
immediately, they'll set up and they will
392
00:33:15.720 --> 00:33:19.799
go and take their shoulder through active
assisted or even active range of motion,
393
00:33:20.279 --> 00:33:23.079
and there's range of motion improvement.
And you don't need to convince somebody when
394
00:33:23.079 --> 00:33:28.240
they see objective improvement. Immediately they
go, whatever you did last time,
395
00:33:28.440 --> 00:33:32.200
do again, and they'll tolerate the
pain absolutely. And it's key. Like
396
00:33:32.240 --> 00:33:35.839
you said, everybody's just trying.
They're trying to get better, they're trying
397
00:33:35.839 --> 00:33:38.000
to feel better, they're trying to
move better as quickly as possible. Have
398
00:33:38.119 --> 00:33:45.079
there been any conditions you've treated with
shockwave that were surprising in terms of how
399
00:33:45.559 --> 00:33:49.720
well they responded to the treatment,
or you've received a better outcome than you
400
00:33:49.799 --> 00:33:53.680
expected. I think we generally try
to do it on the areas that have
401
00:33:53.839 --> 00:33:59.559
high validity and we're not just experimenting. Let me comment on the opposite end
402
00:33:59.599 --> 00:34:06.359
of that question. I would say
neoste arthritis is my least responsive. So
403
00:34:06.559 --> 00:34:13.320
just a pure primary NEOA patient,
they're my least responsive to shockwave. But
404
00:34:13.599 --> 00:34:21.719
typically the tendinopathy patients are very responsive. I guess my later upicondulosis and medio
405
00:34:21.800 --> 00:34:25.280
upicondylosis patients because before Shockwave, I
would say, if I didn't have to
406
00:34:25.320 --> 00:34:30.880
see a medial lateralpicondylosis patient again,
I would be okay with that, because
407
00:34:30.920 --> 00:34:35.880
generally the people that don't come in
day one with that condition, they come
408
00:34:35.920 --> 00:34:38.159
in day one hundred and one.
They've been dealing with for some time.
409
00:34:38.599 --> 00:34:43.119
There's a lot of adhesion around the
area, there's a lot more micro tears
410
00:34:43.119 --> 00:34:45.880
that have been produced, there's a
lot of compensatory issues that have been built
411
00:34:45.920 --> 00:34:52.239
around that, and the compliance is
low because it doesn't impact them every moment
412
00:34:52.280 --> 00:34:55.199
of every day. It impacts them
during certain activities, so maybe the person
413
00:34:55.239 --> 00:35:00.559
avoids that activity, maybe they've compensated
around it. So usually people don't want
414
00:35:00.599 --> 00:35:06.880
to sit and do ecentric exercises and
loading on a forum that it's boring,
415
00:35:07.199 --> 00:35:10.920
it's boring rehab. So usually the
outcomes are that I've seen have been more
416
00:35:12.000 --> 00:35:17.039
poor in the chronic epicondylosis patient.
But incorporating Shockwave and particularly with that android
417
00:35:17.079 --> 00:35:22.159
needling and applications, I've said,
I've seen a much greater outcome in that
418
00:35:22.239 --> 00:35:28.280
population, So I guess if I
were to answer that question apicondalosis. So
419
00:35:28.320 --> 00:35:30.360
again, thank you so much,
Doctor Rednet. We really appreciate you presenting
420
00:35:30.360 --> 00:35:44.000
today. Thank you everyone for joining
us. Be sure to tune in on
421
00:35:44.039 --> 00:35:47.840
December twenty ninth for our last episode
of twenty twenty three. I'll have a
422
00:35:47.840 --> 00:35:52.280
few special guests on that serve on
the sports medicine team for USA Gymnastics.
423
00:35:52.960 --> 00:35:57.960
We'll chat about the path to working
with elite athletes and the crucial components of
424
00:35:58.000 --> 00:36:02.079
what it's like to work on a
diverse healthcare team where several professions and specialties
425
00:36:02.119 --> 00:36:07.280
are represented. You won't want to
miss it. Episode seventy drops in two
426
00:36:07.320 --> 00:36:10.039
weeks. Be sure to check our
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00:36:10.039 --> 00:36:14.559
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only a few Fridays remaining in December, so be sure to go now to
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00:36:31.199 --> 00:36:36.000
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to all of you around the globe, we wish you a very merry and
439
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happy holiday. Hey guys, if
you like what you heard today, I
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encourage you to visit our website at
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