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Extracorporeal Shock Wave Therapy

Discussion in 'General Issues and Discussion Forum' started by Dieter Fellner, Oct 20, 2004.

  1. podrick

    podrick Active Member

    eswt

    robert,
    my name is rick reyes,d.p.m. graduated from barry university school pod med,psr24,adjunct clinical instructor,i own two practices in the south florida area,feel free to look me up.what are you going to do beat me up in the playground.
    i get my information from the same articles that our administrator and craig payne do.read those articles and you will see something lacking in the original research presented on eswt,large sample patient population and long term follow up.
    in terms of fda standards for approving a modality's indications,give me a freaking brake.this is the same fda that approved cold laser therapy for everything from neuropathy to tennis elbow,without significant research.considering recent scandals,such as the ones with vioxx.this doesn't strenghthen your argument much.
    i am not saying that it doesn't have its place in terms of treating painful conditions.but it shouldn't take the place of good diagnosis and conservative care.the reality is that this is very unlikely if you are leasing one of these babies.there is too much of a financial stake involved.

    later bobby,
    don't forget to look me up
     
  2. R.S.Steinberg

    R.S.Steinberg Active Member

    ESWT - From Experience

    Rick,

    I am not leasing one of those "Babies". I wanted to know about you so that I could better understand your experience, and where you might be coming from. I am not looking for a playground fight, but I guess I know where to find you if I was. (Just kidding!) I have been in practice since 1976. I have been a surgical instructor for some 18 years. Until this past January, I was Podiatry Section Chief for 4 years at Norwegian American Hospital, Chicago, where I continue as a surgical instructor and Director of the Residents' Foot & Ankle Clinic.

    You did not answer my question: How many high-energy ESWTs have you done? Many times, I am not a patient's first treating DPM. Some come to me with one, two & 3-year histories of recalcitrant plantar fasciitis. Post high-energy ESWT on these patients is remarkable. This class of patients is my single largest source for new patients needing heel pain treatment. You can argue with me if you want, but the proof is in. High-energy ESWT just plain works. If you want, I can arrange for you to be certified to perform the procedure.

    Craig,

    Would you be so kind as to e-mail me a copy, or a link to the Cochrane collaboration? If you do not mind, I would like to see the methodology and then draw my own conclusions.

    As I said, 70% of my patients respond very well to conservative therapy. Each patient gets a gait cycle analysis and biomechanical exam. I review their lifestyle and their shoes choices. ESWT is for that 10-30% who are very frustrated by the lack of relief provided by the multiple conservative modalities applied multiple times over a 6-month period. If I, a foot and ankle expert, cannot offer anything further except surgery, then I have failed my patient.

    None of you has talked about just how bad a release of the medial portion of the plantar fascia is. Is this because you do not view this surgery as being bad?

    Robert Scott Steinberg, DPM, DACCPPS (BP)
    Hoffman Estates, IL USA
    Doc@FootSportsDoc.com
     
  3. Don ESWT

    Don ESWT Active Member

    Rick,
    ESWT is used as a last resort prior to surgery. A lot of people who post are also missing that ESWT is about to evolve again with the treatment of heart damage and ulcer repair.
    Since the mid 70's when Dornier used it for Metalergical application (Wing strength), 80's Kidney and Gall Stone (ESWL) and 90's ESWT tendon repair,
    Yes as one postee stated hit "it with a hammer", pretty close to the truth.

    ESWT is for some and not for others.
    With over 50million treatments under theri belts the European ESWT community is happy.

    On another happy note at least 250 Million people have read the Harry Potter series at least once.

    Donald Iain Scott
     
  4. Don ESWT

    Don ESWT Active Member

    Craig,
    Sorry to put you on the spot, but what is the "Gold Standard" for the treatment of Plantar Fasciitis.

    Hands on ground feet in air (Could get Carpal Tunnel Syndrome)
    Don't wear Footwear (Too much broken Glass and syringes)
    Stay in bed all day (Watch TV and eat Chocolate "ummm chocolate" and reruns of the Simpsons)
    My wife says amputation. A bit drastic, but she has the MRI and the screws in her right foot (Triple Arthro) and no PF in her Left foot after ESWT.



    There is really no such thing as a "Gold Standard", as what may work for one may not work for another. All we can do is our best with the resources available.

    Donald Iain Scott
     
  5. podrick

    podrick Active Member

    eswt

    ron,

    you seem like a reputable practitioner and i have no problem even referring a recalcitrant case of plantar fasciatus to you.however,at least in south florida where i practice.there are practices that touted it,as a first line treatment for every heel or arch pain that walks through the door.this i feel is strictly due to the financial stakes in such an expensive modality.

    you asked me how many i have done the answer is directly none.when i was doing my fellowship,eswt was becoming popular and i participated in a few cases.i can only tell you the same thing craig stated.in some cases it worked very well and in others it didn't ,not that much different than other methods.

    i did do a bunch of endoscopy procedures when i was in training and agree with your views of it.yet with endoscopy the motivating factor was economical as well.you had a huge investment in a system and (at least in florida) mega medicare reimbursements.it was basically a fad, bolstered by ample research sponsored by the system's manufacturer.

    we owe it to our patients to offer diagnosis and choices,not a one size fits all modality.i am not saying you do this.but unfortunately a good percentage of practitioners using this modality are doing this.

    best regards,

    rick
     
  6. admin

    admin Administrator Staff Member

    The 2003 conclusion from the Cochrane collaboration was:
    This analysis was done prior to several of the recent most major RCT's in plantar fasciitis (the most significant of which is still 'in press').

    Their conclusion on EWST was posted above, with the meta analyis showing small effect sizes. Now that there are sufficiant RCTs on foot orthoses in pantar fasciitis (not all yet published), there is now sufficent for a meta analysis to show the effect sizes with foot orthoses.

    The only the study published since the above Cochrane reviewvthat would have been worthy of inclusion is one that showed strecthing is effective.

    But given that the natural history of plantar fasciitis is to get better without treatment (ie look at the placebo groups in the longer term RCT's) I am not sure that we can have 'gold standard'.
    [/font]
     
  7. R.S.Steinberg

    R.S.Steinberg Active Member

    Ok Everyone,

    The Cochrane Collaboration has been quoted and re-quoted, yet no one is willing to provide a copy of the study. Is it because it cannot stand the "light of day"? I would like to review the methodology for my self.

    Funny thing about treatments, ever notice you get better at them with time? I have seen less then successful post ESWTs and have discussed this with others. Most often it is a failure of technique, not equipment, When the Ossatron was first introduced, I heard of a number of failures. Maybe this was because you cannot visualize the abnormal area of the plantar fascia with this device. I remember the first time the Dornier EPOS Ultra was demonstrated. Identifying the abnormally thickened plantar fascia and measuring it – alone its entire length of the abnormal thickness -- allowed precise targeting, but further, it also allowed me to modify the procedure isf the length of the abnormal plantar fascia was 20 mm or more. This came from using the device and getting better at it.

    So, for someone to weight in on the efficacy of any treatment and not ever really used it is, is, is, well, ................. Oh someone think of a good word, please!!!

    Robert Scott Steinberg, DPM, DACCPPS, (BP)
    Doc@FootSportsDoc.com
     
  8. admin

    admin Administrator Staff Member

    The Cochrone Collaboration is NOT a study - its a very highly respected international non-profit unbiased clearing house for meta analyses of RCT's done by others. Its was established by the "founding father" for evidence based practice (Archie Cochrane):
    http://www.cochrane.org

    Only studies of the highest quality are incorproted into the meta-analyses and all meta-analyses are subjected to the highest standard of peer review.
     
  9. Don ESWT

    Don ESWT Active Member

    To All,
    To Me Chochrane is, excuse the word "Bull***t". Meta analysis the same. It is assumption that the other researshers work is accurate or complete.
    I looked up Chrochane and type in ESWT, only 2 studies in there. Both are on elbow papers (NOT ACTUAL WORK) done by Buchbinder in 2005. She uses Jan Romps paper and another from 2001 and 2003 and says ESWT does not work.
    Without a machine to do her own research how can we rely on impartiality, and you can look up www.monash.med.edu.au "They are compiling data" "BUT WHOS"
    She is gleening data from sources. It is not true research.

    I am about to contact Jan Romp and see if he you care to comment.

    Donald Iain Scott.
     
  10. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    I have made a mistake above (more on that in a moment)

    BUT, you really showing your lack of understanding of what a meta analysis is and how powerful they are with evidence. Ony two studies may have been included in the elbow meta analyses, but that is because only two were of good enough or high enough standard to be included! A RCT is a powerful form of evidence, but the meta analysis is even more powerful (as it combnes the data of several studies) - it may not be true research to you (all researchers consider it real research), but it the best kind of evidence!!! (you really need to go an look up epidemiology 101 before making the claims you do). Meta analyses rank at the top of the hierarchy on the quality of evidence they provide.

    The mistake I made was that I did not notice that the meta analsyses on EWST in heel pain was not part of he Cochrane Collab ---- but its conclusons on the small effect size of EWST still stands. This is what I was refering to:
    http://www.biomedcentral.com/1471-2474/6/19/abstract

    Those who do the Conchrane collab reports and those authors of the meta-analysis on EWST and heel pain have no bias, no conflicts of interest and no vested interests.
     
  11. DrPod

    DrPod Active Member

    I'm with Craig on this one. EWST was an overhyped fad, that is still useful in some limited cases. Fortunately in my area it is now being used more sensibly. I was less than impressed wth the success rates on patients I sent off for it when the hype started. It only helped a couple of the dozen or so I refered. They were all chronic and nothing else seems to want to work. What is really needed is some better guidance so I could better pick the 2/12 that it helped, rather than just send off so many for it (it hurts, it costs and it has inconviences).
     
  12. Don ESWT

    Don ESWT Active Member

    craig,
    Did Buchbinder do the work herself or was it her lackies
    Don
     
  13. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    I have no idea. Why is it important?

    I have research assistants and research students do the bulk of the data collection on my projects.... its the usual way. Why is it a problem, just because you do not like the results of a particular study?

    All I know is Buchbinder is part of a radiology group that owns some ESWT machines (the ones we also happen to refer to), so she has a vested financial interest in showing they work. Its commendable that they rose above that....
     
  14. Don ESWT

    Don ESWT Active Member

    Craig,
    When she compiled her data, did she take into consideration what machine were being used there could be as many as 10 manufactures out there.
    To DrPod, Ask the 5million kidney stone free patient if they unhappy since ESWL same process different letters

    Don
     
  15. podrick

    podrick Active Member

    eswt

    don,

    the problem is that in the states,it is being touted as a first line treatment.many times by-passing the biomechanical work up necessary to treat the majority of plantar fasciatus cases.

    the reason here being the money invested in it.you simply are not going to invest $100,000 in a devise to use it as a last resort on less than 5% of the cases you see.

    you forget my freind,sadly american medicine is very much profit driven.craig is correct when he states that the original studies don't stand up to any real scrutiny( small group of patients,very subjective grading system and very little long term follow up).in the states,most of the research is sponsored either directly or indirectly by the system's manufacturer.

    i am not saying it can't work.however,it isn't this silver bullet their marketing states.

    regards
     
  16. DrPod

    DrPod Active Member

    Whats that got to do with it? Kidney stones are very different pathological process to the degenerative changes of plantar fasciitis. I have no idea of the evidence on kidney stones and ESWL, but assume its good. From what I read above the evidence for its use in plantar fasciitis is very weak.
     
  17. Don ESWT

    Don ESWT Active Member

    Craig,

    Monash University does not have an ESWT machine so there is no vested interest. They have been anit ESWT from the start.

    I do not have the facilites or staff to carry out mass research that you can accomplish.

    Have a good weekend

    Don
     
  18. Don ESWT

    Don ESWT Active Member

    DrPod,
    The application for ESWL and ESWT are many and varied.
    Since the mid 80's the Dornier machines have been treating Kidney and Gall Stones.
    Since the mid 90's treatments on Plantar Fasciitis, Achilles Tendonitis, Haglunds' Deformity, Knees, Hips, Elbows, Shoulders and Non Union fractures.
    2000 to present treatment of Diabetic ulcers and more recently Myocardial tissue repair.
    ESWT is also used in the horse racing industry.

    There are thousands of entries on Google relating to ESWT world wide.
    The best site for ESWT is www.ismst.com, of which I am a member, therfore a discosed interest.

    My opinions are at conflict with yours as I will defend the treatment for chronic suffers, So, lets just leave it at that.

    Have a good weekend

    Don Scott
     
  19. R.S.Steinberg

    R.S.Steinberg Active Member

    ESWT - From Experience

    DrPod,

    You should have sent your patients to me for ESWT I guess. :) One thing is obvious, though, you do not perform the procedure yourself, and since you don't, we really cannot get into whether the technique was at fault, can we????? Your comments are about as valid - scientifically - as the Cochrane "Analysis" of someone else's maybe good, maybe not so good "study". You know, medicine is more then this type of Voodo "analysis".

    Robert Scott Steinberg, DPM,DACCPPS, (BP)
    Doc@FootSportsDoc.com
     
  20. podrick

    podrick Active Member

    cochrane's group are the father's of evidence based research.i would suggest you check out the latest issue of podiatry management magazine.it features a panel discussion on the subject.the collaborators include weil and markinson,not exactly lightweights in our profession.this is certainly not b***S***.
    it is considered the most accurate means in which to measure true medical efficacy.it has been embraced by the ama,well before we heard of it.
    sometimes true scrutiny may not give us the answer we are wishing for and we tend to lash out.but this is science,not opinions.

    regards
     
  21. podrick

    podrick Active Member

    craig,

    i commend you on some excellent points with regards to this issue.the fact that a therapy has been used to treat kidney stones is completely unrelated.the reality of the matter is that when it came to shock therapy in kidney stones,it was rigorously tried and tested in different medical schools.
    i know this because one of the first centers,was in my neck of the woods,university of florida.i am sure these studies were published and reviewed.otherwise,major medical schools around the world would not have adopted it and most importantly,insurance wouldn't have covered it.
    keep in mind that in the states,a good litmus of a modality's efficacy is if medicare covers it.i know a lot of my colleagues wont agree with this but it has proven very true over time.
    by the way i read you will be one of the lecturers for the upcoming canadian seminar.i will attend as a guest of a canadian colleague.i look forward to hearing you and saying hi.

    regards
     
  22. R.S.Steinberg

    R.S.Steinberg Active Member

    Rick,

    Still, you expect me to accept the "findings" of the Cochrane group because they were published in PM. Really? Other people have certain vested interests in studies and are supported by manufacturers. No possibility of any bias there, so I should accept - without question - their opinions as well.

    Cochrane's reporting is on "old science", and does not take into account up to date studies. It can't. That's the problem with studies done on emerging technology. Things develop way too fast for "mega analysis" to tell us anything worthwhile. We are not talking about the 15 year use of some heart medication where studies abound, are we?

    Oh, and BTW, Buchbinder has recanted. Another example of not just "bad science”, but more to no science at all. The study used a machine that was designed for high-energy ESWT and used it at low energy. Dahhhhhhhhh, it doesn't work. Yea, so how does that equate to its use - as allowed by the USFDA - as a high-energy treatment? Maybe I am missing something here, but Buchbinder obviously forgot to read the instructions. I hope the ESWT devices that were used in the "study" were plugged in !!!

    It is obvious that you do not like the procedure. What I feel is not fair is that you do not do the procedure and attempt to speak with some authority on ESWT. As well trained as you are, are you not open to advances in procedures, techniques, or other treatment modalities? If Lowell Scott Weil, DPM had your attitude (since you mentioned him), our profession would have missed out on a number of significant advances. Podiatry's biggest problem is that we do not have enough visionaries. We definitely have way too many people with their heads-in-the-sand.

    Robert Scott Steinberg, DPM, DACCPPS (BP)
    Doc@FootSportsDoc.com
     
  23. R.S.Steinberg

    R.S.Steinberg Active Member

    Dr. Payne,

    Since you took the job of being a moderator on the forum, you should know that that requires you to be non-biased. Still it is nice to see you and Rick glad-handing and slapping each other on the back.

    Seriously, comments like yours and Rick's do more harm then good. Neither of you have any real expertise in using high-energy ESWT and only make your arguments based on someone else’s "weird science". That is not allopathic science. It's voodoo.

    It is correct that ESWT of kidney stones has nothing to do with treating PF. Not sure how that came up. Podiatry has always suffered from a lack of research. Our profession is small, and we are routinely ignored for grants to do the kind of studies like ESWT for stones. There isn't enough money in it for drug or equipment companies. So what do you say we should do? Maybe we should all revert back to chiropodists?

    Robert Scott Steinberg, DPM, DACCPPS, (BP)
    Doc@FootSportsDoc.com
     
  24. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    I would suggest the opposite is the case. Its Podiatry's track record in understanding evidence based practice and what good evidence is, is the problem...

    I just find it paradoxical that suppporters of ESWT will go to no ends to discredit and find flaws in studies that do not show ESWT to be useful, but are unwilling to put studies that support it under the same scrutiny (and launch personal attacks on the authors of the "anti" studies, but not the "pro" studies).... don't figure! ... the meta analysis do this in an unbiased way ..... and look at what happens.

    I have nothing to loose or nothing to gain with rgards to ESWT. I have read all the literature and research and have referred patients for it (and have a responsibility to teach it in an unbiased way ---- students get taught to read the literature in such a way that they can make their own minds up) ... my expereince in the early days with those we referred for ESWT was that it was not very successful. Now we just do not see as many chronic plantar fasciitis cases as we use to. We have done 3 RCT's on plantar fasciitis in the last 12 months (who said there is a lack of research in podiatry?) - so we seen a lot of cases this year --- in all that I have only sent one of for ESWT (and it woked).
     
  25. eddavisdpm

    eddavisdpm Active Member

    ESWT vs. Surgery

    We have recently formed the American Society of Musculoskelatal Shockwave Therapy (www.asmst.org) and invite anyone interested to join.

    I took an active role in forming the society at my own expense, building a homemade website, drawing a logo and getting paying to get it registered. After performing several hundred ESWT via the US and via my proximity to Vancouver, BC, being in the Seatlle area of the US, there is no qustion in my mind that ESWT is the treatment of choice for enthesopathies and tendinopathies. I would perform ESWT on my own mother or myself long before considering surgical treatment. IT WORKS! Opposition to it has been politically motivated by very well financed surgical societies and surgery equipment manufactureres, not to mention the powerful hospital lobby in the USA.

    Eddie Davis, DPM
    eddavis@webmail.us
     
  26. eddavisdpm

    eddavisdpm Active Member

    Eswt

    Craig:
    There is a "treatment triad" in plantar fasciitis. Early on, we are dealing with a perdominance of inflammation: later, if pain persists, biomechanics plays are role. when we fix the biomechanics, we often allow the third "leg" of the problem to resolve and that is a breakdown in tissue quality. ESWT directly addresses tissue quality. This is proven in literally scores of papers on the www.asmst.org and www.ismst.com websites. Rompe's research used sonography to show an undisputable difference in tissue quality of the fascia 20 weeks after application.
    Regards.
    Eddie Davis, DPM
    edavis@webmail.us
     
  27. eddavisdpm

    eddavisdpm Active Member

    Who financed the Monash research?

    The Buchbinder study, as shown by Rompe, already broke every rule necessary to prove/disprove ESWT. Buchbinder used a sublcinical dose of shockwave energy on a population of which 50% would not even qualify for ESWT by not having pathologic fascia, defined, ultimately by sonography but, proximally by having had plantar fasciitis for at least 6 months.
    Eddie Davis, DPM
    eddavis@webmail.us

    Note that very few American podiatrists purchased ESWT machines. They use machines owned by kithotripsy companies, and often perform the service without getting paid. As far as you "insult" of fanatacism among ESWT proponents, please levy that insult to the hundreds of researchers published at www.ismst.com and see what their response is.
    Eddie Davis, DPM
     
    Last edited: Aug 6, 2005
  28. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    Thats exactly my point - the lengths that biased people will go to to discredit papers that do not support ESWT and not put papers that support ESWT under the same methodological scrutiny. The unbiased meta-analysis mentioned above that only included those that stood up to methodological scrutiny showed that ESWT worked but the effect size were small --- thats good enough for me.
     
  29. Don ESWT

    Don ESWT Active Member

    Ed,
    I was unable to contact Dr. Rompe for his comments I only have is old email can you help get him online.

    Don Scott
     
  30. eddavisdpm

    eddavisdpm Active Member

    So, you are satisfied to ignore the hundreds of competent research papers on www.ismst.com in favor of a long discredited study by Buchbinder? That says very little for your objectivity. Let the readers here read the two hundred plus abstracts on www.ismst.com and make there own decision.
    Ed Davis, DPM
     
  31. eddavisdpm

    eddavisdpm Active Member

    Ps. Almost all readers familiar with the Buchbinder study realized that she applied a subclinical dose of ESWT on a population, 50% of which did not meet the basic criteria for intractable plantar fasciitis which is a minimimum of 6 months of PF unaffected by standard treatment means. A minimum of 1300 mj/mm squared must be applied to show a tissue effect.
    Ed Davis, DPM
     
  32. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    I agree totally...BUT thats exactly what the set out to do. Their research question was to test if a lower dose worked on shorter duration plantar fascitis - they found it didn't. The research design and methodology was set up to test that hypothesis. Of all the ESWT studies, their research desgin was the soundest.
    All but a couple of those hundred are easier to dismiss than Buchbinder - did you not notice that almost all of them did not have sound enough methodology to be included in the unbiased meta-analysis mentioned above. Thats just not my objectivity - that a lot of others objectivty as well who have no vested interest in the outcome. Why do you not put them under the same scrutiny as Buchbinder's? Why just post the abstracts on the website, so readers can not see all the shortcomings in the methods?

    I will be the first to change my mind as soon as the evidence from methdologically sound studies that are properly controlled, blinded, with adequate statistical power and with the use of validated outcome meaures are available.This level of evidence for EWST for heel pain just does not yet exist. In the mean time I will not be taken in by marketing hype and the outcome of poorly controlled, unblinded studies, underpowered with unvalidated outcome measures.
     
    Last edited by a moderator: Aug 10, 2005
  33. eddavisdpm

    eddavisdpm Active Member

    ESWT studies

    Craig:
    Stop making orhtotics immediately because I know of no study that holds up to the level of methodology proving that orthotics work at the level you hold the Buchbinder study.

    I am missing the point of creating a study for the express intent to lead to treatment failure by applying a subclinical ESWT dose as does Buchbinder. What does that show.

    We now have 12 years of European experience, 7 years of Canadian experience, 5 years of US experience in which ESWT has worked on thousands of patients to whom surgery was recommended as a last resort. That coupled with hundreds of papers that show its efficacy not only on the gross level, but more importantly AT THE TISSUE LEVEL simply makes the evidence overwhelmingly favorable. A paper was presented last year at ISMST by Norris, Werber, et. al. that comes very close to the methodology and research quality of Buchbinder.

    Craig; please tell me-- how many of the papers and abstracts on the www.ismst.com website have you actually read?
    Fraternally,
    Ed Davis, DPM
     
  34. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    There is evidence of that level of quality. .... its just the data on which type of ot orthoses is lacking.
    Probably most of them - I have a huge file of papers on ESWT.
     
  35. eddavisdpm

    eddavisdpm Active Member

    ESWT/orthotics

    Craig:

    I could use the paper or abstract you mention on foot orthotics very much as this is a big battle ground with regards to third party reimbursement in the US.
    We also have a proliferation of minimally trained individuals creating various "customized" insoles and calling them orthotics in the US. As far as ESWT we just will have to respect our mutual opinions and let others study the same evidence that is out there. Keep in mind that private practitioners do place considerable weight to experiential evidence especially when their experience or the experience of their colleagues has been extensive. The agency responsible for health research in the US, the FDA or Food and Drug Administration is known to be heavily politicized by a number of big money interests and has lost much respect.
    Regards,
    Ed
     
  36. Peter

    Peter Well-Known Member

  37. eddavisdpm

    eddavisdpm Active Member

    Eswt

    The "official" governnment propaganda is duly noted. Unfortunately, it appears not based on the factual evidence but politics as usual...
    Ed Davis, DPM
     
  38. Peter

    Peter Well-Known Member

    With respect, this is not a government paper. NICE is the UK NHS National Institute for Clinical Effectiveness. OK you don't like the reading, but it cannot be classed as Propaganda.

    I think this paper will put ECSWT to bed in the UK NHS, for now....
     
  39. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    I can't see anything in the document that is not based on factual evidence.
     
  40. eddavisdpm

    eddavisdpm Active Member

    ESWT statment

    Unfortunately, the use of only a small portion of the available studies to reach a conclusion while simultaneously ignoring the larger body of studies available that contradict the conclusions of the statement demonstrates a bias inconsistent with the level of objectivity expected.
    Ed Davis, dPM
     
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