#68 - Shockwave Therapy for Post-Surgical Care, Part 1

Hi guys, Welcome to another episode of The Factor podcast. I'm your host Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. Today we kick off a new two part training featuring doctor David Rudnick on shockwave therapy for post surgical care, from post surgical applications to enhancing tissue healing and even optimizing rehab for athletes. This two part series is full of great information and insight, especially if you've been considering adding a shockwave device to your treatment toolkit. In this episode, we cover a wide array of topics, including the mechanisms of shockwave therapy, patient responses, and specific case studies where shockwave had a tremendous impact on athletes with delayed bone healing, as well as other cases where improvement and conditions such as impingement, syndromes and degenerative tendon and muscle damage was seen. Doctor Rednick will also share valuable insights from his extensive experience, offering actionable strategies for maximizing the benefits of shockwave devices. So be sure to bookmark this episode or hit that download button. This is one you'll definitely want to listen to more than once and take some good notes. Let's dive in Jessica. Thanks so much. Hello everybody, so again, thank you all for attending, and let's get on. So a little background about myself. I'm a sports certified sports medicine chiropractor. I have a diplomat to the American acadea ford of Sports Physicians. I practice here in South Florida in Boyton Beach. I have a sports medicine focus to practice. Most of my patients are active individuals, whether they're just doing fitness for recreation or performing at an elite level, and we treat a lot of youth athletes as well. All ranges from wreck to semi pro to pro. So our objective today is going to be obviously going through some anatomy and some physiology of the conditions that we're going to be treating. Shockwave is a phenomenal modality and I don't think it's covered enough both in the literature and in the lecture realm. As far as the treatments that we're going to be reviewing today with regards to post surgical and fracture. We obviously see quite a bit of post surgical in my practice and hence why I am covering it as well as fracture care, and we co manage a lot of those with other physicians and they refer their patients to us for that management. So I think it's a unique angle that we're taking with this modality. And obviously we use it on the typical tendinopathy and partial tears and things that you typically see in the literature with regards to shockwave, but we're using it for some wide range stuff as well. We see excellent results. So what's the role. There's increasing evidence with shockwave and muscular skeletal applications as well as post surgical. There's two different types of shockwave out there, whether you're using radial or focus, and we're going to be covering the application of both. I currently use a radial shockwave in my office, but we'll be obtaining a focused shockwave in the next month or so to reach some more wide ranged conditions. So basically, the difference with radial and focus we're going to get here in the next few slides, But is not just how the acoustic wave is delivered and the engineering of that, but also the depth of penetration, which is critical because if you're trying to treat a certain tissue at a certain depth, and you have the wrong modality, you're not going to gain benefit with that. So radial is a more superficial goes down about two and a half inches about six centimeters in depth, where focused can get up to twelve centimeters about five to six inches in depth, So a much wider range of conditions that you can treat, and a lot deeper as well. So here's focus versus radial and how they're both applied to the tissue and how the mechanism of the acoustic wave is generated within each. Interestingly, Focused, despite the depth of penetration, the sound that it emits is much less, it's not as loud as radial, and generally I find that our patients actually don't have as much discomfort with Focused as they do with radial because of the projectile versus the electro hydraulic principle versus radio versus focused, but both produced a very similar effect on the tissue. It's just how that acoustic wave is being emitted is the major difference between the two. So a quick chart. I know that a lot of studies will when we get into our parameters and how we're treating the tissue and what settings we're using on the shockwave. A lot of studies will present in bars, a lot of studies will present in milli jewels or milli jewels per a millimeters squared, and knowing the conversion is going to help you transmit that study that you're reading into a proper clinical application on your unit, depending on whether you're using a focused or a radial. So there's the conversion rate. Take a screenshot of it and it will help you when we get into some studies later in knowing our conversion rates. So for those of you that are not using shockwave in your practices currently, the top image on the slide there is a focused unit and you can see how the acoustic wave is emitted from that unit, where it's a very narrow wave that's emitted from that unit versus the radial is a lot more broad and has a more widespread acoustic wave that's emitted. But the depth is the key, and we're going to see that on some subsequent slides. So the top is a radial and you can see as a quick impulse that dies out fairly quickly and will spread out over a larger area versus the focus is the exact opposite. It has a wider width that becomes more focused once it enters the tissue and the depth. So you can see the radial goes into the mid to deeper muscle belly, where focus reach through the muscle belly and into the deeper tissue and even into and through bone in some cases depending on the unit that you're using. So what are we trying to achieve when we get the shockwave over tissue? And here's another applicant or another visual on the depth of penetration and how that acoustic wave is being applied to the tissue you. So, again, if your shockwave works well, when you know what tissue you're trying to target, why you're trying to target it, what clinical effect you're trying to obtain from it. And if you're trying to achieve a higher depth over a spine, a radial shockwave is not going to do you, but a focused will. Maybe in a more petite individual or a pediatric you might be able to get down to that deeper entity around bone with a radial, but focused is generally your go to there. So what are we trying to achieve when we use a shockwave device, Basically we're creating a hyperstimulation in an analgesic effect, and the effect has a big proponent on pain immediately, and you can actually see that while you're using it over a patient. They're responding favorably as you're using it, so they may have a lot of discomfort while you're starting that treatment over that region, which is good. You do want them to respond that way because you know you're over that injured or inflamed or tender tissue that you're trying to target. But you'll see immediately, within probably a few couple of minutes and sometimes even seconds, they'll produce that analgesic effect, and that is absolutely key because not only does the patient feel the benefits of it, but you know that you're on that target tissue. And it's something we love with regards as shockwave because you get that instant gratification and the trust that the patient is starting to develop in that that modality is going to be good for them because you can talk to them about the path of physiology and the case studies and whatnot. All they want to feel is improvement and pain reduction and function improvement. And if you can get that pain reduction immediately. While you're treating something, you're going to get a huge buy in and a confidence level from the patient, which we know optimism always rules, and their their outcomes are going to be much higher down the line. So what are we doing biological effect wise? We're producing a lot of enzymatic activity in the tissue and we're producing a lot of cellular effects. So you have the VGF growth factors that you're upregulating. You're upregulating nitric oxide, so you're getting a lot of angiogenesis in the area. You're upregulating collagen formation, you're upgrading regulating osteoplastic formation. We're going to get into how that effects on bone osteoclast information ALC FOSS. You're up regulating in sulin light growth factors. So there's a lot of cellular activity that is being produced in the cells and you'll see those things are actually being upregulated even after the treatment. And that's why when you typically do shockwave and you'll see this in a lot of the studies, a lot of the effects are after the effect is the pain modulation is immediate, but and the something as a range of motion effects are obbediate. But the cellular tissue healing is occurring even after that patient leaves your office, and the frequency of utilizing shockwave is much less than some other types of treatments, where you may be only treating that person one or two times a week, sometimes three, depending on the condition, but a lot of the studies point to even just one or two treatments a week is effective at improving the tissue healing in that region. The holiday season is upon us and it is truly the most wonderful time of the year. And while we had a ton of fun with Black Friday and Cyber Monday, we've been counting down the days until December's arrival and the kickoff of our twenty twenty three Season of Giving. Each week we will be sending out a new special offer, freebie, or exclusive limited time flash sale. It's a ton of fun and this year is even more extra with the launch of four new certification programs and the new Factor F five handlebar, a soft tissue tool unlike any other. So be sure to click the Season of Giving link in the show notes to get all of the details. Join us in celebrating the spirit of giving this holiday season. Happy Holidays from Factor so we're going to go through several regions of the body, their post surgical applications and their conditions, the path of physiology, and how we're utilizing shock wave over those are cuff. Probably my most favorite area to treat in general is the shoulder. In the shoulder girdle. FE a lot of overhead athletes in our office, and I love overhead athletes because most of the time, their pain generators are not where they're feeling pain. They're coming from some other mechanical issue, and I love kind of diving into those and figuring out the why in those individuals. So typically what we're treating with regards to post surgical is that degenerative patient sometimes the impingement one and just the tissue overload in the middle to older individual who's needing to get an arthroscopy done on the rotator cuff or a tenonesis where they're taking the bicep tendon repositioning that bicep tend to take load off of the glenoid labram and as opposed to repairing the labrum. I don't know if everyone's seeing those types of surgeries in their office, but they're pretty neat where that individual comes in with a chronic labrum tear, and the surgeon's not necessarily repairing that labram tear in that individual because of their age or their activity level, but they're doing the tenonesis and creating a mechanical alteration on the labrum by repositioning the bicep tendon, and that individual responds really well to rehab and obviously to shockwave post surgical so arthroscopic repair. I think something that I've done in my practice and my career over the years has been to view a surgery by it doesn't matter the surgeon, but obviously they're typically ones that we're referring back and forth from. But I've been able to witness that surgery in a OAR, and so I can understand not just what it looks like on paper, but what that patient is going through interoperatively and seeing what that tissue is going through from a trauma standpoint, surgical trauma standpoint, how the repair is being performed, and then I can discuss the outcomes of that patient with that patient not just from a physical therapy standpoint, but what that tissue went through and what their outcomes are going to be based on the modalities that we're going to be using and why the rehabit structured a certain way. So if anybody ever has an opportunity to do that, if you're doing that, phenomenal. If you're not doing that, I would encourage it because it'll give you a whole other understanding of why that patient is hurting, why that patient is responding quickly. There's a lot of different factors if you can get into that r and witness these surgeries so quick arthroscopic repair obviously, there's different variations and with everybody, whether there's morosceoarthritic implications with that patient or if they're just dealing with degenerative tendin and muscle damage that is needing to be repaired. All right, getting down ready, what's happening with that acoustic wave hits tissue. You're increasing collagen formation. Obviously, we love that. If you have a microtar in an area, or even a partial tear up to even fifty to seventy percent, you're going to increase collagen. Increasing collagen helps to lay down new tissue. You're going to heal that area, That tendon's going to become stronger to tensile load, and then therefore you're going to be able to build that up with rehab and obviously blood flow. Angiogenesis without angiogenesis, without oxygen and new blood formation into that new blood vessel formation into that region, you're not going to get tissue healing. So think about your patients that have some comorbidities like diabetes or some thyroid issues or some other peripheral circulatory issues. That individual is going to heal a lot slower than your patient who doesn't have those comorbidities. But with extracorporeal shockwave, we can help produce and enhance that not just in the healthy patient, but in the comorbid patient as well. And that oxygen flow, that new blood vessel formation is going to significantly improve the tissue healing, because that's all overall what we're trying to get at pain reduction is nice. People like pain reduction, but is that pain going to stay away? And the answer is typically not if you don't get the tissue to heal and you remove the mechanical deficit if it's a movement based issue. So we get any phenomenal effect from shockwave with regards to those cellular activities, all right, neat little study, it was done in rodents tissue tissue. It was actually an interesting study because they surgically repaired these rotator cuffs in rats and then put them on treadmills and we're able to measure their improved load to failure in these their GIT was obviously improving as well on the treadmill, but clinically in human model we're seeing the load improvement improve and obviously in our athletes a lot of times with these overused syndromes and youth and other active individuals, the tissues just breaking down. The capacity is not high enough to handle the load that's being applied to it. And if you could improve that load to or that capacity, you can improve the amount of load that's being applied to a tissue and reduce their risk factors for reinjury or injuries in the future in other areas. So neat little study, and we're going to dive into a bunch of other ones as well. So treatment parameters with regards to rotator cuff. When we see our patients post surgically, we can apply shockwave fairly quickly. Most patients are not coming into us until about seven to ten to fourteen days post surgery in most cases, so most of that really acute pain has diminished at seven to ten days. They may be just taking some insets at the time. And when we start to incorporate shockwave, we actually discourage the end said use because it will counteract the effects of shockwave on that tissue, and the patient's going to receive the analgesic effect of shockwaves, so they're not even going to need to be reaching for the pain medication necessary. But this pain, this analgesic effect is happening via the pain gate theory of blocking pain sensation from the peripheral structures and not allowing the sensation to be felt, which is like I said earlier, is awesome for that patient to go, oh my gosh, I can feel pain relief just from this modality, and that allows me to move a little bit better and then obviously feel confident with strengthening and reap later on, as opposed to having fear factor with movement. So we're not just going to hit over the surgical incision to reduce scar formation and adhesion over that region, and with arthroscopic repair you're not getting that much scar formation, which is fantastic, But if you're having an open bank art procedure, or we'll see in some other surgical procedures the scar is a lot larger and thicker, but we're able to reduce that scar formation pretty immediately over that region with shockwave. Again, parameters, these are guidelines, and I think with shockwave and the more you use shockwave, you're going to see that things are varied and you can dip outside the treatment parameters. So don't take these as they are set in stone. It's a sliding scale and everything is to patient tolerance and you're trying to achieve a specific tissue or a desired effect physiologically, so the parameters can range. And again obviously, if if we're doing two and a half bar or zero point one two milli dules per millionos squared over a acute or subcute region or actually immediately post surgical, that patient may not be able to tolerate that. So we're going to change our head that we're using on the hand piece on the shockwave. We're going to be sliding that bar up and down depending on their tolerance level, so we don't create an increased pain sensation it wants to. We want to keep it in a tolerable range for that patient. So we're treating that patient for about three to six weeks post surgically with shockwave, and that's one to two days a week, so you'll see a lot of the studies are once a week on shockwave application, so you're only treating them three to six times to get that desired effect, and then sometimes the patient's plateaued midway through, we'll come back and start to treat that region. Nothing is over the site of pain only. We are treating that entire shoulder girdle, sometimes down into the lower lat we're treating the peck. We're treating all that tissue that could be affecting that person's range of motion and overall mechanics, so they're not producing any guarding mechanisms in that region. This was an ac joint over that we were treating on a patient that had the bridement, but her surgery was quite a while ago, but still had a lot of adhesion in the region. This was actually a seventy four year old tennis player. She plays three to four days a week and actually does personal training with us in our office two to three days a week, so she's a highly active seventy four year old and maybe even seventy five now, since that video was taken and she had come in with some still some adhesion and some impingement type syndromes post surgically where she had the bribement of that a sea joint to open up the space to produce less impingement. She responded extremely favorably to shockwave. The head that we used on this patient was the C fifteen, which is the ceramic head, which is our mid we use a silicone head or the nano we use the D twenty head, which is a titanium head, and this is the ceramics so it produces a mile to moderate amount of energy through it, a lot more tolerable over a bony area and particularly over a post surgical area, a lot more tolerable for that patient than using a larger titanium head like a D twenty or even larger than that. All right, so post surgical rehab, all of the studies, all of the studies, all of the studies incorporate have the most benefit with rehab and loading the tissue as opposed to just shockwave alone. You get good benefits with shockwave alone, but when it's combined with rehab, the benefits are exponential, particularly with regards to the upper extremity. The DASH scores improve the patient's mechanics significally improve not just the pain reduction, which we all love pain reduction, but we want that patient to stay out of pain, and that's going to be produced with improving tissue load so that particularly our active patients are not re injuring that region. So day one to six we're hitting that patient typically with regards to shockwave for pain modulation, scar tissue reduction, and range of motion improvement right away, tissue healing, more college information right around that area to help them with range and being able to load tissue. We're seeing a lot of times now the surgeons are recommending not to be in a sling or a brace for as long as they used to be in. Obviously the labor and patients are going to be in a sling for a little bit longer, but our typical arthrooscopy or even our tenonsi's patients are going to be in there less, and it's purely a tolerance level thing. So we're seeing them come out of this thing a lot quicker. So obviously a lot less adhesion is being produced, a lot less tissue guarding and hypertonicity is being implemented into that shoulder girdle. So new research and new applications post surgically really helps with our rehab. So here's the nitty gritty. I love this phase of rehab. The patient's starting to get some pain reduction. They're starting to see that there's a light at the end of the tunnel that's seven to day seven to day twenty eight. They're starting to feel, oh my gosh, I can see that this is going to be a benefit. And applying that shockwave at this point has been critical improving range of motion. We have a couple of patients right now that we're getting some post surgical adhesive capsulitis that was starting to form and that can be very detrimental in their overall improvement. And we have reduced those comorbidities in that patient that's producing the adhesive capsulelitis very quickly with early implication of shockwave into that region to reduce capsular thickening. Another post surgery that we see quite frequently is our ORF procedures, our open reduction internal fixation. This patient, I believe this one was a soccer player, seventeen year old sixteen or seventeen year old soccer player who had a trauma collided with another player. These are our academy players, so they're playing at an extremely high level. The game is extremely fast, and this individual collided with another player. They went leg to leg. He lost, unfortunately, so he had a open fracture of the tibia and multiple fractures of fibula as well. The reason that shockwave was highly beneficial to this patient was because they had delayed bone healing around that hardware, and that would have ended up causing that patient to have to go in for a bone graft. Psychologically, this individual was already having a tough time with the acute nature and the traumatic nature of the injury at the height of his youth athletic career and being looked at by colleges and academies and whatnot, so the psychological effects were far outweighing the physical. The physical, in my opinion, is very easy to get this patient back, but he was dealing with the psychological and then to have the delayed bone healing over that region and possibly happening to go in for a bone graft, which was going to delay his return by several several months was a huge weight on him. So with talking with the surgeon, and this is a surgeon that we worked with many times in the past, we suggested that we use shockwave over the bone to produce some bone healing so they did not have to go in and do a bone graft on this patient. And the surgeons are well. This surgeon is highly conservative in that manner. He seemed the effects of it in the past, so we get excellent ousteoblastic activity in that region and he was comfortable with us doing that at that point with the patient. They give us about three to four weeks to work on that individual, and we are doing shockwave a lot more frequently than with tendon and muscle ligament. We're doing about three to four days a week on this individual to produce osteoplastic activity. And particularly because we had a limited amount of time with this individual before, you need to possibly go in for a graph, but you can see that there is a lot of palace formation around that surgical site, particularly on the image on the right, and they had extremely favorable outcomes. So about three weeks post he had about forty to fifty percent bone healing, and at six weeks post utilization of shockwave. He had eighty percent bone formation in that region and he avoided a bone graph. And I'm happy to say that this visual is back to high level soccer, has no pain over the surgical site and is going to be playing in college coming next year. So excellent successful case. If you're not using it on bone and fractures or post surgical fractures, a new realm for you to uprate in that region tury into your practice. That's it for today's training. Be sure to keep an eye on your inbox and follow us on social media for more details on our season of giving that kicks off today through December thirty first. And if you're not on our mailing list, what are you waiting for? Click the sign up link in our show notes to receive our weekly Factor five Things Friday email, where we share free resources to grow your business and elevate your patient care, along with exclusive discounts and early access offers for our new certification programs, free webinars, and hands on courses. All of this is packaged in a nice, no fluff, simple five Things format that's easy to skim and scroll. Be sure to tune in for episode seventy where we wrap up part two of our training on shockwave therapy and talk more about its benefits for athletes with for you syndromes, as well as the research surrounding the use of shockwave to reduce scar formation and post operative symptoms. You won't want to miss it. Episode seventy drops in two weeks. We'll see then. Hey guys, if you like what you heard today, I encourage you to visit our website at Factor hyphenstore dot com that's spelled fak tr hyphenstore dot com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links, as well as info about our sponsors in the show notes, so be sure to check those out.