Stop Injections! Shockwave: Regenerative Healing for Chronic Pain with Dan Ruitenbeek

The reason that we love shockwave for some chronic issues is because of the regenerative properties that come with it. So we get blood flow improvement, we get a lot of great hormonal infusions, we get more collagen lay down, we get more fibrinogen lay down, we get proliferation of stem cells. It can be a great alternative to some of these injections or exploratory surgeries.

Everybody, I'm Dr. Jeff Langmaid with the evidence based chiropractor and I'm fortunate to be sitting with Dr. Daniel, co owner and founder of Shockwave Centers of America. We're going to talk all about shockwave and really dive into what it is, how it's applicable in your practice and some of the technology behind it. And when you are looking for a machine, what you need to look for to make sure you're getting the best results and the best bang for your buck. Thanks for coming on and chatting today.

Thank you so much for having me.

My pleasure. Let's pick it up right at the top. There are many knocks out there that have heard the word shockwave, probably heard it used in a variety of different ways, I guess at a foundational level. What is shockwave technology? Shockwave therapy, sure.

The beauty of shockwave therapy is that it's not new. It may be new to the American system, but it's about 40 year old technology. And we use shockwave as almost a colloquial cloak over all of the different versions of the therapy in the system that we have. But shockwave is the term for the therapy, not necessarily a device or a different device. Got it. Okay. And so just like ultrasound would be, there are different brands, there are different ways of ultrasound and all that kind of fun stuff. Shockwave is the overarching theme. Okay. But shockwave specifically is a acoustic impulse, if you will, different varieties. Again, but an acoustic impulse or a sound wave that's going in to penetrate into the tissue and create some sort of biological change. What change that is is going to vary on what factors are we using during the shockwave itself. But that is the more correct way to approach it. And so you'll see it called acoustic wave therapy, some of them pressure wave therapy, but all kinds of different wave therapies, if you will. But shockwave is the term that we use to kind of cloak over all of them.

Yep, understood. So when you talk about conditions, I know a lot of docs are like, okay, I've heard about this. I get that it's different than what I'm doing. Currently, or maybe what I've done in the past. What are some of the conditions or patient types that respond best to shockwave?

So I want to say to caveat on that just a little bit, is that most people in the realm of chronic pain, if they're more metabolically healthy, they're going to respond faster regardless of the therapy. And so what makes a great therapy versus a not great therapy is kind of pace it selection as well. The reason that we love shockwave for some chronic issues is because the regenerative properties that come with it. So we get blood flow improvement, we get a lot of great hormonal infusions, we get more, you know, collagen lay down, we get more fibrinogen lay down, we get proliferation of stem cells. We get all kinds of great things that can help move people from not healing to healing y in such an easy way to implement that it's not, you know, too toxic to the system or there's not too much downtime. And it can be a great alternative to some of these injections or exploratory surgeries.

So I've always thought about it, and the way I've described it to people, talking casually, you can correct me if I'm wrong, is I say, you know, it's not a panacea, but what shockwave does is it does a really good job at reducing and pushing out inflammation and helping you move and feel better. Am I accurate with that?

Yeah, no, of course. It's. It's one of those. It's so useful in so many different aspects. We thrive in that chronic pain area or things that aren't healing because they don't have enough blood flow, they're not getting enough juice to get mobile again. That's a great option to put shockwave on the table as far as a care plan goes. And I want to make sure that we're going after things that we know are going to get better. And, you know, we have to know what our limits are within there. But absolutely, it's so useful in the chiropractic space because we see those patients all the time.

Yeah, yeah, let's dive in. You mentioned stem cells, you mentioned regenerative. These are hot button words. Have been for a while a lot of confusion in the space. And I'm sure you hear that all the time. So when it comes to shockwave, how does shockwave fit in with regeneration, regenerating tissue and or stem cells? A lot of confusion. How does shockwave fit in?

The best way that I can describe it Is the same way that chiropractic helps the body heal. Shockwave works the same way. We're not infusing exogenous anything. No new stem cells, no new x, y or z, no new blood flow. All of it is stimulating the body in the right way at the right time for the right person to create that environment for healing. So once we go through that initial phase of inflammation after an injury, we're supposed to hit that two week mark of subacute level of healing. Right? Which is where collagen lay down should happen, where all the stem cells should be proliferating and creating new tissue. And oftentimes with how busy we are or how immobile we are, or how unhealthy we are, we can just lay down scar tissue and the body says, that's enough, I'm stable, we're good. And our job then with the shockwave and other regenerative therapies, we go into that old and decrepit tissue, we stimulate that process that's supposed to happen at that two week mark, which is getting the collagen improvement, Getting the blood flow improvement, and proliferating the stem cells. So what we're doing is we're stimulating the tissue that already exists to replicate itself some more.

Got it.

And so when I'm talking about bringing in, you know, chondrocytes or fibrinogen or anything like that to have more of it, I need that already there. So there are some people who are too far gone. And I can't just go in and build tissue from nothing.

Right.

Which is sometimes a misconception. And people get really over the ridge, over the bridge of like, hey, no matter where I'm at, I can bring back collagen or bone. I can reformat that tissue. No, unfortunately, we can't go that far. If somebody is completely bone on bone with no cartilage whatsoever, Regardless of the stimuli that I create in there, and shockwave being one of, of the best at proliferation of regenerative cells, there's nothing I can do about it. Right. If there's a little bit there that we can make more robust, fantastic, let's do it. But definitely that's, that's what I'm looking to do. And it's not the therapy, it's the human body's nature in the response of that particular stimuli.

That makes sense. I've talked with dozens of docs. I think there are thousands that literally that have heard about shockwave and have considered adding it to their practice, but haven't yet. What are Some of the primary considerations you'd recommend that a chiropractor who's thinking about it, thinks about before they make a buying decision, for sure.

As much, and I love to make sure people have their foundations in the right place before we start thinking about bringing a technology into the practice. When we talk to the chiropractors, there's some of the things that we can get lost in. I can bring in red light therapy is going to change my world. I can now do weight loss. Now I'm going to see more patients. I'm going to do this. It has to be congruent with the type of patients that you want to see. First of all, you have to have a good foundation of your systems, make sure you know your numbers and all this kind of stuff, because regardless of the machine you get, there's an investment in there, whether it's time, a lot of money, combination of the two. If we don't know what we're doing from a chiropractic standpoint and a business standpoint, then regardless of the technology coming in, it can be a stress on the system. Yep. My whole goal when somebody's looking to add this into the practice is that they're doing great. They're looking to amplify themselves without bringing on maybe another new doctor in the realm. They want to see the same type of people they're already seeing, but almost expand just the width of their practice to be able to. To tune in to other ailments that they're not necessarily targeting, like tennis elbow, golfer's elbow, frozen shoulder. Yes, we. We see those patients chiropractically, but then they're also being seen by the orthopedist for those problems. Right. If we can keep those problems in house, we're making a more robust therapy option for the patients that we already love to see. So those are some of the things that I want to make sure that we consider going into it, is that it's the right time for that therapy to be added into the practice.

Yeah, yeah, that makes a lot of sense to me. There's quite a few, as we've seen over the last few years, shockwave units on the market. Some are actual shockwave, some are not. So, yeah, you can certainly break the difference down there. The other is, and one of the reasons I was excited to partner with your company is I feel like you provide a very high quality product at an affordable price point for the dock. I guess when you think about what's on the market and where Shockwave Centers of America fits into that marketplace. What are some things that you hang your hat on?

Sure. One of the things that we built our company around is affordability, but access to great training for getting great results at the same time. That was one of the things that I was missing when I wanted to buy my first shockwave machine in the states. Right. Coming from the Canadian system, where shockwave is more active, there's more of them, It's a little bit more competition between brands. There's a big monopoly at least five, six years ago in shockwave in the states, Whereas one company or maybe another company, and now, which is lovely even from my standpoint, somebody who owns a company that makes shockwave machines, we see so many more companies coming out because the therapy is not good, it's worth it. And I'm happy to have competition because my machine might not be the right one for every single client on the market. And we have to know that going in, our big things that we go for is people who maybe never used the therapy before that need kind of their handheld all the way through the process. They've enjoyed it themselves as a patient. And they're said, okay, how do I translate that from being a patient to them being the provider in the world of shockwave? Because until recently, they're not teaching it at the higher level. The DPT programs now teach it. They didn't five, six years ago. The chiropractic clinics and the schools that we know of, some of them now are teaching it, Some of them still aren't. And so we have to have the foundational education, too. And that's one of the big things that we pride ourselves on, is our doctor training and our ca training, as well as to make sure that we at least understand the fundamentals and how to put the right kind of person on the therapy and then how to get them great results. That's our biggest thing. And we love to work with clients that have other machines, too, because education is the biggest missing point between where we're at here and then having the patients start asking for it. Because if we can get there, that's our bigger mission. If we can get patients saying, oh, you know what? I tuned myself up. I got this tennis level thing. I got to find somebody who does shockwave in my area. Now we know we're winning because we have this understanding, not only from the provider standpoint, but the general public has the understanding that this is an option that's not an injection, that's not a, you know, a steroid pack, and it's not you know, an unnecessary surgery.

Yeah. Creating consumer demand is massive. That's, that's exciting to hear that you're even considering it because I feel like most companies aren't. One of the things that you mentioned I would love to dig deeper on is the educational component. There's many docs who have brought in many different things in their practice and then it ends up in what I call the closet of seminars. Past it like a good idea. At the time they purchase something, they're all excited, but they're like, ah, I can't get this lifted and off the ground. So how easy is it for a practice to actually get started with Shockwave? Is the training super difficult? Hard learning curve? Is it easy? But great support later on, I guess. What have you seen?

I love this question because it's. There's so many different ways we can go understanding that aspect of it. When we think about bringing something new into the practice that has lasting power that the provider wants to keep doing five, six, you know, 10 years down the road becomes very difficult as long as you're going outside of your normal patient base. Right. Which we all think is the right move because now it's bringing new people in. But if it's not the type of people that you would normally see, you're splitting the focus of the practice. And so to be successful with a long term engagement with a new therapy or a new technique or whatever it might be that's new for the practice, if it's so different from what you normally do, it becomes very, very challenging. Now you're running two businesses in one where Shockwave and you know, there's other great therapies like decompression that we love too. They're very chiropractic focused because they don't have to change the type of people that come in the doors. Right, Right. It's the same, you know, Joe Smith down the road who comes for great chiropractic care. He also plays pickleball and he's got this issue with his elbow that he'd love a solution for. That's so easy for us to diagnose, so easy for us to treat. Give them a robust option in the practice so that we don't have to ship to another provider. And now I've created two patients in one that's still in house. I didn't have to again, I can have my train, my staff train in it. Those are the things are going to make it so much easier to keep around versus something, you know, and I've done it myself, put red light in the office, get somebody to run the weight loss clinic part of it. And it's fruitful for like six months to a year. And now it sits there for when me and my wife want to go tune up on the red light and be like, that's really what it says. And it happens, unfortunately, over and over and over and over and over again. But I wasn't excited about it. Right. I'm already excited about the people that I love to see. The families, the armchair quarterbacks, the guys that come in, the, um, that just need a little help getting through all the activities that they love to do. And if I can keep seeing those people, just more of them and help them in a bigger way, that Shark Wave is not going anywhere in my practice.

Yeah, that makes, that makes a lot of sense. You mentioned, like, tennis elbow and elbow issues a few times. I just love to hear from you. What's kind of your top five, like home runs? You're like, when somebody walks in with these 3, 5, 7, I'll let you do as many as you want. What are those home run conditions? You're like, this is an 80, 90% chance we're going to get a positive result. What are some of the conditions?

Plantar fascia is the one that we have the biggest breadth of research on. It's been around for so many years when it comes to shockwave and plantar fascia. And it's the one that we get a lot of people from the community already searching for us when they don't even know what shockwave is like. I heard that helps with plantar fascia, so that has to be on that list of the top five. And for me especially, I'm not going to sit there because I'm soft tissue certified in a couple other techniques. I'm not going to sit there and dig through somebody's plantar fascia. I'm going to use a shockwave. It's way more efficient. The research is phenomenal. We've got got great numbers behind it. It's easy for me and my staff to take care of. It's not an easy problem, but there's not a lot of great other solutions. Right. The surgeries can lead to worse outcome. If we don't get them on a great regimen of strengthening the foot, then this thing comes back over and over and over again. So keeping them in house, where we look beyond just the problem, is super beneficial. When it comes to plantar fascia, tennis elbow, golfer's elbow, I kind of wrap in together. And I just see so many of them, you know, Georgia probably like for Florida, a lot of tennis, a lot of golf. And those people will continue to play through it regardless. And if we can make sure that they can do that without screwing themselves up even more. We're going to see a ton of those. Calcific tendonitis of the shoulder. Which sounds kind of more like a niche, but you see more of it. Especially when you start looking into it.

Yeah.

And start looking for it. You're going to see more of them. Is the one that I don't think there's any other option on the market, surgical, pharmaceutical or therapy wise that beats shock waves efficacy for that particular problem. So it needs to be on that list too. Because nothing will. Nothing will knock that out as well as shockwave can frozen shoulder. I will kind of connect with that. And then I love this around surgery, pre and post replacements, pre and post major repairs. It's almost like using prp. Like we are now too to prime the joint. So we have shockwave to prime it to get more blood flow and collagen production before the surgery. And then three, four, five, six weeks later, depending on the surgery, we can start doing Shockwave again to get their body healing their particular spot and inhibiting some of those scar tissue growth, giving them such a more robust outcome or a much easier transition back into regular life. So those are the things that I say we see most often with some of the best results.

Yeah. When somebody adds in a shockwave unit into their practice. What's some of the top feedback that you've heard from docs that have utilized Shockwave Centers of America? And they brought it in. They've been on the fence for a while. They finally make the decision. They bring it in with some of the early feedback that you hear.

We always recommend people start by treating their patients, their family, their friends, their staff members, people that they've seen in their community for a long time. Because they're a little bit juvenile with using the therapy. Right. They need time to learn it and to practice. But some of my favorites, like my CA has had, you know, TMJ pain for 17 years. Nothing's touched it. This is the first thing that does it because the way that Shockwave works with interrupting how the brain perceives the pain that they're dealing with most of the time, if it's going to be effective, it's the first visit. They're going to feel significant different within three visits. They're going to continue to be better. And if it's not significantly better within three visits. Then we're moving on to either more imaging or a different type of therapy. So it's not this huge investment in time and energy by the patient or by the provider to figure out if this is going to work. And that's one of the things our clients love about it. It's going to work or it's not. And we need to know right away. And it sells itself. When you get somebody better in one visit, they're like, how do I do more of this doc? You finally found the thing that's going to do it. And I think one of the biggest pieces of feedback we get is like, why aren't we teaching this? Yeah. Right. And I thankfully the answer is we are now.

All right.

Right. We're 40 years behind, you know, the European system, but we're finally learning about it in school because it's. It deserves its day in the market. It deserves to be a part of an option for our patients that's non invasive.

Yeah. And if I'm not mistaken, Shockwave Centers of America, two different units.

Yeah.

What's the difference between the two?

Nice thing is there's very little. We built our flagship, which is our clinical model, which we call the Mark three. I'm a super marvel nerd and so I named them after Iron man suits. But the Mark 3 is the first perfect unit, the one that actually works well for him and he crushes it in one of the movies. And then we have our portable model which is the Mark V which he carries around the suitcase in the second movie. But we created the second unit, that portable unit for the clinic, the clinician on the go. So pts and kairos who will go to events and they need to actually have it with them. When you go smaller form factor, you give up some niceties when it comes to the longevity of the device. So if you're a higher volume doc or the machine stays in the office 100% of the time, the clinical one is going to be the better choice for longevity. Easier to swap parts out in the future. Because it's one of those things like pretty much every other technology is that things will wear out over time and how easy is it to change out and how often do you need to do it will make or break the decision making process. Right. A lot of our providers will go with clinical and then they'll end up with a portable one as their second unit. Right. And for me, I use the clinical one in its own room with my consult stuff and then the Portable one comes out with me. If I need to wheel it up to my, my semi open adjusting area. I can do a quick trigger point therapy or I can do a quick elbow that doesn't disrupt the flow of everything. But if I'm doing like a hip and a low back and stuff like that, I might take them to that separate room back there. So some of it's going to depend on the practice. We have independent contractors and mobile Cairos to have the portable one. Of course that makes total sense clinical value wise. They're going to be the same. The how they produce the shockwave is going to be the same. They use the same handles. It's all about how often am I going to use it and where is it going to be actually utilized the most?

Yep. What haven't I asked that you think is really important for docs to know?

Well, what can we do with shockwave? What are the parameters and where we would use it? Where wouldn't we use it? So there's three major items that we can target with the device. One at the most shallow, which is going to be your trigger point and just your pain relieving aspect of shockwave. So when I look at the device, I'm going with a faster and a more gentle shockwave because I don't need it to penetrate very deep. Right. Our devices penetrate up to 8cm deep. Some other devices on the market go up to 12, some of them stop at 4. But depth of penetration is important for safety. For what kind of patients can I see? Which ones can I not see with it? Right. And so for us, if I'm doing, like I said, a gentle one, that's surface level awesome, that's easy. Takes two or three minutes, then you get into a little bit deeper and a little less fast and it's going to be that stimulation of healing. And so that's the regenerative aspect of shockwave. Right. And so that's where we're targeting tissue that can replicate itself to repair and make sure that we're getting full healing in an area that may not have healed properly the first time or something that just needs a little boost in the right direction. And then we can go so far as a really deep, really powerful shockwave that can actually break down some of the scar tissue, fibrous adhesions and calcium deposits that's creating an improper biomechanics or somebody that just wants to knock out, you know, a bone spur or something like that.

Yeah.

The common misconception with that is that we're Actually going in. And the sound wave is strong enough to break things up, which it's not. It works a little bit more like the ocean eroding away at a larger rock where we're actually going to go and deform the tissue enough so that the body's going to go in and take pieces off at one portion at a time. Yeah. It's called spall cracking. S, P, A L. But instead of, you know, severing like I would with a lance or with, with a knife in surgery, we're taking those gap junctions in between all the cells of the scar tissue, creating space for collagen to fill in. And now I have a more functional tissue. Usually where the tendon and the joint meets or where the muscle of the tendon meet. All of those transitional areas are where we see most of that breakdown happen because we just break down with no follow up. There's no benefit. And so it's working with the body versus just a blast away.

Yeah.

Which we will see that with like lithotripsy, for example. Right. So that's the. When people get kidney stones, they go in and they can get shockwave for it. Right. That's been around super long time. A very, very effective. Right. But that's more of just. I'm going to blast it out.

All right.

I'm going to make sure that this is in as many small pieces as I possibly can. And it's great. But that's not what we're doing on the musculoskeletal side. It's more of a slow reformatting versus a busting open. Right.

That makes sense to me. Well, I can't say thank you enough for coming over and chatting. Everybody listening and watching. I'd encourage you if you're thinking about bringing shockwave into your practice or you just would like to learn more about the technology, visit Shockwave Centers of America. I'll drop a link down below. As a listener watcher of this channel, we'll also give you access to a special discount and a free cart to get up and rolling. Dan, thanks so much for coming on Chatting today.

Thank you very much. I appreciate it.

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