#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 2-part training featuring Dr. David Rudnick on shockwave therapy for post-surgical care. From post-surgical applications to enhancing tissue healing and even optimizing rehab for athletes, this 2-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 in conditions such as impingement syndromes and degenerative tendon and muscle damage was seen. Dr. Rudnick 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 going. So a little background about myself. I am a board-certified sports medicine chiropractor. I have a diplomate through the American Academy Board of Sports Physicians. I practice here in South Florida in Boynton Beach. I have a sports medicine-focused 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 rec 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 gonna be reviewing today with regards to postsurgical and fracture. We obviously see quite a bit of postsurgical in my practice, and hence the reason why I'm 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 tendinopathies 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, and we see excellent results. So what's the role? There's increasing evidence with shockwave and musculoskeletal applications as well as post-surgical. There's 2 different types of shockwave out there, whether you're using radial or focused, and we're gonna be covering the application of both. I currently use a radial shockwave in my office, but will be obtaining a focused shockwave in the next month or so to reach some more wide-ranged conditions. So basically the, the difference with radial and focused, we're gonna get in 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, with that. So radial is a more superficial, goes down about 2.5 inches, about 6 centimeters in depth. Where focused can get up to 12 centimeters, about 5 to 6 inches in depth. So a much wider range of conditions that you can treat and a lot deeper as well. So here's, here's focused 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 electrohydraulic principle versus radial versus focused. But both produce a very similar effect on the tissue. It's just how that acoustic wave is being delivered. 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 millijoules or millijoules per millimeter squared. And knowing the conversion is gonna help you transmit that study that you're reading into 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, on some subsequent slides. So the top is radial, and you can see it has a quick impulse that dies out fairly quickly and will spread out over a larger area. Versus the focused 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 focused 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 a shockwave over tissue? And here's another application or another visual on the depth of penetration and how that acoustic wave is being applied to the tissue. 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 and 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, with regards to shockwave because you get that instant gratification and that 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 pathophysiology 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 outcomes are going to be much higher down the line. So what are we getting 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 You have the VEGF 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 upregulating osteoblastic formation. We're going to get into how that affects on bone. Osteoclastin formation, ALK, FOS. You're upregulating insulin-like 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. The pain modulation is immediate, but And the, the sometimes the range of motion effects are immediate, 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 1 or 2 times a week, sometimes 3 depending on the condition. But a lot of the studies point to even just 1 or 2 treatments a week is effective at improving the tissue healing. 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 2023 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 4 new certification programs and the new Factor F5 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 pathophysiology, and how we're utilizing shockwave over those. Our cuff, probably my most favorite area to treat in general is the shoulder and the shoulder girdle. See 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, 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 tendonesis where they're taking the bicep tendon, repositioning that bicep tendon to take load off of the glenoid labrum. 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 labrum tear in that individual because of their age or their activity level. But they're doing the tendinosis 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, in my career over the years, has been to view a surgery by, 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 an OR. And so I can understand not just what it looks like on paper, but what that patient is going through intraoperatively 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 rehab is 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 nother 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 OR. And witness these surgeries. So quick arthroscopic repair. Obviously there's different variations and with everybody, whether there's more osteoarthritic implications with that patient or if they're just dealing with degenerative tendon and muscle damage that is needing to be repaired. All right, getting down to the nitty-gritty. What's happening when that acoustic wave hits tissue? You're increasing collagen formation. Obviously, we love that. If you have a microtear in an area or even a partial tear up to even 50 to 70%, you're gonna increase collagen. Increasing collagen helps to lay down new tissue. You're gonna heal that area. That tendon's gonna become stronger to tensile load. And then therefore, you're gonna 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 gonna 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's gonna 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 gonna significantly improve the tissue healing. 'Cause that's 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 a 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 were able to measure their improved load to failure in these. Their gait 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 overuse syndromes in youth and other active individuals, the tissue's 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 that tissue and reduce their risk factors for Re-injury or injuries in the future in other areas. So neat little study. 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 7 to 10 to 14 days post-surgery in most cases. So most of that really acute pain has diminished at 7 to 10 days. They may be just taking some NSAIDs at the time. And when we start to incorporate shockwave, we actually discourage the NSAID use because it will counteract the effects of shockwave on that tissue. And that patient's gonna receive the analgesic effect of shockwave, so they're not even gonna need to be reaching for it. pain medication necessarily. 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 rehab 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 Bankart 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 gonna 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 desired effect physiologically. So the parameters can range. And again, obviously, if we're doing 2.5 bar or 0.12 millijoules per millimeter squared over an acute or subacute 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 handpiece 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. We want to keep it in a tolerable range for that patient. So we're treating that patient for about 3 to 6 weeks post-surgically with shockwave, and that's 1 to 2 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 3 to 6 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 pec. 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 debridement, but her surgery was quite a while ago, but still had a lot of adhesion in the region. This was actually a 74-year-old tennis player. She plays 3 to 4 days a week and actually does personal training with us in our office 2 to 3 days a week. So she's a highly active 74-year-old and maybe even 75 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 debridement of that AC 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 C15, which is the ceramic head, which is our mid. We use a silicone head or the nano. We use the D20 head, which is the titanium head, and this is the ceramic. So it produces a mild 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 D20 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 significantly 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 reinjuring that region. So day 1 to 6, 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 collagen formation 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, our, the labrum patients are going to be in a sling for a little bit longer, but our typical arthroscopy or even our tendinosis patients are going to be in there less. And it's purely a tolerance level thing. So we're seeing them come out of that sling 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 day 7 to day 28. They're starting to feel, oh my gosh, I can, 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 were 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 capsulitis very quickly with early implication of shockwave into that region to reduce capsular thickening. Another post-surgery that we see quite frequently is our ORIF procedures, our open reduction internal fixation. This patient, I believe, yeah, this one was a soccer player, 17-year-old, 16 or 17-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 an 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 having 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's seen the effects of it in the past. So we get excellent osteoblastic activity in that region. And he was comfortable with us doing that at that point with the patient. They give us about 3 to 4 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 3 to 4 days a week on this individual to produce osteoblastic activity, and particularly because we had a limited amount of time with this individual before you needed to possibly go in for a graft. But you can see that there is a lot of callus formation around that surgical site, particularly on the image on the right, and they had extremely favorable outcomes. So about 3 weeks Post, he had about 40 to 50% bone healing, and at 6 weeks post utilization of shockwave, he had 80% bone formation in that region, and he avoided a bone graft. And I'm happy to say that this individual is back to high-level soccer and has no pain over the surgical site and is gonna 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 incorporate in that region or 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 31st. And if you're not on our mailing list, what are you waiting for? Click the signup link in our show notes to receive our weekly Factor 5 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 5 things format. That's easy to skim and scroll. Be sure to tune in for episode 70, where we wrap up part 2 of our training on shockwave therapy and talk more about its benefits for athletes with overuse syndromes, as well as the research surrounding the use of shockwave to reduce scar formation and postoperative symptoms. You won't want to miss it. Episode 70 drops in 2 weeks. We'll see you then. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R hyphen store 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.