This interview Brodie chats with advanced practice physio, sonographer & shockwave specialist Benoy Mathew. Shockwave therapy is a treatment method administered by therapists and Benoy answers all our questions on this treatment option. Firstly, Benoy helps answer the question of what Shockwave is and what the clinic experience looks like for a patient. Secondly, we help decipher the confusion of who will benefit most from shockwave therapy. Benoy explains which running conditions will respond favorably and which conditions will be ineffective. Also, which characteristics create a suitable candidate for shockwave therapy. Lastly, we answer all your social media questions and delve into specific running conditions such as patellar pain, plantar fasciitis and proximal hamstring tendinopathy. Click here to find Benoy Mathew on Twitter For Benoy's online shockwave course head to https://study.physiotutors.com/course/running-rehab/ Click here to find the Run Smarter App on IOS or Android You can also support the podcast for $5AUD per month and interact with the podcast on a deeper level by visiting our patreon page You can also click here for our smarter runner facebook group
Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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On today's episode, Shockwave Therapy, the do's and don'ts with Benoit Matthew. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission to bring clarity and control to every runner. My name is Brodie Sharp. I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. Back to the run smarter podcast and we are into 2021 now and we have just surpassed our 100 episodes hopefully you enjoyed our. Salivatory episode last week and today we have a repeat guest we have been on Matthew he was on episode 69 he was talking all about lateral hip pain and glute strengthening but he wears a few caps one of them being. a he teaches a lot of shockwave therapy to clinicians. He's been doing it for quite a long time now. I have his bio one second. So Benoit Matthew is an advanced practice physio, a stenographer and teaches shockwave. He's done so for the last four or five years, and he has a special interest in hip groin and running injuries. And he doesn't like being called a shockwave therapist, but he is definitely the go-to when. talking about Shockwave, looking at the latest research in Shockwave, and I couldn't think of a better guest. So today we have decided to split this up into two episodes because it was originally meant to be around about a 50 minute to an hour interview, but went a little bit longer. So I thought instead of having an hour and 15 minutes to listen to an episode, I might just break it into two parts and you can get a smaller dose. Today we're mainly delving into what is Shockwave, what the suitability is, what it actually does, who's it beneficial for, where do you get the most effects. Throughout part two we'll delve more specifically into conditions and answer a fair few of your questions throughout social media. So it was awesome having him on and I hope you get a lot out of this. I always get a lot of questions around shockwave on social media. So I hope, so hopefully this answers a lot of questions that you might have. Let's bring on Benoit Matthew. Uh, Benoit, welcome back to the run smarter podcast. How are you today? Thanks for the invitation. It's great to be back and really enjoyed last time. Yeah, fantastic. I have so many people on social media come to me with running injuries that are super chronic and they're like, Will shockwave benefit me? Um, I've had shockwave. It hasn't worked in the past. So I try again, there's so many questions around shockwave and I can't think of a better person to have on the podcast to talk about this. And I just want to start off with a lot of runners. They don't have this medical background. They don't have the physio knowledge. So if you could start off with just explaining what exactly is shockwave, uh, as a treatment. Yeah. I think. You know, before we go straight into. running injuries, it's quite useful to look at the bigger picture of shockwave. So for example, if you Google shockwave, you know, in a Google search, you're going to see it's been used in variety of different fields. So if you're a physio or somebody using shockwave, or you need to know that it's sort of something been around for a long time. So it's been around for 40 years, first used in breaking kidney stones. So it's called as lithotripsy. So I think it was 1970 where it was first used. So it's still used as one of the non-invasive option for breaking kidney stones and renal stones. It's used in cosmetic industries. It's used in wrinkles cellulite. It's used in men's health and women's health for chronic pelvic pain, erectile dysfunction. It's used in neurology for spasticity and is used in a non-union. So I think it's sort of, is well established. So I think what we know is you've got a technology which has been around for about 40, 45 years, very safe. approved by the US FDA and, you know, nice guidelines. So it's very safe. So what we know is it's a very safe treatment. And obviously there are some side effects which I can go through, and it's not for everyone. There's a specific indication. So I think for me as a journey was, as you might know, my special interest is lower limb. So I love treating active people, hip, you know, hip and groin, runners, achilles. So I was sort of reaching a point where a lot of patients were getting better, obviously, with rehab and exercises. I would say there's a small, quite a significant group, I would say at least one in four, or at least 20 to 30% of patients where despite good rehabilitation, they were still struggling with pain. Obviously they had improvement. So this is sort of nine, 10 years ago. So I'm talking about patients with, runners with Achilles tendon and lateral hip pain and peltier tendon. And many of them didn't want injections or PRP and things like that. So that's where I stumbled across Shockwave and I look at the literature. And obviously, there was some good literature, some not bad. And that's what got in my journey. So I think from a very simplistic point of view, when you talk about shockwave, when I explain this to patients, I don't really use the word shockwave. I say it's a high energy sound wave. So it's basically sound. It doesn't have any magnetism or medications or anything else. It's just high energy sound waves. So if you look at, just to compare it for ultrasound. The peak pressure of shock waves at least thousand times more powerful than ultrasound So you could you could use ultrasound on somebody for 15 hours, but what you can do that in 15 hours You can deliver that in like one minute much quicker So it's a very powerful high energy and it's naturally found in nature. Like when you have thunder In physics, it's called a sonic booms It's powerful enough to break glasses. So so it's sort of modality which is sort of is used to kickstart the healing process by It's a pro-inflammatory response. So what it does is it causes a bit of microtrauma because the idea is in chronic tendon, your body is not healing. It sort of reached a point where it's not kickstarting. So what are we trying to do is create a bit of control microtrauma. I guess it's quite similar with like deep friction massage or dry needling, but what it does is this and it's caused much damage on the skin. So it goes straight to the tissue, causes a bit of inflammation, microtrauma. And then we know inflammation is not a bad thing. as long as it's not chronic. So your body just kick starts the healing. So what do we do when my Mac is not working? What I do is just switch off and start it again. So the same thing is you just like a reset button. So that's what I say to my patient. It's like a bit of a reset button to kickstart the healing process. And the evidence is also quite good in lower limb. And if you're somebody like me who's been using, I've been using it for eight, nine years and we're teaching for the last four years, you would quickly realize that it's very good in lower limb, but I'm not very impressed with the results in upper limb. So I would say in tennis celeb and shoulder, uh, I would say it's not something you're going to miss, but definitely in lower limb. My favorite, my top three would be is a plantar fasciitis, achilles, and lateral hip pain. So those three, I think you're going to have a good result. It doesn't work like anything. It doesn't work equally for everything. So, uh, every tendon is different. You know, tennis celeb is different from my achilles upper limb is different from lower limb. So for a lower limb tendon, which what I see with runners, it's a good, right from the beginning, when I teach courses, I make it very clear. It's a second line of treatment. So it's not something you give when you have pain or symptoms. So I've never given anyone shockwave if the symptoms are less than three months. That's one of the criteria which all guidelines says it's always done after three months of the symptoms and after completion of rehabilitation. So it's not a quick phase. So you've done your physio. you've done your rehab, and we expect changes in 10 to 12 weeks, and it's very reasonable. If you've got a runner who's been coming to you, doing everything you've said, but not making any progress after 10, 12 weeks, it's very normal as a human to get frustrated. You're going to look for something else, isn't it? And that's where I think shockwave is a good option, rather than jumping into more expensive and more painful option like steroid injections, PRP and things like that. So I think it's a step in the treatment ladder is, I think, As a therapist, the more you get experience, you're very comfortable to say, if like a patient comes in, I am more than happy to say, if things don't work, I have a plan B, I have a plan C, because I'm not expecting every patient to respond to physiotherapy and exercises. Although I love exercises, and that's the gold standard, we have to admit that there is, and the literature supports me. And if you look at the Achilles literature, there's at least 30 to 40% of patients who don't respond to rehabilitation after 12 weeks. of exercise. That could be many factors. Maybe they're not loading it enough, or maybe it's because of pain. Maybe they're not interested, but patients are going to look somewhere else. And as therapists, we need to have a plan B when things are not moving forward and we can't put all the eggs in one basket with just exercises and load management. Okay. So if I could just reiterate a little bit. So a runner will go into the clinic if they do have a shockwave session and it's kind of like a a gun kind of thing, it places on the skin, it releases a shock wave multiple times a second, sometimes two or three times a second. And it's releasing this high focused, direct sound wave to try and stir up the tissue. Because like you said, sometimes a tendon might get, say dormant where it's painful and it's sore. But everything that we throw at it treatment wise, it's just not responding in the same way. And it's just needs to get stirred up in order to, like you say, kickstart that rehab. But one of the criteria for shockwave would be you need to have a really good go at rehabbing it properly to start with. You can't just mismanage it for four or five, six months, and then think shockwaves. The answer let's give it a good hard crack at doing some really well designed rehab. And then if it's still remaining dormant and we're not seeing the results we're after that's when we go out that treatment ladder, try another option and say, okay, let's kickstart it with shockwave and then go back to that evidence base. real strength based rehab programs, is that right? Of course, of course. We know that, you know, progressive loading, shockwave, I keep it simple with my patients, say shockwave is for pain relief and kickstart the healing, whereas the function on the long-term recovery and also getting back into that full sport can only come from exercise and progressive loading. Shockwave is not going to make you tend stronger and it's not going to get you into the performance area as well. The two points I would like to pick up here is, It's the timing. So one of the reasons where you might have a bad reaction with shockwave is the symptoms should be stable. So many times I will decline shockwave in my clinic because they come to me with very high levels of pain. So they're coming in like eight out of 10, they're limping, they're having night pain. That is a bad patient to really give shockwave because it's a painful stimulus. You don't want to be really be giving shockwave who's already very sore and tender. So... Sometimes I might give a bit of prehab before shockwave just to make their symptoms quiet. So for me, an ideal patient for shockwave is somebody whose symptoms are stable, sort of not more than five out of 10. They don't have any night pain at a decent level. So I like the sort of pain where it's more like achy pain than a sharp stabbing pain or throbbing pain. So they should be fairly stable. The last thing you want to do is if a patient comes to me with pain nine out of 10, they're really struggling. So I say to them, you're paying me to give you more pain. You know, if you're nine out of 10, after shockwave it will be 12 out of 10. Why do you want that? So let's bring you down to, and sometimes just the rehab might be enough. So a lot of patients, I might start them on rehabilitation just to get them back and they don't need a shockwave to go forward. So the first point I would like to emphasize is the right selection at the right stage. So ideally you want patients who is not in a flare up, not in a reactive stage. more in a stable chronic. So let me give an example. So you could be a runner like a 42 year old, half marathon runner or a triathlete who is saying like he can run for 45 minutes, but after 30, 35 minutes, it starts aching and it's a bit more sore the next day, or it's more painful when he starts doing speed work. So that would be a perfect candidate for shockwave where it's not too sore, you can push hard. And the second thing is if you start giving shockwave and it's too sore, you get a bad flat up and then... people say shockwave doesn't work. It's not because of shockwave, because you didn't choose the right period to give shockwave. So one of the biggest limitation, I would say right from the beginning, I can say what are the key limitations of shockwave? The number one is it doesn't work in acute stage. So it's not a good option. So if somebody comes to the very high levels of pain, you're not going to think of shockwave. And the second major limitation of shockwave is it doesn't work if the pain is diffuse. Maybe that's one of the reason in tennis elbow, because the pain is not just localized. They say the whole arm hurts. So the more focused the pain is, the more likely you'll have shockwave. So it's again, picking the right tool based on a clinical findings. And a lot of times I'm seeing shockwave used as a massage tool everywhere. It's a very powerful tool, but again, you need to pick your patients. So as long as they're stable, they're chronic, and they're willing for the rehabilitation, then you might have a good success if you're going to throw in anyone. So I get a lot of patients who are disappointed once they buy the machine because they think it's going to fix everything. you know, because that's because the human body is more complex than that. So from, from my experience, and I think the literature also supports me, my sort of key areas where I would start somebody who's, you know, like a clinic or starting on the shockwave journey, you know, it would be the, even for a runner, you know, what are the areas where you might get a good result will be heel pain, definitely plantar fasciitis, achilles, both mid portion and insertional, petal tendon, lateral hip, proximal hamstring, tendinopathy. That's pretty much. And I do treat, it might not be relevant for owners. I do treat a lot of groin patient on adductor tendon as well. So that might not be relevant for us. So those are the areas where it's very reasonable to try shockwave, especially if they're failed with good quality rehab. Okay. So we're looking at those areas that you listed and we're looking for a kind of low level, achy, high functioning candidate who might be more suitable. So... Those who will respond less favorably or have a less likelihood of recovery would be those who come in with high levels of pain, just walking around at an eight or a nine, because like you said, that shockwave therapy is designed to irritate things and we can't irritate something that's already a nine out of 10. That's not going to respond too well. Or someone who's very acute, someone who's really flared it up over the past week or so, and it hasn't necessarily settled down just yet and haven't probably, uh, sorted out other options that might be more effective. Yeah, perfect. That's exactly. So it's not a quick fix. So I never give shockwave to a patient. On the other side, it's really bad practice to give shockwave before, in my opinion, before a race, because I'll give an example. So I had this 42-year female runner who had a nagging ecclis tendon, not a surprise there, and she... had a big event and she went had shockwave because I never give shockwave before an event for at least eight to ten weeks because the problem with shockwave is it can numb the pain and you overdo it. So she had shockwave obviously she had a good result and then she did the marathon or half marathon well and after three weeks because she didn't have a pain she overdid it and she had a massive grade three rupture of the medial gastro, luckily it is not the Achilles so and she couldn't run for 10 months. So that is a great example where trying to use it as a quick fix. Sometimes pain is not a bad thing because it protects you from overdoing it because your body doesn't want you to exceed that speed limit. So using it as a quick fix before an event is not a clever idea. I see this all the time. People try to want to do an event two weeks or one week before and they wanna have a shockwave. Obviously it might reduce your pain, but the tissue capacity is not improved. You can't improve a tendon in one week or two weeks. And you're just masking the symptoms and you're just asking for trouble. So... I generally, I've never given anyone like before, even at least you need eight to 10 weeks before you can make a difference. Okay. And I think that's a really nice segue into talking about the dosage of shockwave. And before we started recording, you did mention that you see a lot of cases where shockwave is underutilized and then sometimes it's overutilized and we need to try and find that therapeutic sweet spot. So can you enlighten us on this topic? Yeah, so I think it's, you know, this, if you look at most trials, what we know is there's a sweet spot, like we can't put humans exactly one number, we know that it's a range, most things have a range. And what we know is the minimum dosage is three sessions. So I've seen some clinics offer just one session, two sessions, and that doesn't really do anyone any good because the effect of shockwave is cumulative. You need minimum of three to make any difference. So the way I give an example to my patient is it's like a cause of antibiotics. If your GP has given you seven days of antibiotics, you're not going to stop after day three, just because you feel great. You need to complete the whole thing. And what we know with shockwave is you don't make or break with one session. The thing changes, it takes at least three sessions. So if you're going to have shockwave for any part of the body, the minimum dosage is three. And what we also know is we hit a ceiling effect after five or six. So I've not seen any good study where it's beyond six. So... For me, I think I sort of keep it between that range, between three to six, three to five is pretty much your normal range. So ideally you don't want to be giving less than that. So I was, you know, we are discussing, I had this patient with chronic achilles tendon who had 30 sessions. So this just, in my opinion, just abuse of the system and the body is, it's the, you know, 30 sessions on achilles, you know, two sessions back to back. So I see this quite common. People have 15 sessions, 18 sessions, 20 sessions. So it's being used more like a massage tool rather than trying to kickstart the healing. So the way I explain to the patient is if you've been to the gym and had a very good workout, the full benefits of the exercise you get while you're sleeping, not necessarily when you're doing it. So same thing with shockwave is the full benefits of shockwave happens 12 weeks after your last session. So this is a very crucial point where people are a bit disappointed is when you finish, let's imagine you've got an specialist patient and you're given three sessions. the full benefit of the treatment will take 12 weeks after the last treatment. So therefore it's not a quick fix. So a lot of patients call me after three sessions and tell me like they're not happy. And I said to them, your body, the tendons and for the, you know, your collagen remodeling and everything, it takes good 12 weeks. So we need to educate patients. Most patients when I finish shockwave, they're only 20% better. So, and then you need to start loading them. So the way when I... give shockwave with my patients, the way I say to them is, is three plus 12. What I mean by that is three weeks. You normally give once a week. So three weeks of shockwave plus 12 weeks of rehab. And if you're not happy with that, then I would suggest not to do it. So it's never three plus zero. It's always three plus 12. So three weeks or five weeks of shockwave plus 12 weeks of greater loading program. And that could be one of the main reasons that where I get great results for me. I think it's a facilitator, a tool to reduce the pain. and start loading them so they're going to get the full benefit. So regarding the dosage, anywhere from three to five. So how do I decide whether to go five or six? I keep a very simple rule is if your symptoms are very chronic, suppose. Let's have an example like you have a runner who had plantar fasciitis for four months and you get another runner who had plantar fasciitis for two years. The one who had it for more than a year is more likely to need more. So I keep it quite simple. It's not really based by science. This is based purely by my experience. I tend to give more for patients where the symptoms are more than one year because I feel they need a bit more. But I've never given anyone more than six maximums. So that sort of is my limit. And I don't feel if a patient has not responded in that five or six, in my opinion, you're wasting your time with shockwave. Either the diagnosis is not right. So the two, if a patient is not responding, that might be a good point to raise here. If a patient is not responding to shockwave, it's usually because of three reasons. One is the diagnosis is not right. So a typical example would be, I've seen a lot of runners with plantar fasciitis have shockwave not improving because they have calcaneal bone stress reaction. It's a bone marrow edema, it's not plantar fasciitis. So they're having a lot of swelling because you see that in ultramarathons. So if things are not improving, it might be useful to get a diagnosis. That's number one. The number two reason things don't improve is because they are not given at the right stage. They have been given too sore. They are already very sore. So you make them worse by giving them shockwave. And the third and the most important thing is they have not the rehab. They didn't have the rehab for 12 weeks after. So for me, the shockwave is a part of the package, trying to get that tissue healing and then getting it stronger by your normal thing. So it doesn't replace anything what you've done. It just, because if you're given shockwave, it's very quick, it just takes three minutes. So for me, it's a very simple tool. You just give it for three minutes and then you do everything else you're doing. So it doesn't change your management massively, but it's a quick add-on just to kickstart the healing and then to get things going. Yeah, I like that you're repeating this message and I think it's worth repeating one, that shockwave therapy is used as a tool. It's not the complete treatment. And two, the message that people should realize is that shockwave doesn't heal the tendon. It doesn't make the tendon stronger. It doesn't make the tendon tolerate more capacity. What we're doing is, kickstarting it so that it can tolerate and can respond and adapt to a progressive loading rehab. And so it's not, it's like a, it's like a reset button really, you know, you just, you hit a wall and you're frustrated. What you can't do is as you know, we have got a saying in English, you can't flag a dead horse again and again, if a patient comes to me. So 99% of patients who come to me have had physio, they have seen two physios, they have done rehab. They've done exercise for five months, six months. I can't say to them, come on, let's do another three months. They just, they fed up. And sometimes getting a bit of pain relief with shockwave is just a bit of a psychological, you know, it just gives them a window of hope and then they're more likely to do things. So sometimes we have to have the option for a plan B so that we can get going. Because sometimes you can hit a wall. I'm sure you have the patient like proximal hamstring. They've had done right here for eight months, nine months, one year, two years. We can't just keep on saying, do it, do this because humans, we have a finite amount of patients and hope, you know, they will, if you don't, as a therapist, if you don't offer a plan B, they're more likely to end up with unnecessary, unsafe procedures like surgery. And we know that we should not be sticking in steroid or PRP into the tendons. Because, you know, one, we know that the evidence is very poor. And number two, we don't want to put the risk of ruptures. I don't mind putting injection for a sedentary population for somebody who's like 60, 70 plus. But somebody who's like a runner, very active person, there is no justification for putting a device, like a substance inside the tendon, unless you've exhausted all options and they know the consequences, like ruptures and things like that. So for me, if you're done physio, good rehab, three, six months, if you finish shockwave, then if you're still struggling, maybe there might be a role for surgery and injection, but that should come last because you can never undo surgery, whereas If chocolate works, it works. It doesn't work. That's it. You know, you're not going to lose anything by that. And like you said, you're going through that, uh, that treatment ladder and shockwave is somewhere on that ladder and it's somewhat low down on the ladder. Cause like you said, there's no risks. Well, there's not, not a lot of risks cause you're not damaging any tissue. As in if we were to get injections or if we were to have surgery, there's a whole lot of risks associated with it. That's why it'd be higher up on the ladder. Uh, one of the questions I have. sorry, you can't undo surgery and you can't undo injection. You know, what is done is done. Whereas, you know, the worst thing which can happen is shock waves, it doesn't work. Or you might have a flare up for two weeks. You know, patients are okay with that. So as long as you know, it's a very low risk modality. And as I said, it's used in medicine for kidneys. It's used in the heart. It's used even in very sensitive structure for erectile dysfunction, a different type of thing called the focus shock wave for, you know, men's health. So it's been used in very sensitive parts of the body. So... you're not going to damage anything with the long-term. I guess if you keep on giving people 30 sessions, then you can end up damaging or causing more problem. But if you're just sticking to the guidelines of between three to five, you're very safe in giving shockwave. Yeah. And if we're talking about safety, just fine to your input on this. I hear that a lot of injections for tendinopathy actually make the tendon weaker and actually puts them at risk of further damage. Do you know much about that topic? Yeah. So I think what we know is steroid. you know, one, it sort of causes the weakening of your kinocytes and increases the risk of rupture. So when a patient, for example, let's look at a tennis elbow patient, if they come to me who had a steroid injection, I will not give shockwave for at least 12 weeks, because one, you know, they are high risk of ruptures after steroid injection. And number two, I don't want to start up things. So generally it's good to give shockwave before you know, injection. So a top tip for somebody who is using shockwaves One of the worst patients who will not respond to shockwave is somebody who had multiple injections. Suppose you had a patient, a lateral hip, who had three or four steroid injections, they don't seem to respond. And I've got very good research to back me up there is multiple steroid injection is a poor prognostic factor. So if you get a patient who had four injections in the hip, three into the tennis elbow, you might not get the same response. So you need to be very honest with the patient and say, it's 50-50, you know? it might not respond because I think the tendon changes the whole response, you know, the injection turn changes the response. So I'm not a big fan of giving multiple injections and then having shockwave. So it's best to exhaust shock with first before you go in the injection route. But sometimes you don't have a choice. They've already had injections elsewhere. So and generally more and more people are not giving steroid injection because you know, steroid injection increases the risk of rupture, especially achilles and things like that. should really think very carefully before they put in any steroid. But the problem with the steroid is people, let me give you an example, there's a procedure called high volume injection or tendon stripping, HV, you know, it's high volume injection, HVI, or called tendon stripping. It sounds nice, fancy, and very scientific, but if you look at it, what they do is they put a lot of, you know, local anesthetic, but they sneakily put a little bit of a steroid as well within that injection. So what actually works is actually the steroid, which they put into that tendon, especially at least. So I've seen quite a few patients where they had the high volume injection. They feel fantastic for the first two weeks and they come back after eight weeks with the symptoms back to where they were. And then I've even seen partial tears and ruptures following the procedure. So I think, you know, as a runner, you need to really be wary of putting any steroid near your weight-bearing tendon, especially your Achilles and patella, because... You know, we know that it just causes, you know, it's not worth it really. You're just asking for trouble. And you know, runners won't keep quiet. If the pain is less, they're going to run and start sprinting. And we know that the ruptures are much higher, especially if you're 40 plus, especially a male. So for an active person, steroids should be the last thing on your mind. And in fact, I would say, you know, you shouldn't really be doing that unless you have very strong reason for that. Okay. I have a question written down here, but I think you've already answered it. I wrote down, uh, are there any precautions or any running injuries that are not appropriate for shockwave therapy? But I think you did mention like the, the ones that are really appropriate are the proximal hamstrings, the Achilles, the plantar fasciitis, the patellar tendon. And that that's where a lot of the research has shown benefits with. Um, are there any other precautions? Yeah. That's a good point is. Like with any device, it comes with the manufacturer's safety precaution. So the general ones, if you look at the list, it's pregnancy, obvious. With pacemakers, it's only on the shoulder. So if you have a pacemaker, you can still treat your other parts. So if you want to go more on the guidelines, there's a website, the International Society of Musculoskeletal Shockwave, ISMST. So if you Google ISMST, you'll come with a list of quantification. But anyway, I'll go through the key ones. Active cancer, big one is patients who are taking ophirin and heparin. Shockwave just doesn't go well if you're on blood thinning tablets. I've seen, you know, where you get massive bruising. It's not worth it. So if you're on strong ophirin, heparin, blood thinning tablets, then generally not a good idea. And also acute swelling. So I've seen where people have given shockwave to the calf, where they had a hematoma and then just ended with a DVT. So. The last thing you want to do with a swollen. So basically, if you see anything which is hot and swollen, best not to shockwave, it's already inflamed. Why do you want to add more to it? So it should be stable. So anything which looks not right, you know, inflamed skin, swollen joints, swollen calf, acute injury. I don't think there's much scope for a shockwave. In fact, I would say it's not really good practice to do that. You could look into other modalities rather than giving shockwave. Yeah. And you did mention the chronic. patient who's like two years down the track might respond. Yeah. Um, is there a stage where a particular client is very chronic? Are we talking like five years plus that are demonstrating certain characteristics that you think might not be appropriate for shockwave? Yeah. So I think if you look at the signs, the best patients are symptoms more than more than three months and less than one year. So the more chronic it becomes, for example, like if you had a lateral hip pain for four years. If you know that when you have chronic pain, then you're going to get a lot of changes, central sensitization, psychological issues, anxiety, depression, and also other associated factors with kinetic chain weakness. So generally, the more chronic they are, if a runner comes to me and they had like lateral hip pain for four years, of course, it's very safe to try shockwave, but I'm going to dampen their expectations and say, see, you had it for four years. And once you have it for four years, It's very unlikely that whatever we do, we're going to make it zero, back to zero again. We can make it better, but please don't expect that. I'm going to totally fix it. So it's really important to be honest, especially if they had it for such a long time, that because you know, once pain becomes chronic, it becomes part of the whole fiber, isn't it? There are a lot of adaptations. So we need to be quite mindful of that. And one of the worst prognosis is if they have a neuropathic pain, if a patient has pins and needles, numbness, bit of altered sensation, I generally don't give shockwave neuropathic pain and shockwave don't go well together. So it should be more like a mechanical type of pain, more like an ache. If it's very sharp, very sensitive, too sensitive to touch, then I think shockwave is just going to irritate them. So ideally you want a patient whose symptoms is more than three months. You can sort of up to two years is okay, but once it becomes three years, four years, five years, I guess it's reasonable to try but... don't expect anything great to, you know, massive things to happen, or you might reduce the pain by 20% or 30%. So I think you're totally right. There's that sweet spot, you know, where you don't want to be too, too chronic. But I guess once you have symptoms for four or five years, I think, you know, most things don't work, isn't it? There's no magic fix, you know, whether it's an injection or a story, you know, we just have to educate them on the pain signs about trying to, the coping mechanisms and things like that, and maybe try to make them pain a little bit better, but, you know, we can't be talking about cure. or fixing once you have symptoms for such a long time, isn't it? Like you said, you're dampening their expectations. And I think that makes perfect sense. As we know with chronic issues, it becomes less about the tissue and it becomes more about the body and the brain and how people think about that issue, how people start to associate like depression, anxiety, like all these emotive states with, um, levels of pain. And like you said, like if there's If someone is quite chronic and it does become more of a whole body thing, it's less likely to be that localized pain. It's more likely to be widespread, which you said at the start of the interview, which they don't really respond well, if it's not that high focused in pain area and yeah, like you said, it might need to, if you're, if you're five years down the track, but you're still getting that achy localized pain and you are. I guess, responding to mechanical load, like the example used before, if someone does go for a run, a five K run, and then they're flared up the next day, that's kind of responding to a mechanical load, whereas on some on the other side, if they, uh, say frustrated and depressed and like highly anxious, and they're noticing their flare ups as something completely different, their flare ups are on days where they are feeling particularly stressed or days where they're not getting a lot of sleep. That's not responding to a mechanical load. And then. I guess those expectations or the benefits of shockwave might start to skew in the less likely to respond. Yeah, and the problem is also is if the pain is very high and they're very sensitive, you can't give them the effective dosage because it's too sensitive and they just flat up. So I find a lot of patients when they're very chronic, they just flat up when I give them and it just takes them three, four weeks. So normally this might be quite useful for the listeners is when you have a shockwave. treatment, it's very common to be a bit sore for anywhere from three to five days, but within a week, it should be back to normal. That's why we generally have like once in a week gap. So the gap between session can be anywhere from seven to 10 days. It doesn't have to be where I'll give an example, like if I treat a lot of petal attendants, so those usually are jumpers like young men in their 20s, early 20s. And for them, they're fine within two days. So I usually treat them once in every five days. I for them once in 10 days is not necessary. So The younger you are, the fitter you are, you handle it, you manage it very well. So obviously your general fitness also has an effect on that. So if you generally decondition, you know, having medical issues, poorly controlled diabetes, you will tend to fly it up. So I think your tendency is a good marker of your health. So if your general health is not great, then I don't expect that to happen massively as well. So it's looking into those factors. And if it's very poor sleep, other factors, then the last thing you want to do is give a shockwave treatment, just mech flat up thing. So the more and more I get experience, I'm more confident to say no to patients. I would say at least 30 to 40% of patients who come to me for shockwave, I decline them because they come to me too late or it's not appropriate or they're quite weak. So for example, like, you know, I give you in the case of where I treat on the NHS, where I get a bit of deconitioned patients. So... they come to my clinic, they're struggling, they can't even do like 10 or 12 calf races, I won't give shockwave, they're not strong enough to have shockwave. So a lot of time you need a bit of pre-habilitation just to make them strong enough to handle the shockwave before you can give them, because it's a painful stimulus, your body should be good enough to handle that. So the last thing you want to do, somebody who is in a lot of pain, who is quite deconditioned, is to give them shockwave, because your body can't handle that stimulus. Yeah, it makes a lot of sense and it would be understandable if you have a really weak tendon and then you shockwave them and then they're flared up for 10 days. Yeah, it makes a whole lot of sense. Thanks once again for listening. 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