Kim (00:03.854)
Hello, Dr. Roberts or Stacey, you said I should call you. Welcome to the podcast. I'm really excited to explore the topic of shockwave therapy with you. This is something that's being talked, I saw it first being talked about in the men's health realm with regards to erectile dysfunction, but I'm seeing more and more of it addressing female pelvic health challenges as well. But before we get into that topic, I would love for you to tell us a little bit about yourself, what got you into physical therapy and specializing in pelvic health and
what brought you down the path of shockwave therapy.
Stacey Roberts (00:35.5)
Sure. So I'm a physical therapist of over 30 years. got into physical therapy, actually pre -med. So I got into physical therapy after I tore my ACL playing college athletics. And through the process of developing a relationship with my PT, I'm like, hey, this is kind of cool. The orthopedic surgeon I'm only seeing like 10 for 10 minutes, you know, once every three or four months where I see this PT, you know, three times a week. I thought sports medicine was really cool. So I changed my major into
physical therapy at that time from pre -med. And then I worked at a hospital, then branched out into sports medicine and ortho, into sports medicine fellowship, moved to Australia in 2000, where I had a clinic that was focused more on women's health and then started to get more into women's men's pelvic health and fertility. And so that's kind of how I branched into the male and female sexual health then as well
When moved back to the US, back to Milwaukee area, I was working as a director for a large company and I was like, this just isn't me. I want to have my own clinic again. I opened 10 clinics for them. like, why am I doing this for somebody else? So I opened my own clinic and then utilizing, my passion, because while was in Australia, I did a lot of functional medicine too and more holistic care, became a master herbalist over there.
So I have my foot in both conventional and alternative or holistic medicine as well too.
Kim (02:03.329)
That's very cool. think that's always how I think medicine should be done. I think it would be done best to have this complimentary approach. And there's a little bit more of that now with the two, well, it's not even just two, but the different sides talking to one another a little bit more. So I just think that that's such a beautiful way to manage people's bodies and health conditions and concerns.
Stacey Roberts (02:24.967)
And people are craving that, they really want that. So it's, you know, we're of the generation of wanting to be healthy and active. And sometimes conventional medicine isn't the way to go for that. It doesn't satisfy our needs there. So we start looking for other processes that can be done or other interventions, you know. So I think, you know, and then our, you know, the next generation is learning more about, you know, taking care of the health a lot earlier than
what I learned, for example. So I think people are definitely wanting that type of approach.
Kim (02:59.455)
Yeah, so what brought you to you've opened up your own clinic, you brought what you sort of the complementary approach that you have been doing and then where where did the shockwave piece come in? So before we explore kind of what is it, but how did you get introduced to it and why has that now become a main focus of your practice?
Stacey Roberts (03:16.53)
Sure. So when I first moved back to the U S I started seeing people for fertility issues, but here in the U S people kind of couldn't put together how a physical therapist knew anything about fertility and hormones and things like that. So as I went back to work as a PT, I still was missing my passion of working with, you know, holistically working with people. So I thought, how, what could I do? How could I do this? So I decided to go back to school for nursing and get my master's in nursing and then eventually become a nurse practitioner.
So to expand my scope of practice. So when I did that, friend of mine, I was probably halfway, three quarters of way through my program. So during COVID and a friend came up to me and said, you know, I found this shockwave device. It's a guy has it about an hour and a half away. Do think it would help my shoulder? And I'm like, nah, probably not. I've seen it all. I haven't really heard a shockwave at that time, but like, you know, no modality that I'm very much of a manual therapist. So no modality really ever.
move the needle or was a big game changer for my patients. So I just tended to stay away from them. But, you know, I had treated her before she had calcific tendonitis. So at end range of shoulder motion, she would have pain still, but it wasn't a functional issue. It was more like if she slept on it wrong, you know, that type of thing. So I agreed because of a free lunch to go up if she had the session, just to make sure it safe. Like I didn't want her to do anything that was unsafe. So we went up, she had the treatment.
I was curious as the guy was doing it that she, even though she wasn't moving her arm, when you go over an area, especially that has bony prominences, it will help you to kind of determine where inflammation is. And they could tell exactly where the calcific tendonitis was, which was really interesting. And then after the session, she raised her arm and she goes, hmm, it's gone. And I'm like, all right, well, I'll talk to you in a couple of days. I'm sure it's going to be back. You know, I mean, you know, it's just a fluke, you know, that type of thing.
days go by, weeks go by, she still doesn't have any pain. As a matter of fact, two and a half years went by until she had pain again when she was playing pickleball. Now that doesn't typically happen. So I think serendipitously, I was meant to see that so that I would jump into the research. like, what is this? So then I started getting into the research and it was so confusing. All the different devices, all different outcomes.
Stacey Roberts (05:34.392)
So again, the way my brain works is, okay, I want it, this is challenging. I want to learn about it. If this truly can be something, it's someday I want to put it in my clinic, right? When I become an NP. So I did the research, started answering different questions that people had on different forums for pelvic health. And Holly Tanner, who is an educational director and an instructor for Herman Wallace, reached out and said, you hey, you kind of know a lot about shockwave and it's relevant and good research.
where'd you learn all this? And I said, basically by digging myself and she's like, maybe you put a course together for Herman and Wallace. So I put a course together for Herman and Wallace for shockwave for PTs demystifying the research. Cause again, it's so confusing. So it took me eight to 10 months to learn. I've compacted into four hours with Herman and Wallace. So that's really kind of how I got into shockwave. And then I decided, because I'm a crazy person that instead of waiting until after I got my NP to open a clinic, I would do it at that time.
when Shockwave was presented to me. And so I still have my clinicals to finish for my NP, but I'm busy, crazy busy in my clinic. And I moved from ortho into pelvic health with Shockwave, SoftWave in particular, because I thought, look, it increases blood flow to the muscles. It increases the anti -inflammatory molecules, know, stem cells, M2 macrophages, upregulates toloic receptor 3 related to regeneration. Why can't we do this on on on public health issues?
There were a few studies out there. So then I did it and a patient had vaginismus and know, I kid you not Kim, you've dealt with vaginismus. You know how it's a tough thing to treat, especially manually because it's so darn painful, right? And there's a lot of biopsychosocial aspect to it. After the first treatment, the patient and I were both, I'll use the term from Australia, gobsmacked because I was able to do a full internal after the treatment and she had minimal pain.
prior to I barely could do an internal. The muscles were like butter. What's nice about treating the pelvic floor is the increase of blood flow is immediate. And so you can get that relaxation and then you can do a little bit more manual therapy. So she, after not having intercourse for five years, was having intercourse with her partner after three or four treatments. Which again, exactly, you know from treating people that that's so unusual. And that's what
Kim (07:31.545)
Wow.
Kim (07:53.456)
Wow.
Stacey Roberts (08:00.032)
move me into doing the dyspareunia study where I'm a co -principal investigator. Myself, Holly Tanner, Heather Jeffcoat, and Stacey Futterman around the country are utilizing this with PT because we want to show we already know PT works for dyspareunia, vaginismus, those things, but we want to show that this can accelerate the progress because that's what patients want. That's what they like, right? And I don't like hurting my patients either. So if I can make them more comfortable and my manual therapy is more efficient and effective.
Why wouldn't I want to use something like this?
Kim (08:31.29)
Yeah. Okay. So many questions. I want to start though at the beginning. you, so when you, if you look up shockwave and if, especially if I look up you, it, it, you see soft wave and you even just mentioned soft wave. So can you first distinguish what is, what is shockwave therapy and what is the brand or what, where does soft wave come
Stacey Roberts (08:52.928)
Sure. So there's three different types of true shockwave. Electromagnetic, piezoelectric, and electrohydraulic. Softwave is the name of the company and they produce an electrohydraulic device, which is a little bit unique and I'll get into that later. But in the research, what you have to be careful of is when you look at shockwave, also something called radial wave or radio pressure wave.
EPAT, those types of things are also under the shockwave umbrella, even though strangely enough that they don't even produce shockwaves. So I don't know from the International Society of Medical Shockwave Therapies, somehow included them under the umbrella. Maybe at some point they thought they produced shockwaves, but now we know that they don't. The radial devices are more like a jackhammer on the skin and it's not something that I have utilized on the perineum or in that area just simply because that significant.
microtrauma and pain that it can potentially cause and does cause when you're treating a typical ortho condition. So when I'm talking about shockwave, I'm not relating to radial. It's, even the measurements are different. Everything is different about it. So true shockwave is the electro -hydraulic, case electric, electromagnetic, as I said, soft wave is electro -hydraulic. But the other differentiating factor and what that I liked when I tried all the different devices.
was soft waves applicator comes, the energy comes out of it more like a flashlight. So if we think of shockwave in general, it first started as lithotripsy in hospitals around the world to break up kidney stones. It very, very high intensity, highly focused shockwave needed to be able to break up those kidney stones non -surgically.
Then while they were doing that, they found that there were changes in the vertebral bodies while they were doing this high intensity and they noticed that it had some effect on bones. So they started treating non -union fractures that were resistant to healing and it could have been six months or more. And then they started doing shockwave on them and lo and behold, they started to heal.
Stacey Roberts (11:00.889)
That then went from there into treating tendinopathies, tendonitis, things like that that were more superficial. And then kind ED jumped in because we know it increases blood flow. So they utilize it to increase blood flow to the area. Also increases nitric oxide. Now there's a lot we can get to talk about that because typically it's just the penis that's being treated and that's it. But as you know, pelvic floor has a lot to do with that. The hips can have a lot to do with that. Penis nerve could have a lot to do with it. So.
There's other areas that could be treated. I landed on soft wave because of the fact that it doesn't come out like a laser. It comes out more like a flashlight, which is more like a shock wave in nature, like a volcanic eruption comes out like that. And it's more comfortable for the patient because it's not laser beam focused. That is low energy. So not the kidney stone treatment, but they found that low energy is effective for
orthopedic issues, tendonitis, tendinopathies, things like that. And we use low energy and outpatient because you don't have to, there's no anesthetic, things like that. So my patients have found when I tried all the different machines, patients found SoftWave to be more comfortable. I found there were less shocks needed in comparison to the other one, other devices out there. So that's the one that I went with and the treatments times are shorter as well because less shocks are necessary.
So yeah, so that's why I landed on SoftWave, which is the only one that has this unique applicator.
Kim (12:29.165)
Got
Okay. So now to get to the elephant in the room, when you hear shock, obviously you think pain and shocking. And so what, what does it feel like when you have, what is, what does a treatment look like with the, we'll focus, as you say, you use the soft waves. So you've talked about a flashlight. am envisioning there's some sort of probe that would be delivering this energy to the tissues. Is that accurate?
Stacey Roberts (12:37.742)
Right?
Stacey Roberts (12:54.41)
Absolutely. Yep, that's accurate. So the shockwave device, the one that I have, it's kind of a rounded dome. can bring it over here if you want. don't know. Do you want me to show it to you? don't know if from a podcast. Yep. Move this over. Sorry. I've had that set up for you beforehand. And over there.
Kim (13:07.596)
Sure, if you have it. Yeah, we will put this on YouTube. So
Stacey Roberts (13:25.784)
So probe looks like this and yep, exactly. It's like a big flashlight. So it comes out like this, right? Whereas the other shockwave devices come out like a laser. So they were kind of mimicking the lithotripsy coming out like a laser versus coming out like the flashlight. So that's what this looks like. I don't know if you could see it on camera. You could probably hear it, but you'll see some flashes. That's an electrode inside there creating those flashes of light.
Kim (13:29.676)
Looks like a big flashlight.
Stacey Roberts (13:53.907)
that creates a sound wave that goes through the tissue. The patient will feel a tapping on the tissue until you go over an area that is inflamed, whether it's a trigger point or let's say an arthritic area around a bone or the end of the bones. And then they'll be like, yeah, I can feel that. And then you turn it up to what they tolerate. And then what's the crazy part of it is during the treatment, the pain actually goes down so that immediately after the treatment, they're usually
50 to 100 % better. And unlike my friend who had one treatment and it was amazing for her for over two years, most people need to come back like once a week for about three to four weeks. After the three to four weeks, unless there's severe significant complications from many areas that need to be treated, after three to four weeks, they should be 50 to 100 % better. So in the perineum, they may not have any pain whatsoever. They just might feel that tapping, might feel the wave coming up.
If they don't have a uterus, example, if treating a female who doesn't have a uterus, it can come up and they might feel it around their belly button, almost getting that high. If they have a uterus, they'll feel it potentially coming across towards the ovaries. Men will just feel it if, know, men sometimes can't feel anything really sometimes as we're doing stuff, the disconnect with the body. But if they feel it, it will also kind of feel like a wave going through their pelvic floor. So it's an interesting...
People don't describe it so much as pain unless you crank it up and there's no need to turn it up very high. They'll describe it as more of a sensitivity.
Kim (15:31.03)
Got it. And how long does a treatment session last?
Stacey Roberts (15:34.227)
So for electro -hydraulic devices like SoftWave, anywhere between eight and 12 minutes -ish, or electromagnetic and piezoelectric, because they have to use more shocks, anywhere. The average number of shocks used for electro -hydraulic is about 1 ,000 per session. And then because the laser beam, piezo and electromagnetic, they have to move around a lot. And you can fall off the spot that you really want to treat. There's a lot of kind
you know, not only say guessing, but just a lot of moving to find and stay on that right spot. So that could be 2000 to 4000 shocks. So that could be, you know, 15, 20, 30 minutes, depending on, you know, what you're treating and how many. So there's another factor for me is the electro -hydraulic was a shorter treatment session and it also decreases my manual therapy. So it makes it more effective and it decreases the amount of time that I need to do it. And it's a lot less painful for the patients, which is amazing.
Kim (16:31.766)
Yeah, well, that was a point I was going to say is it also it reduces, but it also even opens up the opportunity for manual therapy in some people. Yeah, interesting. So let's talk a little bit about what conditions. Yes, erectile dysfunction is where I first heard about it. And now it's it's it's being explored. And you can talk about all the different you've talked about vaginismus, dysparenia. So what are what are all of the conditions that somebody could potentially
Stacey Roberts (16:37.745)
Exactly. Right.
Kim (17:01.021)
experience that could benefit from a soft wave or shockwave treatment.
Stacey Roberts (17:05.295)
So any orthopedic type of soft tissue injury or chronic issue. So if we move into from pelvic floor point of view, can vulvodynia, vestibulodynia, we could treat the, like we talked about dyspareunia, vaginismus. ED is different because we're not treating like a pain, like there's not something specific where it's really, the goal there is to increase blood flow to the area, right? Increase nitric oxide to relax the smooth muscle of the penis so
the more blood flow can get into the penis to help it become erect. So it's a little bit different and requires a few more, couple thousand more shocks just in general because of that. But really, mean, like in sclerosis, it's not gonna cure like in sclerosis, but it's gonna decrease the lesion size very quickly, because it has a really nice improvement on wound care as well. So they'll find that the itchiness and the soreness decreases significantly.
Kim (17:55.201)
Wow.
Stacey Roberts (18:02.109)
What else? Throw out another diagnosis for me and I'll let you know if it...
Kim (18:05.835)
So I'm thinking people who have, maybe they don't even yet have a diagnosis of vestibulodin. They have a tight pelvic floor or they say they have burning in their vagina or they have tightness. So people who have been told never do Kegels and just focus on relaxing the pelvic floor. Is this something that could come in and play a
Stacey Roberts (18:12.538)
Yeah.
Sure.
Stacey Roberts (18:26.114)
Yeah. What's nice about it is you know the type of person that comes in and they have no idea what you're talking about when you say relax your pelvic floor or down regulate, right? know, down train. They just don't have a concept, right? So what's nice about this is because when you treat the pelvic floor, you bring blood flow to the area. Now there's feeling there, right? So now they can even feel, the guys especially will walk away and be like, it's kind of warm down there. It kind of just feels warm.
Kim (18:34.304)
Right.
Stacey Roberts (18:54.667)
So now they have this connection, this sensation that they feel, and then we can start giving them a little bit more bio, they've got the biofeedback, we can give them more feedback, then they can kind of understand even where those muscles are, right? It's most of that, most people have no idea there's even muscles there. It's better now with more focus on pelvic therapy, but in general, there's a disconnect, right? So it absolutely will help with that. And then with coaching and PT and going through, you
how to contract and relax, don't train, what that means, how to move in the functional aspect of pelvic floor therapy. It just helps to enhance what we already do. It accelerates the process for the patient and the practitioner and makes what we do more effective and efficient as
Kim (19:43.349)
I'm now thinking in my mind, because you said wound healing, if you think about postpartum or post -op, so post -pelvic surgery or again postpartum, whether if they've had tearing or whether they had an episiotomy, cesarean, is that a place you could start using
Stacey Roberts (19:46.005)
Okay.
Stacey Roberts (19:57.591)
This is absolutely, and there's some exciting new research that just come out of that, but the women involved in the dyspareunia study are so excited to, when they finish that study, want to do scarring because postpartum scars, C -section scars, episiotomy, means all those things just work so well with this. The tissue heals so well and we minimize the scarring. They're using this in aesthetics too after surgeries.
It minimizes scar and minimizes pain, chronic scar, chronic pain around scarring. I've treated several patients now where during the treatment they're like, and we're like, are you okay? And they're like, my God, yes, this is the first time it's felt better. Like when the pain goes down during the treatment, they're like, my God, like this is the first time that it's ever changed, right? So it really is extremely rewarding.
to be able to see that happen much more quickly than it typically would happen in regular session. So yeah, and the new research that I was alluding to, was just in Amsterdam at the International Shockwave Conference out there, Medical Shockwave Conference there, and they're actually saying that by doing shockwave to these, the scars, even if it's been long -term scarring, it's changing the cellular structure of that tissue. More stem cells are coming there, differentiating into healthier tissue, improving collagen.
Kim (21:20.936)
Wow.
Stacey Roberts (21:22.131)
it's fascinating that it's kind of reversing that process of we typically think of scars as dead tissue with no blood supply, right? And then our nerve entrapments, right? So it really significantly helps to improve that blood flow to the area and then helps with that pain response as well too.
Kim (21:42.685)
So what about pudendal neuralgia?
Stacey Roberts (21:44.605)
Great question. So, you know, how sometimes we're like, is it pudendal neuralgia? Or nice thing about this is it has that biofeedback mechanism so that as we trace the pudendal nerve, if they get the referral to the genital area, we can be pretty confident that the pudendal nerve is involved, right? So by understanding our anatomy, if somebody comes in with sensitivity or numbness or pain, if we trace the nerves that we know that are innervating that area with the softwave device,
and that re -creates their symptoms. And we know we're on what we call a hotspot. And then by treating that, usually the pain will start to go down while during the treatment. But like anytime you're treated a nerve, you have to be a little bit more sometimes gentle or work the tissue around it, right? So it's great to bring blood flow to the tissue around it as well. We can do manual therapy. So it again, just really enhances that and minimizes the inflammation around the area.
if there's inflammation around the nerve. A lot of times, like with stress incontinence, the blood flow to the striatum, smooth muscles of the urethra and the bladder are affected. And what they find when they utilize shockwave on patients who have stress incontinence is simply by bringing blood flow to those muscles, they can work better without doing any strengthening, right? The mucosa improves as well in those structures as well too. So we're decreasing inflammation.
or improving blood flow. So now muscle, if I contracted my bicep, I I can't really move it if I don't have any blood flow to it, right? Just continue contracting it, pushing all the blood out, or from disuse, there's not really much blood supply there. You start adding blood flow to that area and okay, I can use that bicep, right? Same thing for those structures in the urethra, the muscular structures in the urethra as well too. And then again, if they do need strengthening, if that's an aspect of the program,
there was blood nourishing those structures to be able to allow them to
Kim (23:48.048)
Yeah, that was another question I had was the prolapse and incontinence categories. Are there any benefits to those people? So this is, as you're saying, increasing blood flow. That, of course, my mind is going to the people like, what? I wouldn't have to do exercise? Great. I'll just do a shockwave treatment.
Stacey Roberts (23:52.284)
Mm -hmm. Mm -hmm.
Stacey Roberts (24:03.556)
Right. Yeah. And then, you know, it's only going to last right for so long and sure they could do a shockwave treatment or they could do their exercises. Right. So we want to be sure. And again, it's the same thing with PT. Right. Right. See, they're feeling good for a while and then they stop doing their exercise because they're feeling good. none of that goes away of counseling and having patients take accountability and responsibility for what they need to do afterwards. But it certainly helps to help them helps to show them.
Kim (24:19.524)
Exactly.
Stacey Roberts (24:31.802)
that this can be something that's addressed. Now prolapse is a little, it's not gonna correct a prolapse. if there's a prolapse, there's torn ligament, things like that. It's not gonna reconnect ligaments by any means. If there's partial tear, it can help with improving that remaining connection. But the pain associated with prolapse, if it's not more structural, and then from a functional and biomechanical point of view, even by increasing the blood flow, we might get some reduction in pain.
that can prolapses are a little bit different animal than just typical pelvic floor issues that we talked about.
Kim (25:08.429)
Yeah. And my mind is also going to levator avulsion, which, you know, there, there is an element where it's again, it's not going to reattach the muscles, but what's the surrounding structures, what's remaining. Can we increase blood flow circulation to help potentially minimize some of the, the, the ongoing lack of function, progressive lack of function. Yeah. Yeah. Interesting. What the, when you showed
Stacey Roberts (25:17.422)
Exactly.
Stacey Roberts (25:29.999)
Correct. Correct. Exactly.
Kim (25:37.379)
sort of the flashlight type thing. It looked like, it almost looked like a crystal ball with, you know, a roundness. so, it's like a jelly. Okay, so you've pressed on it, it's like a jelly, okay.
Stacey Roberts (25:41.355)
Mm -hmm. Yep. Yep. there's water inside here. So when I press on it, I'm pressing against water over that flashlight on the top. And then the electrode is inside there. So this is the electro -hydraulic part. it's a closed soft wave. It has a closed system. Other systems out there open where you pour the water in yourself.
Kim (25:52.772)
Got
Stacey Roberts (26:06.052)
They get rusted relatively easily. This is a nice closed system and the pressure is very reliable. We know what we're getting each time we're using it, know, that type of
Kim (26:17.827)
So is that placed directly on the skin? It's in direct contact with the person.
Stacey Roberts (26:21.413)
That's correct. And a nice external treatment for those who don't really aren't sure about internal, right? So we can actually get to the pelvic floor with this. Electrohydraulic devices will penetrate up to four to six inches. what's nice about, again, SoftWave is that it's a flashlight, so it's not just going straight in. It's also going out, right? So you're getting all three layers of the pelvic floor can get treated with SoftWave, which is really nice. And that's why you get that overall.
Kim (26:41.507)
Bending out,
Stacey Roberts (26:51.158)
relaxation or significant improvement in blood flow where the, where it literally is palpating. Like, I mean, until you palpate it, you don't believe it. Like I wouldn't believe it if I didn't palpate it. And I'm like, my gosh, it literally, like butter. so that's what again is that particular applicator makes it much more comfortable just sitting on the perineum versus the other application you've got to move in order to try to hit all those areas.
Kim (27:19.192)
What about menopause, post menopause, potentially somebody who's well post menopause who was not advised of vaginal estrogen or there's been a lot of atrophy? Is there, again, it's not necessarily going to miraculously return the vulva vagina to the previous state, but could it help potentially reduce some of the atrophy that has occurred?
the lack of blood flow circulation obviously is going to be a yes, even like dryness, do you think that there could be a role
Stacey Roberts (27:52.201)
improves the mucosa as well. Mucus production for sure. As you alluded to, hormones would need to be addressed in some way, shape, form, whether if they're extremely post -menopausal, like long ways past menopause, then looking at adrenal function too, because that's where estrogen progesterones only produced after the ovaries are not producing them anymore. So in conjunction with other things, whether it's topical estrogen or...
Stacey Roberts (28:22.293)
herbs and lifestyle changes to improve things as well too. In combination, you'll see that increased blood flow. You'll see the improvement in blood flow in those vaginal tissues in the vulva right after treatment. So they will look much better. Now keeping them that way is obviously something that, how many treatments do we need to do with this? Does something with that maintenance is required? That's other.
research that is being done now and that we're trying to pioneer as well too for women's health because as you know, like everything else, there's much more men's health research, right, than there is women's public health research. So we want to really see what is a great combination for women who are having those issues. Can shockwave move the needle in combination with these other therapies? So that's where my goal is to keep
Kim (28:56.664)
Mm -hmm. Mm -hmm.
Stacey Roberts (29:15.058)
moving and progressing that research for women's
Kim (29:21.398)
With regards to, again, this could be really, it's pretty much whole body, but I'm thinking I'm staying in the pelvis and for hip, hip, knee, tailbone, like other areas where there could be pain and inflammation, pubic symphysis. So let's say if there's somebody who is having some hip degeneration or hip pain, which can then indirectly influence the pelvis. So that's also another place application.
Stacey Roberts (29:50.11)
100%. So if there's inflammation somewhere else, restricted motion, those types of things, that's affecting the pelvic floor. Absolutely. So I tell physical therapists to think about this as an extension of their manual therapy. So everything that we would normally do, we would assess the pelvis. If they have tailbone pain, we're looking at lumbar spine. We're looking at pelvic torsion, all that type of stuff. None of that changes.
But now we have a tool to kind of pinpoint and narrow down where the inflammation potentially is that we can treat, where we can treat to help us improve our manual therapy as far as its efficacy and efficiency. So to answer your question, yes, we could treat the hip. Maybe there's some capsular issues there. This gets deep enough to get into the capsule to make the capsule more pliable, know, shoulder and hip, you know, whichever we're working on there, frozen shoulder, all that type of stuff.
So to answer your question, yes. And we just need to put on our PT brain to, know, because some places you go and they just go at hurts here and that's where they do the shockwave. So, I mean, if it's say it hurts on your knee and you put it right on your kneecap, 9 .9 out of 10 people aren't going to have pain on their kneecap. And they're like, oh, that's where it must be from. Well, no, it's because you're banging something against the kneecap, right?
Kim (30:59.008)
Yeah.
Stacey Roberts (31:12.806)
But if you understand anatomy and then you go, okay, well, where's the joint line? Where is this going? Does the patient feel it deep or superficial? Again, it's just enhancing what we should be doing in our assessment and treatment of anybody with pelvic floor dysfunction, bringing in all of those areas as well.
Kim (31:12.823)
Yeah,
Kim (31:29.433)
Right. And back to the treatment itself, you've talked about the perineum and different from other types of shockwave that might be more kind of, as you said, laser and require movement around with the, is it, is it accurate to call it the probe? The head? Yeah. So the probe piece. Yeah. Would that then, are you, you're putting it onto the perineum and are you holding it there for the eight to 10 minutes?
Stacey Roberts (31:47.516)
Probe, yep, yep, yep. Applicator, probe.
Kim (31:57.399)
the entire time or do you remove it and apply it or do you go around the external tissues around the vulva?
Stacey Roberts (32:02.843)
So with this device, you basically put it where you're wanting to treat it. You're thinking about how it's coming out like a flashlight. And then all you do is kind of angle up, angle down, angle to the side. I might move it up a little bit more. It can be uncomfortable directly on the clitoral hood. So I'll treat the clitoris laterally and try to increase blood flow to that area as well too. So there's typically very little movement of that in that area.
And you're just chatting with the patient and being like, okay, what about this? feel it here? Again, same thing, same process that we would do with manual therapy, right? So, and it's just a very easy, very straightforward technique to do, which can, you know, if you have a PTA or a physician has a technicians or MAs or whatever, as long as they have a decent knowledge of anatomy and that I believe the practitioner and the provider should do the first treatment.
So they're understanding where this person should be treated so that that person can get the best outcome. I've heard of places doing in their front office, person is doing shockwave because it's that easy to do, but are they really going to be able to make the clinical decision of where do I move this next or what do I do here? So the outcomes we want from the patient to be the best. So that person that's well -trained can really make a huge difference with this.
Kim (33:11.298)
Mm -hmm. Mm -hmm.
Kim (33:28.025)
Right. And I apologize, I think you have said this, but if you can reiterate, the eight to 10 session and then everybody's going to be a little bit different. Some people like your friend who had that one treatment, was fine for two and a half years, but the general person requires how many sessions over what period of
Stacey Roberts (33:44.745)
So if we look at a typical pain diagnosis, that is, let's say, doesn't have multiple areas that we have to treat, right? It's relatively straightforward. We're looking at three or four treatments over three or four weeks. If somebody has chronic issues, you know, they come in and they've had this issue for 20 years, you know, it's on and off, it's now worse, it gets worse, it gets better. You know, those patients might need like, you know, six to nine treatments.
but not necessarily weekly. they'll usually, if it's going well, and if it's only this issue, like from a functional medicine standpoint, I tell my patients, if this isn't better by 50 to 100 % in three to four visits, we need to talk about other things. We need to talk about your gut health, need to talk about your hormones, we need to talk about your diet. We need to talk about different things that could be contributing to inflammation. But typically by that third or fourth visit, we know for sure that they're moving in the right direction, that this is more localized inflammation that we're dealing with, not systemic, and that we can keep them.
moving the needle, then we start going, okay, well, you're feeling great since I saw you last night, let's go out for two weeks. So that fourth, fifth and sixth session might not be weekly, that might be every two weeks or three weeks. And then some of my patients and especially ED patients will come back for monthly treatments to as kind of a maintenance program, right? Especially if they've had a problem for a long time. But now I'm running into after I have to add different services to my membership plan for monthly treatments because like by that six month,
Kim (35:00.692)
My maintenance, yeah.
Stacey Roberts (35:11.393)
They're like, they come in and they're like, I don't even know what to treat. Like, I feel really good. And I'm like, okay. What else can you do? Any other problems? know, so, so now I add like a personal training session instead, like if they're feeling good, you know, so it's enabled me to add a membership program. Now I just have to be more creative because their patients are feeling good, which is a good problem to have, you know.
Kim (35:31.412)
Yeah, that's cool. There was one other, when I was looking into the research and the technology, there was high and low intensity extracorporeal. Or is that if I pronounced it correctly, what does that mean?
Stacey Roberts (35:43.317)
The extracorporeal shockwave therapy means basically on the outside of the body, right? And that encompasses all shockwave, okay? Then there's high intensity, which is the lithotripsy, used in hospitals usually need to be under anesthetic. And then there's low intensity, which is used in the outpatient clinics. So those are what you would see in your PT clinics, your OT clinics, your chiropractic clinics. That's the low intensity. The others cause significant.
can cause significant damage. That's why they break up kidney stones, know, high intensity, break up kidney stones, break up calcific tendonitis if they're using it for that. At low intensity, the piezoelectric and electromagnetic and the electrohydraulic devices that are not, that have the different applicator that are only laser, they work on the adage that they're creating microtrauma, restarting that immune process. What's interesting with shockwave research out of Austria and Germany is
excuse me, soft wave research out of Austria and Germany for that particular product is that or that particular machine, there's no evidence of microtrauma. So just by stimulating the cells, the shearing force of that wave coming across the cells, making the cells contract and expand. I talk a lot about this in the Herman and Wallace course that I have the cells contract and expand and that's sending the signals. It's releasing exosomes from other cells to go to that area, sending signals to the brain and two macrophages are going there.
And the body treats it like, huh, what's going on down there? We need to send some reinforcements in to investigate. then, know, stem cells go to that area as well, too. So we're helping with inflammation and significantly reducing pain.
Kim (37:20.352)
Yeah, and so you've kind of explained it there, like what's the mechanism of action, is, so it's inducing something for the immune system to recognize and the body to recognize and come in and respond to.
Stacey Roberts (37:31.727)
Yeah, they call it mechanotransduction. If you read up on shockwave, which is basically that stimulating the tissues, then there's a chemical effect as a result of that. Then there's the biological effect as a result of that, which is really just supporting the body's own innate healing process, right? So, you know, somebody has a chronic issue. know that, you know, that pain kind of, the pain pathways kind of change, right? So now it's not necessarily a lot of inflammation there, but there can certainly be.
but there's messages from the brain that are still reinforcing that pain. So even helping to break that cycle up by decreasing the pain in the area, it has a lot to do with what's going on in the brain as well. Definitely more research needs to be done there, but we have had patients treating soft wave or did some research on long COVID study. think they're presenting this at the APTA next year, long COVID and treating soft wave on the brain, in the brain stem.
to increase perfusion to the brain. brain fog is going away. People aren't feeling more energetic, that type of thing too. So there's so many applications. It's like too good to be true. Like every time I'm like, really? Like another thing that I can do? People are never gonna believe this works. Cause we say so many things. They use it on the open heart. Like a new study just was published in Europe on using, and SoftWave happens to be the company that was doing this, putting that on the open heart after open heart surgery before they close them
Kim (38:36.01)
Mm -hmm.
Mm -hmm.
Stacey Roberts (38:56.879)
to decrease inflammation, they're finding that that increases ejection fraction, doubles ejection fraction from just having a normal cabbage surgery. And also in another study that's yet to be published, it decreases opioid use by up to 40 % and some 20 to 40%, depending. mean, because of that anti -inflammatory effect, mean, the possibilities are endless, you
Kim (39:00.191)
Wow.
Kim (39:13.353)
Wow.
Kim (39:21.215)
Do you know of any, have you treated anybody or do you know of any research with regards to endometriosis or adenomyosis?
Stacey Roberts (39:27.483)
Yes, so I've treated patients with that. Now, what's really interesting is, you know, it can be difficult to, well, some people, women don't know if they have it, if they haven't had laparoscopy, right, to absolutely confirm it, or if there's no hemorrhagic cysts that they have seen on ultrasound, stuff like that. So, but what's interesting is I've treated patients who I'm usually getting the really bad chronic cases because nothing else is working for them. So when we go over the areas of the lesions or where we think the lesions are,
Some patients will get like this, you know, automatic nervous system response. They feel dizzy, they feel lightheaded. And then that response also decreases with treatment. And then I can get in there and do some good visceral work. They've had surgery, do some work on the, you know, internal scarring that's going on there too. And there's a wonderful OB -GYN, Dr. Mary Ojo -Carnans, I think in West Virginia. And we're doing a pilot on patients that have suspected endometriosis to see
what's the right protocol for this, right? Because again, this is new, we don't know for sure. So we wanna try to establish the best protocol for those patients coming in. So I've treated dysmenorrhea as well too, with it really significantly decreasing the inflammation during the period and after. We have seen some changes in menstrual flow as a result of utilizing it. Kind of makes sense, we're increasing blood flow to the area, right?
And I was hesitant to use it with endometriosis because I was afraid, what if we increase blood flow to the area and that makes it worse? But what made me feel better about that is I also was hesitant to utilize it on hemorrhoids. had, you know, this might be too much information, but I had history of hemorrhoids and I'm like, okay, I'll try it on myself and see. And sure enough, during the treatment on hemorrhoids, you'll get kind of an itchy feeling. Instead of pain, it's more of the itchy and that itchiness goes away during the treatment.
Kim (40:58.505)
Mm -hmm.
Stacey Roberts (41:23.583)
And I literally haven't in three years, haven't had an issue with hemorrhoids. So that's bringing more blood flow to an area that you think, gosh, there's already like a lot of too much blood flow and causing pain. The anti -inflammatory effect of what's happening is helping those hemorrhoids reduce and not become, this is anecdotally my theory because there's no study yet that shows this, but in the patients that I've treated with it, everyone is the same in regards to improvement.
Kim (41:33.341)
Right.
Stacey Roberts (41:52.435)
Endometriosis in my mind, similar, right? Where it can bring blood flow to the area to decrease the inflammation around those lesions so that potentially, fingers crossed, there's minimal pain. And I haven't had somebody who's like, my God, I have absolutely no pain now from my endometriosis, but it has significantly reduced the pain in many cases.
Kim (42:15.804)
Wow. What about speaking of hemorrhoids? hemorrhoids, what about mucosal prolapse, rectal prolapse? We've kind of already touched on the prolapse piece of it, but is it it's a little sometimes a bit more nuanced in the
Stacey Roberts (42:28.041)
Mm -hmm.
Stacey Roberts (42:32.849)
Yeah, exactly. that brings me to there can be a lot of things going on, right? So whenever somebody says, it help with this? The first thing I say is, what are you trying to accomplish? Right? We're not trying, I mean, we're not going to take the prolapse away. But if we can, like we alluded to before, if we can work on the tissue around there to solve and decrease pain that's related to that area, then we have a good chance. And this would need to be from somebody who
does a lot of this treatment, understands the structures, understands what can be done. You can't just put shockwave on, in my opinion, you can't just put shockwave where the rectal prolapse is and then be like, my gosh, okay, I'm expecting this to heal. No, that's not how it works. Somebody understands why prolapses are there, what's going on, what the surrounding structures are dealing with, all that type of stuff.
That's perfect because then you can take the mechanism of action, which is increasing blood flow, modulating inflammation, know, adjusting, know, scarring. talked about, you know, how it changes kind of the cellular structure at times. So if I can think that those things are going to help based on my knowledge of anatomy and the diagnosis in front of me, then, then yes, it can, it can help to a certain extent, depending on what the issue is.
Kim (43:56.786)
Very cool. Back to the terminology extracorporeal, all of the therapies I understand right now are external, correct? And do you feel like there ever could be or would be intra, like intravaginal? Could there potentially be even more benefit to get deeper into the tissues or access more tissues? You've already said that does it address the three layers, what you're currently doing? Maybe it's not needed, I don't
Stacey Roberts (44:07.067)
Yeah.
Stacey Roberts (44:25.701)
Right, so when I first started using this, like, my gosh, we have to have an intravaginal probe, we have to have one. And then I thought, well, why? mean, patients would rather we not do anything internally because it hurts, right? But there is something that after maybe after they are able to sustain intercourse or anything internally, then potentially, yeah, maybe it would have some good
Kim (44:37.404)
Right. Yep.
Stacey Roberts (44:54.759)
application for those types of things. So we're thinking about soft waves, the manufacturer in Germany is thinking about coming up with one. At this point, it's like, we don't necessarily need it because patients don't necessarily want it or need it. There is one probe out there that does do intravaginal, but it's either electromagnetic or piezo, so it doesn't get much depth, right? And if you use it before, in my opinion, if you use it before, you treat externally with like soft wave or shock wave.
Again, it's gonna be really, really painful for the patient, right? Vaginal ultrasounds are like, nobody wants to have that when they have vaginismus, dyspheronia, things like that, right? We wanna avoid that. So could there be an application down the road? I think absolutely. With the electro -hydraulic, it gets deep enough that we just don't really need it at this point. But that's something that's being thought about, especially for things like, I think about like primary ovarian failure. Yep, can we treat externally above where the ovaries are?
Kim (45:34.404)
Yep. Yep.
Kim (45:52.122)
Yeah. Yeah.
Stacey Roberts (45:53.079)
Yeah, absolutely. And I have, and we've worked on loosening up, know, scarring around those areas. Absolutely. But would there be more, what if we could stimulate the ovaries to bring more blood flow to the, and people have POI. Could we, you know, get their body producing eggs again? I mean, I don't know, in combination with hormonal therapy. Who knows? These are all questions that are exciting to now think about because of this mechanism of action of this device.
Kim (46:13.205)
Mm -hmm.
Kim (46:22.372)
Totally. Could somebody have the treatment if they have an IUD or a pessary inserted? So an IUD is obviously going to stay there. A pessary could potentially be removed by the person.
Stacey Roberts (46:32.087)
Yeah, correct. So I always tell patients, yes, you can. There's no, at least with our device, the one that is more spread out like a flashlight. When I asked the manufacturer about that very question, they said there's no reason that should damage the device or should have any problems with it. But I always say to patients, we're also softening the tissue around the things you're holding these devices in place.
So I always say things like, I want you to use another form of contraception. want you to, if you feel any discomfort or whatever in between sessions, you might need to get it checked, make sure that the positioning is right. I've treated many patients with that, with both Pestri and IUD and haven't had any issues, but I still always have that conversation because it's possible. So that's kind of the precaution, not a contraindication, but more of a precaution.
Kim (47:28.097)
Yeah, it doesn't sound like there's any downtime to this. you could, you could, if they, so you mentioned your person, your patient who was able to have intercourse, I think after five years you said, and so that may not happen after that very first session, but there's no, you wouldn't need to wait to insert a tampon or put your pessary back in or anything like
Stacey Roberts (47:32.114)
No, shouldn't be.
Stacey Roberts (47:49.344)
Correct, and that person, a lot of times the person feeling really good after that first or second treatment, especially if it's dyspareum evangelism and that whole like fear of pain, right? That whole biopsychological response. Sometimes maybe they could try because they don't think they have a lot of pain or the dialyric size we've used is much higher, you know, but there's that confidence level too. So I was, you know, that coaching
okay, it feels better. doesn't mean you have to have intercourse, right? So, you know, kind of work up to it and then you kind of have fun with it with your partner, you know, and make it more of a relaxing, enjoyable experience than one that where you're like, you know, oh my God, is this going to hurt, right? So, same things we do as far as coaching patients when they're, you know, if they've needed 15 treatments, I'm doing the same in the second and third treatment because they're nervous to have intercourse because it's been so painful.
Kim (48:34.413)
Right, right, right.
Kim (48:46.839)
Mm -hmm. Mm -hmm. What's the typical cost of a session or a package of sessions and is this something that potentially somebody's insurance could cover?
Stacey Roberts (48:58.322)
So right now in the US, there are CPT codes for it and insurance is not paying. think ED, there's some exception. SoftWave actually helped pioneer the first, right? Exactly. I know we talked about before, but men versus women stuff. So ED, is a shockwave to the Corpus Cavernosa that was actually pioneered by SoftWave to get that push through and get the CPT code. And there are occasional places around the country that are getting
Kim (49:09.109)
Of course.
Stacey Roberts (49:27.161)
some reimbursement from it. However, there is also a CPT code for ortho, just musculoskeletal, and very few, if any, are getting reimbursement utilizing that. So at this point in time, insurance doesn't cover it. And here's what I think why, because there are so many different devices. There's the radio device. That's not even shockwave, but that's under ESWT. And insurance, basically barely know anything about anatomy, or probably don't know anything about anatomy, even though they're making decisions about it.
They don't know, they see all the protocols have, know, some as a thousand shocks, some as 5 ,000 shocks because of the different devices. Some of the protocols are, you know, the person's better in three or four visits, some it takes 15, 20. I mean, so it's all over the place though. It's a great excuse for insurance not to cover it. As we get more research and the protocols become more standard, hoping that, you
that will change, but at this point, it's usually a cash -based practice. The exception is wounds. Wounds do have some reimbursement. If you utilize them and correct sequencing with other treatments, you can get some reimbursement if people do wound healing. But at this point, right now, it's cash -based. And the average, yeah, the average section cost, it could be anywhere between, you
Kim (50:40.575)
Yeah. And what's the... Sorry, go ahead.
Stacey Roberts (50:46.842)
$150 to $75 a session, which is a very, very, very low end, up to, you know, ED, because you're using a lot of shocks, to $600 a session. So most people land, positions are usually upper from $150 to $200, $300 per session. Me as a PT, I'm somewhere between, you $120 and $175 per session. But I'm including, actually, it's probably around $150 on average.
I'm including PT with that as well too. I do less manual therapy. So it really depends. I tell people it needs to fit your business model, right? So some people will buy it, bring it in and raise their prices across the board, whether people are getting Shockwave or not. So that would also help them increase their revenue. And then some people just say, okay, we're doing this, you're doing great. But if you want to accelerate your healing, we can add Shockwave in and that's an additional $100. What's nice about that too Kim is it's not
$100 for an hour and 15 minutes. It's still $100 for an hour of treatment because it decreases your manual therapy by half. So you're still able to do the same within that hour timeframe or 45 minutes or 30 or whatever you do. So the pricing really varies and a lot of times it's some people charge per shock, some people just charge a flat fee. So again, when I help people who are deciding whether they're bringing this into the clinic or if they have,
Kim (51:50.751)
Yeah, yep.
Kim (52:08.595)
wow.
Stacey Roberts (52:14.328)
projects or their clinic, I'll help them go through what's your business structure now because it has to make sense with that, right? And then we kind of build in and make sure that you because the revenue can be a nice addition to the bottom line. Whereas, you know, reimbursement is not going up. bringing in these cash based services significantly improves the ability to stay open, you know, as a clinic.
Kim (52:42.655)
Before I wrap up, if somebody was looking for a treatment and they're not in your neck at the woods, would you say preferably to find somebody who is offering the softwave version? we're obviously we're being very pelvic centric here in this conversation. So the softwave seems to be the preferable one. And is there like, do you find that there are more practitioners?
offering this and is it something that's offered now as you said even like med spas are offering it so it doesn't even have to be a pelvic PT per se that's delivering
Stacey Roberts (53:17.717)
Right, great question. yep, so there are, as long as it's within their scope of practice to treat the genitals. If they have soft wave, I love soft waves, so I'm a bit biased to it, but I also like how it works, and that's why it makes more sense to me to use on the pelvic floor. However, if somebody has the piezo or electromagnetic, and they again have that in their scope of practice, and they treat the pelvis, certainly they would be people to go to as well to get treatment.
What I would say is that if you do go to a med spa or a chiropractor that could treat that has the device or an NP or PA, I always encourage them to partner with a pelvic floor therapist, whether it's a PT or OT or even a physician or whatever that understands what they're doing so that they can have that treatment along with it. Because it just, I mean, we're showing this in the study and it just enhances their results. So even if they don't do that themselves,
for the patient's benefit to be like, okay, let's partner up with this person. They may not have the device, but I'm gonna refer you to them to do the pelvic PT along with this because it just enhances that in the patient's
Kim (54:29.352)
Yeah. And the course that you've created with Herman and Wallace, is that a continuing education or is that actually, does somebody take that to get certified to be able to deliver a shockwave?
Stacey Roberts (54:38.164)
Now it's a continuing education course. The next one's running in October, 2024. And it's a remote course, which is nice. So it's really beginner. you're either have a shockwave device, true shockwave device, you want know how to utilize it. You're trying to decide, you know, you're as confused as I was when you go into the research and you're like, what the heck? I don't understand that. You're getting inundated by salespeople to say this, that, and the other device. In that, in that course, I talked about all.
shockwave devices and why radial is not. even some of the things I've now added, some studies that are out on radial, there's just not a lot in pelvic health because of the reasons that we talked about before. So I try to be as unbiased as possible and say, here's the information. Now you can go and talk to those reps. You can decide which one is best for your clinic based on what you treat. And now that you understand what shockwave is and what shockwave does.
So it's really a great overview and people can walk away from that and then talk to the different companies, know, talk to me about my experience and decide on their own which one is best for them.
Kim (55:47.548)
Very cool. Where can people learn more about you? So we've talked to Herman and Wallace will have that course, but you as a practitioner, if somebody wanted to potentially come to Milwaukee and work with you, where can we find
Stacey Roberts (55:57.937)
Sure. Sure. My name and my company is New You Health and Wellness. So they can go to new you health and wellness dot com. That's any W. Y. O. U. Health and wellness dot com. There's what we treat how we treat on there that they can click on. Our blog is up. We're going to be starting a podcast next month releasing a book next or this fall called The Pain Free Formula. So that'll be available to again we'll be talking about.
other, you know, what we do in PT, but then expanding that out to the functional medicine stuff that I talked about before. So if patients aren't getting better, what else can we do to manage and help them get better? So that's coming out in the fall, so they can look for that on Amazon at some point, fingers crossed. And those, yeah, so those are the places for
Kim (56:48.048)
Amazing. Thank you so much for sharing your knowledge. I've learned so much that I really knew very little and you've really expanded my knowledge. Thank you so much and I know that this will benefit my listeners greatly.
Stacey Roberts (56:55.865)
No problem. Absolutely. Kim, thank you so much for having me. I love this. I really enjoyed it. And when I start my podcast, I'll be reaching out to you. Okay. All right. Thank you.
Kim (57:05.064)
Thank
