A complaint I have about all the shockwave research I've seen is that the size of the applicator is not described as part of the study method.  Almost all the studies describe the energy density, most commonly 0.09mJ/mm(2), and the number of shocks.  

If water comes out of a fire hose with the same pressure (per mm(2)) it comes out of a garden hose, a lot more water is flowing from the fire hose.  The same principle applies to shockwave therapy.  The total amount of energy applied depends on the energy density, the number of shocks and the size of the applicator.

The size of the applicators used in ED treatments seem to range from a minimum of 15mm up to a rather large size that I can only estimate by looking at pictures and videos.  The manufacturers' web sites don't document applicator size.

Here are some pictures of applicators found in YouTube videos:

Storz Medical - DUOLITH SD1 ultra
The doctor has his finger adjacent the applicator at time t=225 (3:45) in the video.  The applicator attachment looks somewhat larger than 15mm, but I can't tell for certain.  What is certain that the other end of the applicator, the end that attaches to the hand piece, is huge.  The hand piece without the applicator is shown at 3:17 in the video and looks like it could be 40 or 50mm.
https://www.youtube.com/watch?v=PYum6KmeFXw&t=225

Elvation Medical, Richard Wolf - LSTC-ED
The diagram shown at time t=122 (2:02) confuses me. The diagram shows the shocks as focused.  But somehow the shocks become linear when they reach the skin of the patient.  The diagram seems to indicate that the applicator head is about 30mm wide.  
https://www.youtube.com/watch?v=y12s5ykQeUU&t=122

Omnispec ED 1000 - Medispec
The applicator is shown with the demonstrator's finger at t=155 (2:35) in the video.  It looks like its about 40mm or so. It's really hard to tell - the applicator is filled with water and may deform when pressed against skin.  I'm not sure.  This is the unit most frequently used in clinical trials.  It showed efficacy in the first human study (Vardi), so other researchers adopted it.
https://www.youtube.com/watch?v=CsFOQFHiKgQ&t=155

Medispec's research page:
http://us.medispec.com/physicians/urology-center/erectile-dysfunction/link-to-research-center/

Now, where this is leading is this.  The area of a 15mm applicator is:
(7.5) x (7.5) x 3.14 = 176.6mm(2)
The energy from one shock of a 15mm applicator at an energy density of 0.09mJ/mm(2) is:
176.6mm(2) x 0.09mJ/mm(2) = 15.9mJ
So the machine should be set to 16mJ to get an energy density of 0.09mJ/mm(2) with a 15mm applicator.

On the machine I just bought (SW5B), I measured the default applicator's size as 1 5/8", which is 41.275mm.  I wish the documentation included the exact size of all the applicators, but it does not.  My measurement is probably not exact, but I'm sure it's close so I'll go with it.  The area of this applicator is:
(20.6) x (20.6) x 3.14 = 1332.5mm(2).

This is 7.5 times the area of the 15mm applicator.

The energy from one shock of the larger applicator at 0.09mJ/mm(2) is:
1332.5mm(2) x 0.09mJ/mm(2) = 119.9mJ
So the machine should be set to 120mJ to get an energy density of 0.09mJ/mm(2) with this applicator.

Maybe it's just me, but I am shocked - just shocked - that researchers are not documenting the total energy delivered in their studies.  Aside: Maybe as shocked as I was to learn that there is gambling in a Casablanca night club.

But the lack of common sense extends even further when you look at the "Meta" analysis studies.  These researchers take a bunch of studies and attempt to figure out what these studies are saying when considered as a group.  What is happening is a study such as Fojecki's, which delivered 600 shocks per treatment and did not show efficacy is lumped together with Vardi and others that delivered 1500 or more shocks per treatment and showed efficacy.  My thought is all you can say about the results is that 600 shocks per treatment was not enough.  Lumping these studies together makes no sense at all to me.

So, in setting our own protocols, it seems to me we don't have as much guidance from research as we should

Last edited by Yobro (6/19/2019 4:36 pm)